Revisional bariatric surgery for failed restrictive procedures

Revisional bariatric surgery using robotic-assisted surgery in a national medical center in Mexico

Long-term postoperative complications of metabolic and bariatric surgery (MBS) are more frequent than those of primary surgery. Robotic-assisted procedures offer several advantages over traditional laparoscopy, but there are limited data. A retrospective study of 29 patients who underwent a revisional robotic-assisted Roux-en-Y gastric bypass (RRYGB) in a Tertiary Level Hospital. Variables included were demographics, causes for revision, operative details, complications, and weight loss outcomes up to 54 month post-RRYGB. Causes for conversion were weight loss failure (WLF), weight regain (WR), Gastroesophageal Reflux Disease (GERD), or Joint Pain (JP). We assessed 29 patients. Causes for conversion included WLF (34%), WR (15%), WR with GERD (20%), GERD (24%), and JP (3%). Initial BMI was 53.43 kg/m2 ± 8.75. Mean length of hospital stay (LOS) was 2 days. Total operative time was 126 min. ± 43.45. Excess weight loss at 1 year post-surgery was 82.66% (p < 0.0001), with mean BMI of 30.93 kg/m2 (p < 0.001). At 3 years, mean %EWL was 71.26% and a mean BMI 33.81 kg/m2 (p < 0.0001). At 4.5 years, mean %EWL was 59.29% and mean BMI 37.27 kg/m2 (p < 0.0001). One complication (8%) was found (jejunojejunal stenosis). There was no mortality. The initial experience with RRYGB shows acceptable outcomes, including low morbidity, no mortality, excellent weight loss after the revisional surgery, and promising reduction in operative times, with important implications on reduction of the total cost of the procedure.

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.

Metabolic and Bariatric Endoscopy: A Mini-Review

We are currently in a worldwide obesity pandemic, which is one of the most significant health problems of the 21st century. As the prevalence of obesity continues to rise, new and innovate treatments are becoming available. Metabolic and bariatric endoscopic procedures are exciting new areas of gastroenterology that have been developed as a direct response to the obesity crisis. These novel interventions offer a potentially reversible, less invasive, safer, and more cost-effective method of tackling obesity compared to traditional bariatric surgery. Minimally invasive endoscopic treatments are not entirely novel, but as technology has rapidly improved, many of the procedures have been proven to be extremely effective for weight loss and metabolic health, based on high-quality clinical trial data. This mini-review examines the existing evidence for the most prominent metabolic and bariatric procedures, followed by a discussion on the future trajectory of this emerging subspecialty.

Factors Associated with Weight Loss After Endoscopic Transoral Outlet Reduction (TORe)

INTRODUCTION

Endoscopic transoral outlet reduction (TORe) has emerged as a safe and effective treatment option for weight regain after Roux-en-Y Gastric Bypass (RYGB). Factors that predict successful weight loss after TORe are incompletely understood. The aims of this study were to evaluate procedural factors and patient factors that may affect percent total body weight loss (%TBWL) after TORe.

METHODS

A retrospective cohort study was performed on patients after TORe. The primary outcomes were %TBWL at 6 and 12 months based on four procedural factors: purse-string (PS) vs. non-purse-string (NPS) suture pattern, gastric pouch sutures (N), change in the diameter of the gastrojejunal anastomosis, and change in the length of the gastric pouch. Secondary outcomes included patient factors that affected weight loss.

RESULTS

Fifty-one patients underwent TORe. Weight loss for completers was 11.3 ± 7.6% and 12.2 ± 9.2% at 6 and 12 months. There was a correlation between %TBWL and change in pouch length at 6 and 12 months and number of sutures in the pouch at 6 months. The difference in %TBWL between PS and NPS groups at 6 months (PS, n=21, 12.3 ± 8.5% and NPS, n=8, 8.7 ± 3.7%) and 12 months (PS, n=21, 13.5 ± 9.2% and NPS, n=5, 7.0 ± 7.9%) did not reach statistical significance. For secondary outcomes, depression was associated with %TBWL.

CONCLUSION

Change in pouch length and number of sutures in the pouch correlated positively while depression correlated negatively with weight loss after TORe. Further studies are needed to understand these effects.

Weight Recidivism and Dumping Syndrome after Roux-En-Y Gastric Bypass: Exploring the Therapeutic Role of Transoral Outlet Reduction

Obesity is a chronic, relapsing disease representing a global epidemic. To date, bariatric surgery is the most effective treatment for morbid obesity in the long-term. Roux-en-Y gastric bypass (RYGB) is one of the most performed bariatric interventions, with excellent long-term outcomes. However, about one-third of patients may experience weight regain over time, as well as dumping syndrome. Both these conditions are challenging to manage and require a multidisciplinary and personalized approach. The dilation of the gastro-jejunal anastomosis is a recognized etiological factor for both weight regain and dumping syndrome. Dietary modifications, behavioral interventions, and medications represent the first therapeutic step. Revisional surgery is the traditional approach when non-invasive treatments fail. However, re-interventions may be technically difficult and are associated with increased morbidity and mortality. Transoral outlet reduction (TORe) is an endoscopic procedure aimed at reducing the size of the anastomosis and is proposed as a minimally invasive treatment of weight regain and/or dumping syndrome refractory to conservative therapies. This review is aimed at providing a narrative overview of the role of TORe as part of the multidisciplinary therapeutic toolkit nowadays available to approach weight regain and dumping syndrome after RYGB.

Revision Bariatric Procedures and Management of Complications from Bariatric Surgery

Bariatric surgery is effective, but may be associated with adverse events. A multi-disciplinary approach including endoscopic interventions can be effective to manage these. Endoscopists should familiarize themselves with gastrointestinal pathology which can occur after bariatric surgery, including nutritional deficiencies, acid reflux, anastomotic stenosis, gallstone disease, leaks, fistulas, and weight regain. Endoscopic interventions including anastomotic stricture dilation, control of bleeding, endoscopic ultrasound-guided approach for endoscopic retrograde cholangiopancreatography, leak or fistula closure via endoscopic suturing or stent placement, and transoral outlet reduction (TORe) or revision obesity surgery endoluminal (ROSE) to address weight regain are among the endoscopic tools which have demonstrated safety and efficacy in the management of adverse events after bariatric surgery.

Surgical Prevention of Weight Regain and Type 2 Diabetes Recurrence in 3 Different Bariatric Operations and Their Differential Long-Term Outcome: An 8-Year Prospective Observational Study

Introduction

Comparative data on long-term outcomes of mechanistically different bariatric operations are scarce.

Methods

In this prospective, observational study, consecutive patients with severe obesity were studied using a predefined reoperation algorithm to determine long-term health outcomes after bariatric surgery (BS): adjustable gastric banding (AGB), Roux-en-Y gastric bypass (RYGB), or biliopancreatic diversion (BPD). All patients were assessed for mortality, postoperative weight loss, rate of reoperation, comorbidities, and quality of life (QoL) 8 years after surgery.

Results

Between 1996 and 2008, 2364 Swiss patients, with a mean body mass index of 43 ± 7 kg/m2 (mean ± SD) underwent AGB (n = 1404), RYGB (n = 790), or BPD (n = 170). Two thousand two hundred twenty-eight (94%) were followed for 8 years after BS. Eight-year mortality of the whole study group was 34.3 per 104 person-years. Percent excessive weight loss at 8 years was 56.7 ± 1.4% (95% confidence interval) in AGB, 62.5 ± 2.4% in RYGB and 64.8+-3.0% in BPD. The rate of major reoperation was highest in AGB and significantly lower in RYGB and BPD (63.4 vs 54.3 vs 47.2 per 103 person-years, P < 0.001). Remission of comorbidities was observed across all 3 groups, with key improvement (P < 0.01) in esophagitis in the RYGB group, and type 2 diabetes (T2D) (>60%) in procedures involving duodenal exclusion. Total improvement in QoL was similar between the 3 types of operations but was strongly correlated with weight loss preservation (P < 0.001).

Conclusions

BS, at the expense of a high reoperation rate but low procedural mortality, considerably improves the QoL and results in sustained remission of comorbidities, especially T2D using a predefined reoperation algorithm developed to prevent weight regain and operation-specific complications.

One anastomosis gastric bypass vs. Roux-en-Y gastric bypass, remedy for insufficient weight loss and weight regain after failed restrictive bariatric surgery

Background

Failure occurs in up to 60% of the patients that were treated with primary restrictive bariatric operations such as Laparoscopic Adjustable Gastric Banding (LAGB), or restrictive/metabolic operations like Laparoscopic Sleeve Gastrectomy (LSG). Insufficient weight loss and weight regain are the most commonly reported reasons of failure. The aim of this retrospective multicenter study was to compare One Anastomosis Gastric Bypass (OAGB) to Roux-en-Y Gastric Bypass (RYGB) as a revisional procedure in terms of weight loss, procedure time, complication rate and morbidity.

Methods

491 patients operated on between 2012 and 2017 for failed restrictive surgery were included in this study (OAGB (n=185) or RYGB (n=306)). Failure was defined as total weight loss (TWL) less than 25%, excess weight loss (EWL) less than 50% and/or a remaining body mass index (BMI) larger than 40 kg/m2 at two years of follow up. Primary outcome measures were %TWL and % excess BMI loss (EBMIL) at 12, 24 and 36 months of follow-up. Secondary outcomes were procedure time, reduction of comorbidity, early and late complication rate, and mortality.

Results

%TWL was significantly larger in the OAGB group at 12 months (mean 24.1±9.8 vs. 21.9±9.7, p = 0.023) and 24 months (mean 23.9±11.7 vs. 20.5±11.2, p = 0.023) of follow-up. %EBMIL was significantly larger in the OAGB group at 12 months (mean 69.0±44.6 vs. 60.0±30.1, p = 0.014) and 24 months (mean 68.6±51.6 vs. 56.4±35.4, p = 0.025) of follow-up. Intra-abdominal complications (leakage, bleeding, intra-abdominal abscess and perforation) occurred less frequently after revisional OAGB (1.1% vs. 4.9%, p = 0.025). Surgical intervention for biliary reflux (5.4% vs. 0.3%, p < 0.001) was more prevalent in the OAGB group. Surgical intervention for internal herniation (0.0% vs. 4.9%, p = 0.002) was more prevalent in the RYGB group.

Conclusions

This study suggests that OAGB is superior to RYGB as a remedy for insufficient weight loss and weight regain after failed restrictive surgery with more weight loss and a lower early complication rate. To substantiate these findings, further research from prospective randomized controlled trials is needed.

Reversal of Long-Term Weight Regain After Roux-en-Y Gastric Bypass Using Liraglutide or Surgical Revision. A Prospective Study

Purpose

This study investigates whether pharmacotherapy with liraglutide is similarly effective in reversing weight regain more than 6 years after Roux-en-Y gastric bypass (RYGB) as revisional surgery aimed at restoring restriction.

Methods

Ninety-five consecutive patients (11 male, 84 female; mean BMI 45 ± 6 kg/m²) undergoing RYGB 9 ± 4 years ago were treated for 24 months as follows: Patients, who gained less than 10% from weight NADIR, served as controls and were provided lifestyle counseling (DC, n = 30). The others were allowed to choose between three different treatment groups: daily s.c. administration of liraglutide (LG, n = 34); endosurgery using Apollo’s Overstitch System™ (ES, n = 15), or implantation of a Fobi-ring with pouch resizing (FP, n = 16).

Results

Controls kept their weight stable during 24 months of study (− 0.1 ± 1.7 kg/m²). Weight loss was 4.8 ± 2.9 kg/m² for LG and 5.5 ± 2.9 kg/m² for FP, both losing more than 85% of regained weight from weight NADIR (p < 0.001). In contrast, weight loss in ES was 1.0 ± 0.9 kg/m² (i.e., 20% of regained weight). Thirty-seven percent of FP experienced serious complications (p < 0.05) in contrast to the other groups. An improved prevalence of hypertension and dyslipidemia was observed in LG and FP (p < 0.02) 24 months after intervention.

Conclusions

Weight regain during more than 6 years after RYGB can be safely and effectively reversed with liraglutide. Compared with revisional surgery, pharmacotherapy with liraglutide was low risk and resulted in an important improvement in hypertension and dyslipidemia. Therefore, daily subcutaneous injections of liraglutide are a valid option to treat weight regain after RYGB.

A Spanish Society joint SECO and SEEDO approach to the Post-operative management of the patients undergoing surgery for obesity

PURPOSE

Bariatric surgery is the method of choice for the management or treatment of obesity. Bariatric surgery brings about several physiological changes in the body and is associated with set of complications. The aim of this study is to provide guidelines on post bariatric surgery management based on consensus by the Spanish society for Obesity Surgery (Sociedad Española de Cirugía de la Obesidad) (SECO) and the Spanish Society for the Study of Obesity (Sociedad Española para el Estudio de la Obesidad) (SEEDO).

METHOD

The boards proposed seven experts from each society. The experts provided the evidence and a grade of recommendation on the selected topics based on systematic reviews/meta-analysis. A list of clinical practical recommendations levels of evidence and grades of these recommendations was derived from the consensus statements from the members of these societies.

RESULTS

Seventeen topics related to post-operative management were reviewed after bariatric surgery. The experts came with 47 recommendations and statements. The mean number of persons voting at each statement was 54 (range 36-76).

CONCLUSION

In this consensus, we have designed a set of guidelines to be followed while managing patients after bariatric surgery. Expertise and knowledge of the clinicians are required to convey suitable considerations to the post-bariatric patients. There should also be extensive follow-up plans for the bariatric surgery patients.

The Use of the Overstitch for Bariatric Weight Loss

Obesity is a public health pandemic and leading contributor to morbidity and mortality. Endoscopic bariatric therapies have emerged as a viable minimally invasive treatment option to fill the therapeutic gap between conservative and surgical approaches. The ability to reliably place full-thickness sutures throughout the gastrointestinal tract has opened the door to novel endoscopic gastric restrictive procedures. A growing body of literature supports endoscopic sleeve gastroplasty as a safe, effective, and reproducible endoscopic treatment of obesity and metabolic syndrome. In addition, endoscopic sutured revision procedures following gastric bypass and sleeve gastrectomy are now first-line with demonstrable safety and long-term efficacy.

Single- or double-anastomosis duodenal switch versus Roux-en-Y gastric bypass as a revisional procedure for sleeve gastrectomy: A systematic review and meta-analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) is one of the most commonly performed bariatric procedure worldwide. There is currently no consensus on which revisional procedure is best after an initial SG.

OBJECTIVES

To compare the efficacy and safety between single-anastomosis duodeno-ileal bypass (SADI) or biliopancreatic diversion with duodenal switch (BPD-DS) versus Roux-en-Y gastric bypass (RYGB) as a revisional procedure for SG.

SETTING

University Hospital, Canada.

METHODS

MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and PubMed were searched up to August 2018. Studies were eligible for inclusion if they compared SADI or BPD-DS with RYGB as a revisional bariatric procedure for SG. Primary outcome was absolute percentage of total weight loss. Secondary outcomes were length of stay, adverse events, and improvement or resolution of co-morbidities (diabetes, hypertension, or hypercholesterolemia). Pooled mean differences were calculated using random effects meta-analysis.

RESULTS

Six retrospective cohort studies involving 377 patients met the inclusion criteria. The SADI/BPD-DS group achieved a significantly higher percentage of total weight loss compared with RYGB by 10.22% (95% confidence interval, -17.46 to -2.97; P = .006). However, there was significant baseline equivalence bias with 4 studies reporting higher initial body mass index (BMI) in the SADI/BPD-DS group. There were no significant differences in length of stay, adverse events, or improvement of co-morbidities between the 2 groups.

CONCLUSION

SADI, BPD-DS, and RYGB are safe and efficacious revisional surgeries for SG. Both SADI and RYGB are efficacious in lowering initial BMI but there is more evidence for excellent weight loss outcomes with the conversion to BPD-DS when the starting BMI is high. Further randomized trials are required for definitive conclusions.

Transoral outlet reduction: a comparison of purse-string with interrupted stitch technique

BACKGROUND AND AIMS

Weight regain after Roux-en-Y gastric bypass (RYGB) correlates with dilated gastrojejunal anastomosis (GJA). Endoscopic sutured transoral outlet reduction (TORe) is a safe and effective management and has predominantly been performed by either placing interrupted sutures at the GJA or the creation of a purse-string suture. The aim of the current study was to compare these techniques.

METHODS

All patients undergoing TORe for weight regain after RYGB were prospectively enrolled. Primary outcome was mean percent total weight loss (%TWL) at 3 and 12 months. Secondary outcomes included percent excess weight loss (%EWL), percent regained weight lost (%RWL), and total weight loss. Proportions were compared using the Fisher exact test and continuous variables using the Student t test. A P = .05 was significant. Multivariable regression analysis was performed.

RESULTS

Two hundred forty-one patients were enrolled (purse string = 187, interrupted = 54). There was no statistical difference between the purse-string and interrupted groups at 3 months in %TWL (8.6 vs 8.0, P = .41), %EWL (20.5 vs 16.7, P = .39), % RWL (44.7 vs 33.3, P = .56), and total weight loss (9.5 vs 11.3, P = .32). At 12 months the purse-string group achieved statistically significant improvement in %TWL (8.6 vs 6.4, P = .02), %EWL (19.8 vs 11.7, P < .001), %RWL (40.2 vs 27.8, P = .02), and total weight loss (9.5 vs 7.8, P = .04). Multivariable regression showed that technique (P = .006) was an independent predictor of %TWL at 12 months.

CONCLUSIONS

TORe is effective in treatment of weight regain after failed gastric bypass. The purse-string technique results in greater weight loss at 12 months than the traditional interrupted suture pattern.

Radiofrequency ablation for the treatment of weight regain after Roux-en-Y gastric bypass surgery

BACKGROUND AND AIMS

Roux-en-Y gastric bypass (RYGB) surgery is an established modality for the treatment of morbid obesity. However, approximately one-quarter of patients experience weight regain after initially successful weight loss. Endoscopic therapy targeting the gastric remnant pouch represents a novel potential strategy to re-induce weight loss in this population. We performed a pilot trial of radiofrequency ablation (RFA) of the gastric remnant pouch after RYGB to determine feasibility, safety, and efficacy for weight loss.

METHODS

We identified patients who had undergone RYGB, achieved >40% excess body weight loss (EBWL), and then regained >25% of lost weight. RFA was applied to the gastrojejunal anastomosis and the entire surface area of the gastric remnant pouch. Treatment was repeated at 4 and 8 months if patients did not meet specified weight loss targets. Weekly weights were obtained for 12 months. The primary efficacy outcome was percent EBWL at 12 months, compared with baseline.

RESULTS

Twenty-five patients were enrolled at 4 centers. Mean (± standard deviation [SD]) age was 45.4 ± 9.1 years, and 84% (21/25) were female. Mean (± SD) baseline body mass index was 40.2 ± 7.8. Twenty-two of 25 patients completed 12 months of follow-up. At 12 months, median (± SD) EBWL was 18.4% (interquartile ratio 10.8, 33.7; P < .0001). Significant weight loss was seen at 3.5 months (P < .0001) and at 7.5 months (P < .0001), with a significant trend for continued weight loss over the 12-month period (P = .013). Two patients had serious adverse events requiring hospitalization.

CONCLUSIONS

RFA of the gastric remnant pouch in patients with weight regain after RYGB resulted in significant reductions in excess body weight with an acceptable safety profile. Continued weight loss was observed after each RFA treatment. Further clinical trials in well-selected populations are warranted to determine the optimal number and frequency of RFA treatments and to assess durability of weight loss. (Clinical trial registration number: NCT01910688.).

Transoral outlet reduction with full thickness endoscopic suturing for weight regain after gastric bypass: a large multicenter international experience and meta-analysis

BACKGROUND AND AIMS

Many patients who undergo bariatric surgery will experience weight regain and effective strategies are needed to help these patients. A dilated gastrojejunal anastomosis (GJA) has been associated with weight recidivism after Roux-en-Y gastric bypass surgery (RYGB). Endoscopic transoral outlet reduction (TORe) with a full thickness endoscopic suturing device (Overstitch, Apollo Endosurgery, Austin, TX) is a minimally invasive therapeutic option. The primary aim of this project was to examine the safety and long-term efficacy data from three bariatric surgery centers and to conduct a systematic review and meta-analysis of the existing literature.

METHODS

Patients who underwent TORe with the Overstitch device from Jan 2013 to Nov 2016 at 3 participating bariatric surgery centers were included in the multicenter analysis. For the systematic review and meta-analysis, a comprehensive search of multiple English databases was conducted. Random effects model was used.

RESULTS

130 consecutive patients across three centers underwent TORe with an endolumenal suturing device. These patients (mean age 47; mean BMI 36.8) had experienced 24.6% weight regain from nadir weight after RYGB. Average weight lost at 6, 12, and 18 months after TORe was 9.31 ± 6.7 kg (N = 84), 7.75 ± 8.4  kg (N = 70), 8 ± 8.8 kg (N = 46) (p < 0.01 for all three time points), respectively. The meta-analysis included 330 patients. The pooled weight lost at 12 months was 8.4 kg (95% CI 6.5-10.3) with no significant heterogeneity across included studies (p = 0.07). Overall, 14% of patients experienced nausea, 18% had pain and 8% required a repeat EGD. No serious adverse events reported.

CONCLUSION

When implemented as part of a multidisciplinary intervention, TORe using endolumenal suturing is safe, reproducible, and effective approach to manage weight recidivism after RYGB and should be utilized early in the management algorithm of these patients.

"Candy cane syndrome:" an underappreciated cause of abdominal pain and nausea after Roux-en-Y gastric bypass surgery

BACKGROUND

"Candy cane" syndrome (a blind afferent Roux limb at the gastrojejunostomy) has been implicated as a cause of abdominal pain, nausea, and emesis after Roux-n-Y gastric bypass (RYGB) but remains poorly described.

OBJECTIVES

To report that "candy cane" syndrome is real and can be treated effectively with revisional bariatric surgery SETTING: All patients underwent "candy cane" resection at University Hospitals of Cleveland.

METHODS

All patients who underwent resection of the "candy cane" between January 2011 and July 2015 were included. All had preoperative workup to identify "candy cane" syndrome. Demographic data; pre-, peri-, and postoperative symptoms; data regarding hospitalization; and postoperative weight loss were assessed through retrospective chart review. Data were analyzed using Student's t test and χ² analysis where appropriate.

RESULTS

Nineteen patients had resection of the "candy cane" (94% female, mean age 50±11 yr), within 3 to 11 years after initial RYGB. Primary presenting symptoms were epigastric abdominal pain (68%) and nausea/vomiting (32%), particularly with fibrous foods and meats. On upper gastrointestinal study and endoscopy, the afferent blind limb was the most direct outlet from the gastrojejunostomy. Only patients with these preoperative findings were deemed to have "candy cane" syndrome. Eighteen (94%) cases were completed laparoscopically. Length of the "candy cane" ranged from 3 to 22 cm. Median length of stay was 1 day. After resection, 18 (94%) patients had complete resolution of their symptoms (P<.001). Mean body mass index decreased from 33.9±6.1 kg/m² preoperatively to 31.7±5.6 kg/m² at 6 months (17.4% excess weight loss) and 30.5±6.9 kg/m² at 1 year (25.7% excess weight loss). The average length of latest follow-up was 20.7 months.

CONCLUSION

"Candy cane" syndrome is a real phenomenon that can be managed safely with excellent outcomes with resection of the blind afferent limb. A thorough diagnostic workup is paramount to proper identification of this syndrome. Surgeons should minimize the size of the blind afferent loop left at the time of initial RYGB.

Endoscopic Treatments Following Bariatric Surgery

Weight regain after bariatric surgery is common and can be managed with surgical interventions or less morbid endoscopic techniques. These endoscopic approaches target structural postoperative changes that are associated with weight regain, most notably dilation of the gastrojejunal anastomosis aperture. Purse string suture placement, as well as argon plasma coagulation application to the anastomosis, may result in significant and durable weight loss. Furthermore, various endoscopic approaches may be used to safely and effectively manage other complications of bariatric surgery that may result in poor weight loss or weight regain after surgery, including fistula formation.

Gastrojejunal anastomotic reduction for weight regain in roux-en-y gastric bypass patients: physiological, behavioral, and anatomical effects of endoscopic suturing and sclerotherapy

BACKGROUND

Weight regain is common after Roux-en-Y gastric bypass.

OBJECTIVES

To assess the mechanisms of weight loss after 2 gastrojejunal anastomotic reduction (GJAR) procedures to treat weight regain.

SETTING

University hospital, United States.

METHODS

Forty-three Roux-en-Y gastric bypass patients with weight regain were prospectively enrolled. Weight, ghrelin levels, responses to the 21-item three-factor eating questionnaire, and gastrojejunal anastomotic diameter were assessed. Nine patients underwent endoscopic suturing and 34 patients underwent sclerotherapy. At 3 months, weight, ghrelin levels, eating behavior, and outlet diameter were reassessed.

RESULTS

Patients were aged 47±10 years and regained 43%±26% of maximal lost weight. Ghrelin levels were 123±106 ng/mL and outlet diameter was 21±6.3 mm. At 3 months, the entire cohort lost 4.1%±5.9% of total weight (TBW) and showed improvement in cognitive eating habits (P<.01). Endoscopic suturing and sclerotherapy patients lost 10.4%±2.2% TBW and 2.7%±5.5% TBW (P<.01), respectively. Suturing and sclerotherapy reduced the outlet diameter by 15.0±6.7 mm and 2.6±5.7 mm (P<.01). Ghrelin levels increased after suturing by 46±55 ng/mL and decreased by 37±110 ng/mL after sclerotherapy (P = .02). Suturing resulted in greater improvement in cognitive eating behavior than sclerotherapy (P = .03). Reduction in outlet size and changes in cognitive and emotional eating behaviors were predictors of weight loss after GJAR on a univariate analysis. On a multivariate analysis, the only predictor of weight loss was a reduction in outlet size (P< .01).

CONCLUSIONS

Endoscopic suturing resulted in greater reduction in outlet size, improvement in eating behavior, and weight loss than sclerotherapy. Reduction of anastomosis size was a significant predictor of weight loss after GJAR.

Effect of Intragastric Balloons on Liver Enzymes: A Systematic Review and Meta-Analysis

BACKGROUND

Intragastric balloons (IGBs) are safe and effective in inducing weight loss in obese patients. The objective of this study was to review and analyze the available data of the effect of IGB on markers of nonalcoholic fatty liver disease (NAFLD) and liver enzymes.

METHODS

Searches were performed of MEDLINE and Embase databases from inception through January 2016. Study inclusion criteria were the following: ≥5 overweight or obese adult patients undergoing intragastric balloon placement, with liver tests [alanine aminotransferase (ALT) or gamma-glutamyl transpeptidase (GGT)] or markers of NAFLD (e.g., imaging, biopsy) reported before balloon insertion and after balloon removal at 6 months.

RESULTS

Nine observational studies and one randomized trial were identified. ALT decreased by -10.02 U/l (95 % CI, -13.2, -6.8), GGT decreased by -9.82 U/l (95 % CI, -12.9, -6.8), and BMI decreased by -4.98 kg/m(2) (-5.6, -4.4) with IGB therapy. Hepatic steatosis improved from baseline after 6 months of balloon therapy by magnetic resonance imaging (fat fraction, 16.7 ± 10.9-7.6 ± 9.8, p = 0.003), ultrasound (severe liver steatosis, 52-4 %, p < 0.0001). Histological NAFLD activity score was lower after 6 months of IGB versus control with sham endoscopy and diet (2 ± 0.75 vs. 4 ± 2.25, p = 0.03).

CONCLUSION

The use of intragastric balloon decreases liver enzymes and is potentially an effective short-term treatment for NAFLD as part of a multidisciplinary approach. Larger, more rigorous trials are needed to confirm the effect of IGBs on NAFLD.

Weight loss endoscopy: Development, applications, and current status

Obesity and its comorbidities - including diabetes and obstructive sleep apnea - have taken a large and increasing toll on the United States and the rest of the world. The availability of commercial, clinical, and operative therapies for weight management have not been effective at a societal level. Endoscopic bariatric therapy is gaining acceptance as more effective than diet and lifestyle measures, and less invasive than bariatric surgery. Various endoscopic therapies are analogues of the restrictive or bypass components of bariatric surgery, utilizing gastric remodeling or intestinal anastomosis to achieve proven weight loss and metabolic benefits. Others, such as aspiration therapy, employ novel mechanisms of action. Intragastric balloons have recently been approved by the United States Food and Drug Administration, and a number of other technologies have completed large multicenter trials (such as AspireAssist aspiration therapy and Primary Obesity Surgery Endolumenal). Endoscopic sleeve gastroplasty and transoral outlet reduction for endoscopic revision of gastric bypass have proven safe and effective in a number of studies. As devices are approved for use, data will continue to accumulate for safety, effectiveness, and cost effectiveness. Bariatric endoscopists should be prepared to appropriately target and apply various endoscopic bariatric therapies in the context of a comprehensive long-term weight management program.

Eating Behavior, Low-Frequency Functional Mutations in the Melanocortin-4 Receptor (MC4R) Gene, and Outcomes of Bariatric Operations: A 6-Year Prospective Study

OBJECTIVE

Data on the effects of eating behavior and genetics on outcomes of gastrointestinal surgery for diabesity have been sparse, often flawed, and controversial. We aimed to assess long-term outcomes of bariatric operations in patients characterized for eating behavior and rare mutations in the melanocortin-4 receptor (MC4R) gene, which is strongly implicated in energy balance.

RESEARCH DESIGN AND METHODS

Between 1996 and 2005, 1,264 severely obese Swiss patients underwent current laparoscopic adjustable gastric banding, gastroduodenal bypass, or a hybrid operation. Of these, 872 patients were followed for a minimum of 6 years and were screened for MC4R mutations. Using regression models, we studied relationships between eating behavior and MC4R mutations and postoperative weight loss, complications, and reoperations after 6 years.

RESULTS

At baseline, rare functional MC4R mutation carriers exhibited a significantly higher prevalence of binge eating disorder (BED) or loss-of-control eating independent of age, sex, and BMI. Six years after bariatric surgery, the mutation carriers had more major complications than wild-type subjects independent of age, baseline BMI, sex, operation type, and weight loss. Furthermore, high baseline BMI, male sex, BED, and functional MC4R mutations were independent predictors of higher reoperation rates.

CONCLUSIONS

Sequencing of MC4R and eating typology, combined with stratification for sex and baseline BMI, might significantly improve patient allocation to banding or bypass operations for diabesity as well as reduce both complication and reoperation rates.

Transoral outlet reduction for weight regain after gastric bypass: long-term follow-up

BACKGROUND AND AIMS

Dilated gastrojejunal anastomosis aperture is associated with weight regain after Roux-en-Y gastric bypass (RYGB). Transoral outlet reduction (TORe) has proved safe and effective for the treatment of weight regain. The objective of this study was to determine the long-term weight trend and number needed to treat for TORe.

METHODS

This prospective series included consecutive post-RYGB patients with weight regain and a gastrojejunal anastomosis aperture greater than 15 mm. TORe was performed with a full-thickness endoscopic suturing device.

RESULTS

A total of 150 patients who had regained 49.9% ± 3.6% of the weight lost after gastric bypass (4.1 ± 0.3 kg/y after nadir) before TORe. At TORe, body mass index was 40.2 ± 0.8 kg/m(2) and weight was 110.7 ± 2.2 kg. At 1 year, weight loss was 10.5 ± 1.2 kg or 24.9 ± 2.6% excess weight loss (EWL); at 2 years, weight loss was 9.0 ± 1.7 kg or 20.0% ± 6.4% EWL; at 3 years, weight loss was 9.5 ± 2.1 kg or 19.2% ± 4.6% EWL. The number needed to treat for arrest of weight regain was 1.0 at 6 months, 1.1 at 1 year, and 1.2 at 2 and 3 years. The number needed to treat to maintain weight loss of ≥5 kg from TORe was 1.2 at 6 months, 1.5 at 1 year, 1.9 at 2 years, and 2.0 at 3 years.

CONCLUSION

TORe safely and effectively arrested weight regain and provided durable weight loss with a low number needed to treat. Patients with weight regain after RYGB should be evaluated for dilation of the gastrojejunal anastomosis, as TORe can be part of a multidisciplinary strategy to address post-RYGB weight regain.

Outcomes of a third bariatric procedure for inadequate weight loss

Background and Objectives:

The robust volume of bariatric surgical procedures has led to significant numbers of patients requiring reoperative surgery because of undesirable results from primary operations. The aim of this study was to assess the feasibility, safety, and outcomes of the third bariatric procedure after previous attempts resulted in inadequate results.

Methods:

We retrospectively identified patients who underwent a third bariatric procedure for inadequate weight loss or significant weight regain after the second operation. Data were analyzed to establish patient demographic characteristics, perioperative parameters, and postoperative outcomes.

Results:

A total of 12 patients were identified. Before the first, second, and third procedures, patients had a mean body mass index of 67.1 ± 29.3 kg/m², 60.9 ± 28.3 kg/m², and 49.4 ± 19.8 kg/m², respectively. The third operations (laparoscopic in 10 and open in 2) included Roux-en-Y gastric bypass (n = 5), revision of pouch and/or stoma of Roux-en-Y gastric bypass (n = 3), limb lengthening after Roux-en-Y gastric bypass (n = 3), and sleeve gastrectomy (n = 1). We encountered 5 early complications in 4 patients, and early reoperative intervention was needed in 2 patients. At 1-year follow-up, the excess weight loss of the cohort was 49.4% ± 33.8%. After a mean follow-up time of 43.0 ± 28.6 months, the body mass index of the cohort reached 39.9 ± 20.8 kg/m², which corresponded to a mean excess weight loss of 54.4% ± 44.0% from the third operation. At the latest follow-up, 64% of patients had excess weight loss >50% and 45% had excess weight loss >80%.

Conclusion:

Reoperative bariatric surgery can be carried out successfully (often laparoscopically), even after 2 previous weight loss procedures.

Endoscopic management of bariatric surgical complications

PURPOSE OF REVIEW

Bariatric surgery is recognized as the most effective treatment against obesity as it results in significant weight reduction and a high rate of remission of obesity-related comorbidities. However, bariatric surgery is not uncommonly associated with complications and an endoscopic approach to management is preferred over surgical reintervention. This review illustrates the latest developments in the endoscopic management of bariatric surgical complications.

RECENT FINDINGS

For successful management of complications, precipitating and perpetuating factors must be addressed in addition to directing therapy at the target pathology. Endoscopy is well tolerated even in the acute postoperative setting when performed carefully with CO2 insufflation. Chronic proximal staple-line leaks/fistulas frequently do not respond to primary closure with diversion therapy, and a new technique of stricturotomy has been reported to improve outcomes. Innovations in the field of transoral endoscopic instruments have led to the development of a single-session entirely internal endoscopic retrograde cholangiopancreatography by creating a gastrogastric anastomosis.

SUMMARY

Endoscopy allows for early diagnosis and prompt institution of therapy and should, therefore, be the first-line intervention in the management of complications of bariatric surgery in patients who do not need urgent surgical intervention. Computed tomography-guided drainage may be necessary in patients with drainable fluid collections.

VIDEO ABSTRACT

http://links.lww.com/COG/A11.

Endoscopic therapy for weight loss: Gastroplasty, duodenal sleeves, intragastric balloons, and aspiration

A new paradigm in the treatment of obesity and metabolic disease is developing. The global obesity epidemic continues to expand despite the availability of diet and lifestyle counseling, pharmacologic therapy, and weight loss surgery. Endoscopic procedures have the potential to bridge the gap between medical therapy and surgery. Current primary endoscopic bariatric therapies can be classified as restrictive, bypass, space-occupying, or aspiration therapy. Restrictive procedures include the USGI Primary Obesity Surgery Endolumenal procedure, endoscopic sleeve gastroplasty using Apollo OverStitch, TransOral GAstroplasty, gastric volume reduction using the ACE stapler, and insertion of the TERIS restrictive device. Intestinal bypass has been reported using the EndoBarrier duodenal-jejunal bypass liner. A number of space-occupying devices have been studied or are in use, including intragastric balloons (Orbera, Reshape Duo, Heliosphere BAG, Obalon), Transpyloric Shuttle, and SatiSphere. The AspireAssist aspiration system has demonstrated efficacy. Finally, endoscopic revision of gastric bypass to address weight regain has been studied using Apollo OverStitch, the USGI Incisionless Operating Platform Revision Obesity Surgery Endolumenal procedure, Stomaphyx, and endoscopic sclerotherapy. Endoscopic therapies for weight loss are potentially reversible, repeatable, less invasive, and lower cost than various medical and surgical alternatives. Given the variety of devices under development, in clinical trials, and currently in use, patients will have multiple endoscopic options with greater efficacy than medical therapy, and with lower invasiveness and greater accessibility than surgery.

Worthy or not? Six-year experience of revisional bariatric surgery from an Asian center of excellence

BACKGROUND

Revisional bariatric surgery (RBS) is increasing. The various primary operations with their distinctive complications make this group of patients quite heterogeneous, and treatment has to be individualized. There are concerns regarding the safety profile and efficacy of these procedures. The objective of the present study was to analyze the indications, safety, and efficacy of RBS at a high-volume Asian center and provide insight into the different treatment options.

METHODS

Of a total of 1578 bariatric surgeries from July 2006 to June 2012, 52 patients underwent revisional bariatric procedures. The primary operations included 6 different procedures. The indications for surgery were grouped into weight loss failure (n = 21) or complications related to the primary operation (n = 31). The revisional operations performed were conversion to another procedure (n = 22), revision of existing anatomy (n = 29), or reversal to normal anatomy (n = 1).

RESULTS

96% of revisional surgeries were performed laparoscopically. The median operating time was 72 minutes (25-240 min), and the median duration of hospital stay was 4 days (3-25 d). The mean body mass index for weight loss failure decreased significantly from 36.3 to 29.6 kg/m(2) after 1 year of revisional surgery (P<.01). However, revision of RYGB was only associated with a body mass index loss of 3.2 kg/m(2) and percentage of excess weight loss of 31.8%. More than 90% of the patients with complications had complete resolution of their preoperative symptoms. There were 3 major complications with an overall morbidity rate of 5.8%. There was no mortality.

CONCLUSIONS

RBS is well-tolerated, with satisfactory early outcomes, in high-volume centers. However, larger studies with longer follow-up periods are needed to determine the long-term efficacy of these procedures.

Perioperative risk and complications of revisional bariatric surgery compared to primary Roux-en-Y gastric bypass

INTRODUCTION

Growing number of patients requires revisional bariatric surgery. This study compares perioperative course and outcomes of revisional versus primary bariatric surgery.

METHODS

Patients who underwent revisional bariatric surgery from Jan 1997 to Sept 2012 were reviewed retrospectively. Every revisional patient with BMI >35 and age <70 was matched with a primary Roux-en-Y gastric bypass control patient based on preoperative BMI, age, sex, and year of surgery. Patients' preoperative indications, intraoperative/postoperative course, and complications were analyzed.

RESULTS

Two hundred and fifty five patients underwent revisional bariatric surgery with resulting Roux-en-Y gastric bypass anatomy while 1,674 patients underwent primary gastric bypass in the same time interval. Of 255 patients, 172 patients were paired with 172 primary gastric bypass patients. Revisional bariatric group had preoperative BMI 48 ± 9, age 52 ± 9 years, 93 % female, 44 % laparoscopic, 30 % diabetic, 60 % hypertensive. Primary bypass patients had preoperative BMI 49 ± 8, age 52 ± 9 years, 93 % female, 97 % laparoscopic, 49 % diabetic, 67 % hypertensive. Compared to primary bypass patients, revisional patients had significantly higher estimated blood loss (463.7 vs. 113.3 mL), longer operative time (272.5 vs. 175.5 min), greater risk for ICU stay (N = 24, 14 % vs. N = 2, 1 %), and longer hospital stay (5.6 vs. 2.5 days). There were significantly more intraoperative liver (N = 13, 8 % vs. N = 1, 1 %) and spleen (N = 18, 10 % vs. N = 0) injuries, and more enterotomies (N = 9, 5 % vs. N = 0) in the revisional group. There were also significantly more postoperative complications (N = 94, 55 % vs. N = 48, 28 %), readmissions (N = 27, 16 % vs. N = 12, 7 %), and reoperations (N = 16, 9 % vs. N = 3, 2 %) within 30 days of surgery. Mean percentage weight loss at 1 year was significantly less for revisional patients (27 vs. 37 %). There was no significant difference in 30 day mortality between the two groups (N = 6 vs. 0).

CONCLUSION

Even in experienced hands, complex revisional bariatric surgery should be approached with significant caution, especially given that weight loss is less substantial.

Comparison of a superficial suturing device with a full-thickness suturing device for transoral outlet reduction (with videos)

BACKGROUND

Larger gastrojejunal (GJ) anastomosis aperture is one independent predictor for weight regain after Roux-en-Y gastric bypass. Transoral outlet reduction (TORe) has proven safe and effective for treatment of weight regain by using a superficial-thickness (ST) suturing device. Full-thickness (FT) suturing devices are now available, potentially providing more effective results.

OBJECTIVE

To compare effectiveness of superficial-thickness with full-thickness TORe.

DESIGN

Matched cohort study: patients were matched sequentially by GJ anastomosis aperture, body mass index, and age.

SETTING

Tertiary-care center.

PATIENTS

A total of 59 consecutive patients undergoing full-thickness TORe were matched with 59 patients undergoing superficial-thickness TORe. All had GJ anastomosis apertures >20 mm.

INTERVENTION

Transoral outlet reduction.

MAIN OUTCOME MEASUREMENTS

Weight loss and rate of adverse events.

RESULTS

Post-TORe GJ anastomosis apertures were similar between groups (ST 6.9 ± 0.2 mm vs FT 7.1 ± 0.3 mm). Weight loss was greater at 6 months in the FT group (10.6 ± 1.8 kg in FT vs 4.4 ± 0.8 kg in ST; P < .01) and at 1 year (8.6 ± 2.5 kg in FT vs 2.9 ± 1.0 kg in ST; P < .01). Excess weight loss was greater in the FT group at 6 months (20.4 ± 3.3% in FT vs 8.1 ± 2.5% in ST; P < .01) and at 1 year (18.9 ± 5.4% in FT vs 9.1 ± 2.3% in ST; P = .03).

LIMITATIONS

This was a single-center, retrospective, cohort study.

CONCLUSION

There is level 1b evidence for effectiveness of TORe by using a superficial mucosal suturing device. This matched cohort study compared TORe by using the same ST suturing device with TORe by using a newer, FT suturing device and the same operative methods. FT TORe resulted in significantly more weight loss than ST TORe at 6 months and at 1 year. Full-thickness TORe is a significant improvement over ST TORe for endoscopic therapy of weight regain in patients with dilated GJ anastomosis.

Revisional bariatric surgery is more effective for improving obesity-related co-morbidities than it is for reinducing major weight loss

BACKGROUND

Patients having previous bariatric surgery are at risk for weight regain and return of co-morbidities. If an anatomic basis for the failure is identified, many surgeons advocate revision or conversion to a Roux-en-Y gastric bypass. The aim of this study was to determine whether revisional bariatric surgery leads to sufficient weight loss and co-morbidity remission.

PATIENTS AND METHODS

From 2005-2012, patients undergoing revision were entered into a prospectively maintained database. Perioperative outcomes, including complications, weight loss, and co-morbidity remission, were examined for all patients with a history of a previous vertical banded gastroplasty (VBG) or Roux-en-Y gastric bypass (RYGB).

RESULTS

Twenty-two patients with a history of RYGB and 56 with a history of VBG were identified. Following the revisional procedure, the RYGB group experienced 35.8% excess weight loss (%EWL) and a 31.8% morbidity rate. For the VBG group, patients experienced a 46.2% %EWL from their weight before the revisional operation with a 51.8% morbidity rate. Co-morbidity remission rate was excellent. Diabetes (VBG:100%, RYGB: 85.7%), gastroesophageal reflux disease (VBG: 94.4%, RYGB: 80%), and hypertension (VBG: 74.2%, RYGB:60%) demonstrated significant improvement.

CONCLUSION

Revision of a failed RYGB or conversion of a VBG to a RYGB provides less weight loss and a higher complication rate than primary RYGB but provides an excellent opportunity for co-morbidity remission.

Endoscopic suturing for transoral outlet reduction increases weight loss after Roux-en-Y gastric bypass surgery

BACKGROUND & AIMS

Weight regain or insufficient loss after Roux-en-Y gastric bypass (RYGB) is common. This is partially attributable to dilatation of the gastrojejunostomy (GJ), which diminishes the restrictive capacity of RYGB. Endoluminal interventions for GJ reduction are being explored as alternatives to revision surgery. We performed a randomized, blinded, sham-controlled trial to evaluate weight loss after sutured transoral outlet reduction (TORe).

METHODS

Patients with weight regain or inadequate loss after RYGB and GJ diameter greater than 2 cm were assigned randomly to groups that underwent TORe (n = 50) or a sham procedure (controls, n = 27). Intraoperative performance, safety, weight loss, and clinical outcomes were assessed.

RESULTS

Subjects who received TORe had a significantly greater mean percentage weight loss from baseline (3.5%; 95% confidence interval, 1.8%-5.3%) than controls (0.4%; 95% confidence interval, 2.3% weight gain to 3.0% weight loss) (P = .021), using a last observation carried forward intent-to-treat analysis. As-treated analysis also showed greater mean percentage weight loss in the TORe group than controls (3.9% and 0.2%, respectively; P = .014). Weight loss or stabilization was achieved in 96% subjects receiving TORe and 78% of controls (P = .019). The TORe group had reduced systolic and diastolic blood pressure (P < .001) and a trend toward improved metabolic indices. In addition, 85% of the TORe group reported compliance with the healthy lifestyle eating program, compared with 53.8% of controls; 83% of TORe subjects said they would undergo the procedure again, and 78% said they would recommend the procedure to a friend. The groups had similar frequencies of adverse events.

CONCLUSIONS

A multicenter randomized trial provides Level I evidence that TORe reduces weight regain after RYGB. These results were achieved using a superficial suction-based device; greater levels of weight loss could be achieved with newer, full-thickness suturing devices. TORe is one approach to avoid weight regain; a longitudinal multidisciplinary approach with dietary counseling and behavioral changes are required for long-term results. ClinicalTrials.gov identifier: NCT00394212.

Endoscopic management of complications after gastrointestinal weight loss surgery

As more patients undergo bariatric surgery, gastroenterologists will increasingly encounter variant postsurgical anatomies and postoperative complications. We discuss the diagnosis and management of bleeding, ulcers, foreign bodies, stenoses, leaks, fistulas, pancreaticobiliary diseases, weight regain, and dilated outlets.

Gastric pouch reduction using StomaphyX in post Roux-en-Y gastric bypass patients does not result in sustained weight loss: a retrospective analysis

BACKGROUND

Gastric bypass is the "gold standard" procedure of bariatric surgery. However, 20.4-34.9% of these patients may fail to achieve or maintain the weight loss on long-term follow-up and may require additional procedures. StomaphyX has been promoted for weight reduction in such patients.

OBJECTIVES

To study whether endoluminal reduction of gastric pouch and stoma using StomaphyX results in sustained weight loss in patients who regain weight after gastric bypass.

METHODS

Retrospective chart review was performed on 59 postgastric bypass patients who underwent revision of gastric pouch using StomaphyX from 2007 to 2008. Postprocedure weight at 1 week, 1 month, and 6 months follow-up as well as weight at the time of the review was recorded for each patient.

RESULTS

Average weight loss and excess body weight loss (EBWL) were 2.6 ± 2.3 kg and 7.3 ± 7.1% (n = 42) at 1 week, 3.7 ± 2.9 kg and 11.6 ± 12.1% (n = 31) at 1 month, and 3.8 ± 4.5 kg and 11.5 ± 17.9% (n = 10) at 6 months respectively. At the time of review, the average follow-up was 41 months, average weight loss was 1.7 ± 9.7 kg, and EBWL was 4.3 ± 29.8% (n = 53). Endoscopy in 12 patients at average 18 months follow-up showed no sustained reduction in pouch and stoma size.

CONCLUSIONS

StomaphyX results in weight loss that is not sustained on long-term follow-up. Pouch and stoma tend to regain their preprocedure size on follow-up. StomaphyX cannot be recommended as a weight loss strategy in postgastric bypass patients who regain weight.

A pathway to endoscopic bariatric therapies

The American Society for Gastrointestinal Endoscopy (ASGE) is dedicated to advancing patient care and digestive health by promoting excellence in gastrointestinal endoscopy. The American Society for Metabolic and Bariatric Surgery (ASMBS) is dedicated to improving public health and well-being by lessening the burden of the disease of obesity and related diseases. They are the largest professional societies for their respective specialties of gastrointestinal endoscopy and bariatric surgery in the world. The ASGE/ASMBS task force was developed to collaboratively address opportunities for endoscopic approaches to obesity, reflecting the strengths of our disciplines, to improve patient and societal outcomes. This white paper is intended to provide a framework for, and a pathway towards, the development, investigation, and adoption of safe and effective endoscopic bariatric therapies (EBT).

Preliminary report: search for a transgastric approach for managing gastrogastric fistulas

BACKGROUND

Revision surgery to eliminate a gastrogastric fistula (GGF) is often associated with high morbidity.

METHODS

This report describes a percutaneous transgastric approach for revision surgery in three patients with GGF using a transgastric, totally extraperitoneal approach.

RESULTS

The access was performed successfully in all the patients. There were no intraoperative complications, and the patients had an uneventful recovery. One patient had a recurrence 8 months after the procedure but had achieved satisfactory weight loss during the period. We were able to perform a second percutaneous transgastric repair. The second patient showed an asymptomatic recurrence of the fistula, which was later completely repaired. The third patient has had moderate weight loss.

CONCLUSIONS

Although current results are not optimal, we believe that this approach could represent an alternative for patients with a hostile abdomen or in whom co-morbidities comprise a prohibitive factor. Further experience, technical improvements, and longer follow-up are needed to evaluate and optimize this approach and evaluate its potential use in other surgical areas.

Current status of endoluminal bariatric procedures for primary and revision indications

Endoscopic bariatric procedures are gaining traction as possible minimally invasive treatment modalities for obesity. This article focuses on the various endoscopic devices and procedures that pertain to primary and revisional treatments. Additionally, the article discusses the potential for applying these various devices and procedures to other points of intervention, including early intervention, bridge to surgery, and primary metabolic treatment (eg, diabetes management). Devices that are currently in human use are preferentially discussed, followed by references to devices that may see clinical use in the near future.

Revisional vs. primary Roux-en-Y gastric bypass--a case-matched analysis: less weight loss in revisions

With the increase in bariatric procedures performed, revisional surgery is now required more frequently. Roux-en-Y gastric bypass (RYGB) is considered to be the gold standard revision procedure. However, data comparing revisional vs. primary RYGB is scarce, and no study has compared non-resectional primary and revisional RYGB in a matched control setting. Analysis of 61 revisional RYGB that were matched one to one with 61 primary RYGB was done. Matching criteria were preoperative body mass index, age, gender, comorbidities and choice of technique (laparoscopic vs. open). After matching, the groups did not differ significantly. Previous bariatric procedures were 13 gastric bands, 36 vertical banded gastroplasties, 10 RYGB and two sleeve gastrectomies. The indication for revisional surgery was insufficient weight loss in 55 and reflux in 6. Intraoperative and surgical morbidity was not different, but medical morbidity was significantly higher in revisional procedures (9.8% vs. 0%, p = 0.031). Patients undergoing revisional RYGB lost less weight in the first two postoperative years compared with patients with primary RYGB (1 month, 14.9% vs. 29.7%, p = 0.004; 3 months, 27.4% vs. 51.9%, p = 0.002; 6 months, 39.4 vs. 70.4%, p < 0.001; 12 months, 58.5% vs. 85.9%, p < 0.001; 24 months, 60.7% vs. 90.0%, p = 0.003). Although revisional RYGB is safe and effective, excess weight loss after revisional RYGB is significantly less than following primary RYGB surgery. Weight loss plateaus after 12 months follow-up.

Abdominal pain after gastric bypass: suspects and solutions

BACKGROUND

Gastric bypass remains the mainstay of surgical therapy for obesity. Abdominal pain after gastric bypass is common and accounts for up to half of all postoperative complaints and emergency room visits. This article reviews the most important causes of abdominal pain specific to gastric bypass and discusses management considerations.

METHODS

The current surgical literature was reviewed using PubMed, with a focus on abdominal pain after gastric bypass and the known pathologies that underlie its pathogenesis.

RESULTS

The etiologies of abdominal pain after gastric bypass are diverse. A thorough understanding of their pathogenesis impacts favorably on clinical outcomes.

CONCLUSIONS

The differential diagnosis for abdominal pain after gastric bypass is large and includes benign and life-threatening entities. Its diverse causes require a broad evaluation that should be directed by history and clinical presentation. In the absence of a clear diagnosis, the threshold for surgical exploration in patients with abdominal pain after gastric bypass should be low.

Band revision versus Roux-en-Y gastric bypass conversion as salvage operation after laparoscopic adjustable gastric banding

BACKGROUND

With the increasing popularity of laparoscopic adjustable banding (LAGB), reoperations to treat band complications have become increasingly more common. Few studies, however, have documented the outcomes of such revisional procedures. The purpose of the present study was to compare the different reoperative approaches after LAGB placement. The present study was conducted at a tertiary referral academic medical center in the United States.

METHODS

We reviewed our bariatric database to identify patients who had undergone LAGB from 2004 to 2007 and had undergone either revision of their original band or conversion to Roux-en-Y gastric bypass.

RESULTS

Of the 66 patients who met our inclusion criteria, 47 (71.2%) had undergone revision and 19 (28.8%) conversion. The patient demographics were similar between the 2 groups. The interval to revision or conversion was 22 and 28 months, respectively. Band slippage was the most common surgical indication in the revision group, and inadequate weight loss was the most common in the conversion group. Although patients in the revision group had experienced good weight loss before their reoperation, the conversion group had not. However, the conversion group experienced good weight loss after their reoperation, with an average excess body weight loss of 48%.

CONCLUSION

Patients who have experienced successful weight loss with LAGB and experience band complications will have satisfactory outcomes with band revision, maintaining their excess body weight loss. These data suggest that patients with inadequate weight loss after LAGB can do well after conversion to Roux-en-Y gastric bypass.

Comparison of 30-day outcomes after non-LapBand primary and revisional bariatric surgical procedures from the Longitudinal Assessment of Bariatric Surgery study

BACKGROUND

The goals were to compare the morbidity and mortality between primary and revisional bariatric surgery and to identify the clinical predictors of adverse outcomes among patients undergoing revisional surgery in the Longitudinal Assessment of Bariatric Surgery consortium. The study was multi-institutional at university hospitals in the United States.

METHODS

Data from the LABS-1 (safety) cohort were analyzed, excluding primary gastric banding patients. A total of 3802 LABS-1 patients were included: 3577 who underwent primary surgery and 225 who underwent revisional surgery. The demographic, clinical, operative, and 30-day outcome data were compared between the 2 groups. A nonlinear mixed effects logit model was used to identify independent risk factors for adverse outcomes (death, deep vein thrombosis, pulmonary embolism, reintubation, reoperation, or discharge after 30 days).

RESULTS

Compared with those undergoing revisional surgery, the primary surgery patients were younger (median age 44 versus 49 years, P <.0001) and more likely to be male (20.5% versus 12.7%, P = .006) and heavier (median body mass index 47.3 versus 41.2 kg/m(2), P <.0001) and to have more co-morbidities (P <.0001), including hypertension (56.0% versus 46.0%, P = .0044), diabetes (35.7% versus 20.0%, P <.0001), and sleep apnea (50.3% versus 27.2%, P <.0001). The operative time for the revisional procedures was longer (median 181 versus 135 min, P <.0001) and associated with greater blood loss (median 100 versus <50 mL, P <.0001). Adverse outcomes were more likely after revisional surgery (15.1% versus 5.3%, P <.0001, odds ratio 2.4, 95% confidence interval 1.6-3.6). After adjusting for patient characteristics previously shown to be associated with adverse outcomes, this difference remained statistically significant (odds ratio 2.3, 95% confidence interval 1.5-3.8). The 30-day mortality rate was similar in the 2 groups (.4%).

CONCLUSION

Revisional surgery was performed without substantial mortality but with a greater incidence of adverse outcomes than was primary bariatric surgery.

Laparoscopic conversion of adjustable gastric banding and vertical banded gastroplasty to duodenal switch

BACKGROUND

The aim of this retrospective consecutive study was to evaluate the feasibility, safety, and efficacy of the conversion of laparoscopic adjustable gastric banding (LAGB) and open vertical banded gastroplasty (VBG) into duodenal switch (DS) by laparoscopy.

METHODS

From November 2003 to February 2007, laparoscopic conversion into DS was performed in 1-step in 43 patients, 31 after LAGB and 12 after VBG. The reason for conversion was weight loss issues, such as insufficient excess weight loss (EWL) or weight regain. The mean interval from LAGB and VBG to conversion to the DS was 42.7 +/- 28.7 months and 172.2 +/- 86.9 months, respectively. The mean %EWL at conversion was 8.3% +/- 19.3% after LAGB and 20.8% +/- 30% after VBG.

RESULTS

The mean operative time was 205.8 +/- 44.8 minutes for LAGB and 210.9 +/- 53.7 minutes for VBG. No conversions to open surgery occurred. One patient in the LAGB group died on the third postoperative day of sudden death syndrome, as shown by the postmortem examination. Major complications occurred in 6.4% of patients with LAGB (1 hemoperitoneum and 1 ileoileostomy leak) and in 50% with VBG (1 sleeve gastrectomy leak with subsequent duodenoileostomy leak, 3 duodenoileostomy leaks, 1 pancreatitis, and 1 respiratory insufficiency). The mean hospital stay was 5.5 +/- 5 days for the LAGB group and 34.5 +/- 50.3 days for the VBG group. After a mean follow-up of 28 +/- 15.7 months for LAGB to DS and 43.5 +/- 6 months for VBG to DS, reoperations for late complications were required in 6 patients (20.6%) in the LAGB to DS group and in 5 patients (62.5%) in the VBG to DS group. Three patients (25%) died within 8 months after conversion of VBG. The 29 surviving patients (LAGB to DS) showed a mean %EWL and percentage of excess body mass index loss of (%EBMIL) 78.4% +/- 24.9% and 77.8% +/- 23.7%, respectively. The 8 surviving patients (VBG to DS) had a mean %EWL and %EBMIL of 85.1% +/- 20% and 85.8% +/- 18.7%, respectively.

CONCLUSION

According to these results, laparoscopic conversion of LAGB to DS seems feasible and effective, despite the 1 death. However, in our hands, laparoscopic conversion of VBG to DS had an unacceptable rate of complications and deaths.

One-year weight loss after primary or revisional Roux-en-Y gastric bypass for failed adjustable gastric banding

BACKGROUND

Adjustable gastric banding has been widely used in Europe, but recently gastric bypass (Roux-en-Y gastric bypass [RYGB]) has become the procedure of choice. With a gastric banding failure rate of nearly 40% at 5 years, the need for revisional surgery is increasing. The effect of a failed previous bariatric surgery on the weight loss curve after RYGB is still a controversial issue.

METHODS

A total of 259 patients underwent RYGB from 2003 to 2007, 58 after failed gastric banding and 201 as primary surgery. All the procedures were laparoscopically performed by the same surgeon at a single institution. The postoperative course and the percentage of excess weight loss were compared between the 2 groups.

RESULTS

The 2 groups were similar in age and initial body mass index (46.3 +/- 7.2 kg/m(2) for revision versus 47.7 +/- 6.7 kg/m(2) for primary RYGB). In contrast, the prerevision body mass index was 43.2 +/- 7.0 kg/m(2). Revisional RYGB required a significantly longer operative time (128.3 +/- 25.9 minutes versus 89.0 +/- 14.7 minutes, P <.0001) and the morbidity was greater (8.6% versus 5.5%), but no patient died in the postoperative period after revision. As determined from the initial body mass index, the 1-year percentage of excess weight loss was comparable between the 2 groups (66.1% +/- 26.8% and 70.4% +/- 18.9%).

CONCLUSION

When RYGB is performed after an adjustable gastric band failure to restore weight loss or because of a complication, the weight loss curve is similar to that after primary RYGB. Therefore, the strategy of adjustable gastric banding first is an option that does not seem to preclude satisfactory weight loss after revision to RYGB.