Endoluminal revision of gastric bypass for weight regain--a systematic review

Single Anastomosis Jejuno-ileal (SAJI): a New Model of Malabsorptive Revisional Procedure for Insufficient Weight Loss or Weight Regain After Roux-en-Y Gastric Bypass

BACKGROUND

In case of insufficient weight loss or weight regain or relapse of weight-related comorbidities after Roux-en-Y gastric bypass (RYGB), other procedures such as reduction of a large gastric pouch and stoma, lengthening of the Roux limb, conversion to sleeve gastrectomy and/or bilio-pancreatic diversion with duodenal switch have been advocated. Single anastomosis jejuno-ileal (SAJI) is a new revisional simple operation performed after RYGB failure which adds malabsorption to the previous gastric bypass.

METHODS

SAJI includes a single jejuno-ileal anastomosis specifically joining the ileum 250-300 cm proximal to the ileo-caecal valve and the jejunum 30 cm below the gastro-jejunal anastomosis on the Roux limb of the previous RYGB. Thirty-one patients underwent SAJI for insufficient weight loss and/or weight regain after RYGB. The percent total weight loss (%TWL) after RYGB and before SAJI was 21.8 ± 7.8. All SAJI operations were performed laparoscopically. The SAJI mean operating time was 145 min.

RESULTS

Regarding weight loss after SAJI, %TWL is 27.2 ± 7.4, 31.2 ± 6.4, 33.7 ± 5.9 and 32.9 ± 5.2 at 12, 24, 36 and 48 months, respectively. Our series recorded a low rate of peri-operative and medium-term complications with a low grade of severity (Clavien-Dindo classification grade). One patient required reoperation 36 days after SAJI for epigastrium incarcerated incisional hernia at the previous RYGB laparotomy site. Mortality was 0. Comorbidity reduction/resolution after SAJI is 83.2% for type 2 diabetes mellitus, 42.8% for arterial hypertension, 72.8% for dyslipidemia and 45.3% for OSA.

CONCLUSIONS

Treatment of failed RYGB is challenging. SAJI is a less complicated, purely low invasive malabsorptive operation that should reach satisfactory %TWL and comorbidity reduction/resolution.

Laparoscopic Vertical Sleeve Gastrectomy

Bariatric surgery has emerged as the most effective means of achieving weight loss. Obesity surgery is a quickly expanding field. Laparoscopic vertical sleeve gastrectomy is a great option for patients because it is simple, exceedingly safe, has a fairly defined postoperative complication profile, and is as effective as more complex bariatric surgery options. Specific consideration of patients' comorbidities, assessment of surgeon's skill, and knowledge of preoperative, perioperative, and postoperative course is a must for all surgeons who wish to perform this procedure. If properly used, vertical sleeve gastrectomy is a powerful tool in combating obesity and its deleterious effects.

Treatment Options for Poor Responders to Bariatric Surgery

PURPOSE OF REVIEW

This review aims to evaluate the latest evidence on the treatment options for perceived poor responders to bariatric surgery and provide practitioners with a guide on when to consider revisional surgery and when to consider alternatives.

RECENT FINDINGS

The use of adjuvant pharmacotherapy has been increasingly described in the literature as an adjunct to primary bariatric surgery, in order to attain more weight loss or better control of obesity-related complications. The newer anti-obesity and anti-diabetes drugs also have cardiorenal benefits, which are shown in recent cardiovascular outcome trials. Revisional bariatric surgery has emerged as a distinctive entity and can be broadly organized into three categories: corrective, conversion, and reversal surgeries. Careful patient selection and preoperative optimization are needed to ensure long-term favorable outcomes. Newer treatment modalities involving the use of anti-obesity medications and endoscopic bariatric interventions provide patients and healthcare providers with more options, when faced with the challenge of poor response after bariatric surgery.

Bariatric reduction system - BARS: device, technique and first clinical experience

BACKGROUND

Roux-en-Y gastric by-pass (RYGB) is one of the most effective bariatric procedures, but the rate of weight regain (WR) can reach 63% after the second year. Enlargement of the gastrojejunal anastomosis is one of the reported causes. A newly CE-marked flexible endoscopic system, Bariatric Anastomotic Reduction System (BARS) (Ovesco Endoscopy, Tuebingen, Germany), derivative of the well-established endoscopic over-the-scope-clip (OTSC) clipping system, has been recently developed. It was tested in pre-clinical and preliminary clinical use for feasibility and effectiveness in bariatric anastomotic reduction.

MATERIAL AND METHODS

Using a single-channel endoscope with external supplemental working channel, the BARS device captures the two limbs of the anastomosis, reducing its size, thus slowing food passage. After preclinical assessment, six patients with at least a 15% WR and the presence of an enlarged gastrojejunostomy > 20 mm were enrolled. The mean patient age was 49 years (range 24-67). Average interval between gastric bypass and BARS procedure: 8 years (4-13).

RESULTS

All procedures were safely performed without complications. Mean procedure time: 52 min (37 - 75). Preliminary results: mean weight loss 6 kg (4-9) at a 3-month FU.

CONCLUSIONS

BARS could be a promising endoscopic system in case of WR after gastric bypass due to enlargement of the anastomosis.

Efficacy of Utilizing Argon Plasma Coagulation for Weight Regain in Roux-en-Y Gastric Bypass Patients: a Multi-center Study

BACKGROUND

Endoscopic approaches exist for targeting weight regain after Roux-en-Y gastric bypass (RYGB), including endoscopic suturing, clipping, and sclerotherapy. Argon plasma coagulation (APC) is a noncontact electrocoagulation method, and when used in RYGB patients, it has shown reduction in the diameter of the gastrojejunal anastomosis.

OBJECTIVES

To study the effectiveness of APC for weight regain in terms of weight loss for RYGB patients, from eight bariatric centers.

METHODS

A retrospective chart review was performed for 558 patients at eight bariatric centers in the USA (1) and Brazil (7) who underwent APC procedure between 31st July 2009 and 29th March 2017. APC was performed on patients who regained weight after RYGB procedure.

RESULTS

Upon exploratory analysis of the individual BMI data, the mean BMI decreased slightly during the first 24 months and increased slightly afterwards following the APC intervention. The mean weight was 94.5 ± 18.6 kg and the mean BMI was 34.0 kg/m² at APC. Where data were available, the mean of lowest weight was 67.0 ± 23.0 kg and the mean of lowest BMI was 24.1 kg/m² following gastric bypass. The mean weight loss was 6.5, 7.7, and 8.3 kg at 6, 12, and 24 months, respectively, and the changes in weight over time was statistically significant (p < 0.0001). Multi-level for change model showed the low body mass index (BMI) group (BMI < 30 kg/m²) to have greater TWL than the high BMI (BMI ≥ 30 kg/m²) group at 6, 12, and 24 months. In the low BMI group, the mean TWL was 4.7, 6.1, 6.9, and 2.4%, at 6, 12, and 24 months, respectively. In the high BMI group, the mean TWL was 7.5, 10.4, 13.4, and 3.7%, at 6, 12, 24, and 36 months, respectively. Of the 333 patients in four centers who provided complication information, complications after APC included stenosis (n = 9), GJ ulcer (n = 3), vomiting (n = 3), GJ leakage (n = 2), and melena (n = 1).

CONCLUSION

APC can be useful in reducing the regained weight after RYGB, and patients showed 6-10% total weight loss at 12 months. Randomized trials would be needed to validate the findings.

Outcomes in conventional laparoscopic versus robotic-assisted revisional bariatric surgery: a retrospective, case-controlled study of the MBSAQIP database

Introduction

Revisional bariatric surgery is being increasingly performed and is associated with higher operative risks. Optimal techniques to minimize complications remain controversial. Here, we report a retrospective review of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant User Files (PUF) database, comparing outcomes between revision RBS and LBS.

Methods

The 2015 and 2016 MBSAQIP PUF database was retrospectively reviewed. Revision cases were identified using the Revision/Conversion Flag. Selected cases were further stratified by surgical approach. Subgroup analysis of sleeve gastrectomy and gastric bypass cases was performed. Case–controlled matching (1:1) was performed of the RBS and LBS cohorts, including gastric bypass and sleeve gastrectomy cohorts separately. Cases and controls were match by demographics, ASA classification, and preoperative comorbidities.

Results

26,404 revision cases were identified (93.3% LBS, 6.7% RBS). 85.6% were female and 67% white. Mean age and BMI were 48 years and 40.9 kg/m². 1144 matched RBS and LBS cases were identified. RBS was associated with longer operative duration (p < 0.0001), LOS (p = 0.0002) and a higher rate of ICU admissions (1.3% vs 0.5%, p = 0.05). Aggregate bleeding and leak rates were higher in the RBS cohort. In both gastric bypass and sleeve gastrectomy cohorts, the robotic-assisted surgery remain associated with longer operative duration (p < 0.0001). In gastric bypass, rates of aggregate leak and bleeding were higher with robotic surgery, while transfusion was higher with laparoscopy. For sleeve gastrectomy cases, reoperation, readmission, intervention, sepsis, organ space SSI, and transfusion were higher with robotic surgery.

Conclusion

In this matched cohort analysis of revision bariatric surgery, both approaches were overall safe. RBS was associated with longer operative duration and higher rates of some complications. Complications were higher in the robotic sleeve cohort. Robotic is likely less cost-effective with no clear patient safety benefit, particularly for sleeve gastrectomy cases.

Dual Ring Wound Protector Reduces Circular Stapler Related Surgical Site Infections in Patients Undergoing Laparoscopic Roux-En-Y Gastric Bypass

BACKGROUND

While there are various techniques to create the gastrojejunostomy during a laparoscopic Roux-en-Y gastric bypass (LRYGB), many surgeons prefer using a circular stapler. One drawback of this method, however, is the higher incidence of surgical site infections (SSIs). To investigate the effect of a dual ring wound protector on SSIs during LRYGB.

METHODS

In April 2016, our bariatric surgical group implemented an intervention whereby a dual ring wound protector in conjunction with a conical EEA stapler introducer was used when creating the gastrojejunostomy. SSIs from pre- and post-intervention were compared using Fisher's exact test. Only LRYGBs performed with a circular stapler were included in our analysis. Student's t test and χ2 were used to compare pre- and post-intervention groups with respect to demographics and co-morbidities.

RESULTS

Between April 2015 and January 31st, 2017, our surgeons performed 158 LRYGBs using a circular stapler for the gastrojejunostomy. There were 84 patients (53%) in the pre-intervention group and 74 (47%) in the post-intervention group. The pre- and post-intervention groups were not statistically different. The SSI rate for the pre-intervention group was 9.5% while the SSI rate was 1.35% in the post-intervention group (p = 0.0371). The use of a dual ring wound protector for LRYGBs with circular stapled gastrojejunostomy was associated with an 86% relative risk reduction in SSIs.

CONCLUSION

Using a dual ring wound protector in conjunction with a conical EEA introducer for LRYGBs with circular stapled gastrojejunostomy significantly decreased SSIs.

What the radiologist needs to know about gastrointestinal endoscopic surgical procedures

Natural orifice transluminal endoscopic surgery (NOTES) is a novel surgical approach, currently performed for an array of conditions. Endoscopic procedures offer significant benefits, including lower cost, no surgical incisions, and shorter hospital stays. These advantages align with the current trends in health care, namely a push for "cost-effective care." There are a multitude of health issues which are now being addressed by the endoscopic surgical approach, including peroral endoscopic myotomy (POEM), which is a relatively new technique used in the treatment of achalasia. Endoscopic treatment utilized for GERD includes transoral incisionless fundoplication. Endoscopic bariatric surgical procedures include intragastric balloon placement, endoscopic sleeve gastroplasty, and revision of prior bariatric procedures including Roux-en-Y gastric bypass and conventional gastric sleeve procedures. Endoscopic clips are routinely utilized for achieving hemostasis, treating iatrogenic gastric and bowel ulcerations and perforations and for the closure of enteric fistulization. Novel endoscopic procedures are now replacing conventional surgery due to their non-invasive nature, faster recovery and lower healthcare costs. Radiologists need to understand how these procedures are performed, as well as expected post-procedural imaging appearance and potential complications.

Pouch Reshaping for Significant Weight Regain after Roux-en-Y Gastric Bypass

BACKGROUND

Significant weight regain after Roux-en-Y gastric bypass (RYGB) occurs in around 20 % of patients in the long term. Anatomical reasons include dilatation of the gastric pouch and/or the pouch-jejunal anastomosis, leading to loss of restriction. Pouch reshaping (PR) aims at reestablishing restriction with a subsequent feeling of satiety. This study reports the outcome of PR embedded in a multidisciplinary treatment pathway.

METHODS

Twenty-six patients after PR for weight regain >30 % following RYGB in a university hospital between October 2010 and March 2016 were analyzed. Excluded were patients with PR for gastro-gastric fistulae, hypoglycemia, candy cane syndrome, and concomitant alteration of limb lengths. PR consisted in laparoscopic lateral resection of the gastric pouch, the anastomosis and the proximal 5 cm of the alimentary limb over a 32F bougie.

RESULTS

Median follow-up after PR was 48 months (range 24-60). Median BMI at PR was 39.1 kg/m² (32.7-59.1). Median operation time was 85 min (25-190), and median length of stay was 3 days (1-35). Minor complications (grade ≤ 2) occurred in seven (27 %) patients and major complications (grade ≥ 3) in four patients (15 %). Nadir BMI and %EBMIL after PR were 32.9 kg/m² and 43.3 %, reached after a median of 12 months (3-48). Comorbidities were resolved in 81 %. After 48 months, median BMI was 33.8 kg/m² (20.4-49.2) and %EBMIL was 61.4 (39.1-121.2).

CONCLUSIONS

Used selectively in a multidisciplinary treatment pathway, PR leads to prolonged weight stabilization around the previous nadir. However, its associated perioperative morbidity must not be disregarded.

Weight regain after Roux-en-Y gastric bypass has a large negative impact on the Bariatric Quality of Life Index

BACKGROUND

Despite initial successful weight loss, some patients may experience weight regain following Roux-en-Y gastric bypass (RYGB).

OBJECTIVE

To assess the impact of weight regain on bariatric patients' quality of life (QoL).

METHODS

This was a prospective cross-sectional study. Fifty-six consecutive RYGB patients were recruited and divided into weight-regain and weight-stable cohorts. QoL was assessed using the Bariatric Quality of Life (BQL) questionnaire. The BQL Index scores of the weight-regain and weight-stable groups were compared using Student's t-test. Additionally, the BQL Index score of the weight-regain group was compared with that of historical prebariatric patients. Predictors of BQL were assessed using univariate and multivariate linear regression analyses.

RESULTS

Of 56 RYGB patients, 41 (73%) had weight regain. On average, patients had body mass index (BMI) of 37 ±7.5 kg/m2 and gained 34 ±26% of maximal weight initially lost. Weight-regain patients had lower BQL Index scores than weight-stable patients (44.8±6 vs 53±7, p<0.001). Patients with weight regain had similar BQL Index scores as the prebariatric patients despite lower BMI (BMI of 39.7±6.8 vs 47.2±7.6, p<0.05; BQL Index of 44.8±6 vs 41.6±10.4, p=0.144, respectively). Years from RYGB, BMI and amount of weight regain were associated with BQL Index on a univariate analysis (β=-0.55,-0.52, -0.7; p<0.0001). Only weight regain was a significant predictor of BQL on a multivariate analysis (β =-0.56; p=0.001).

CONCLUSION

Weight regain had a negative impact on bariatric patients' QoL. Patients who regained at least 15% of maximal weight lost appeared to have as low QoL as those who had not undergone bariatric surgery despite a lower BMI.

Recent advancements in bariatric/metabolic surgery

Obesity and type 2 diabetes mellitus (T2DM) are currently two pan‐endemic health problems worldwide and are associated with considerable increase in morbidity and mortality. Both diseases are closely related and very difficult to control by current medical treatment, including diet, drug therapy and behavioral modification. Bariatric surgery has proven successful in treating not just obesity but also in significantly decreasing overall obesity‐associated morbidities as well as improving quality of life in severely obese patients (body mass index [BMI] >35 kg/m²). A rapid increase in bariatric surgery started in the 2000s when the laparoscopic surgical technique was introduced into this field. Many new procedures had been developed and changed the face of modern bariatric surgery. Recently, bariatric surgery played as gastrointestinal metabolic surgery has been proposed as a new treatment modality for obesity‐related T2DM for patients with BMI >35 kg/m². Strong evidence has demonstrated that bariatric/metabolic surgery is an effective and durable treatment for obese T2DM patients. Bariatric/metabolic surgery is now becoming an important surgical division. The present article examines and discusses recent advancements in bariatric/metabolic surgery and covers four major fields: (i) the rapid increase in numbers and better safety; (ii) new procedures with better outcomes; (iii) from bariatric to metabolic surgery; and (iv) understanding the mechanisms and personalized treatment.

Endoscopic Bariatric Therapies

Obesity and its associated cardio-metabolic comorbidities have emerged as a global pandemic. The efficacy of various hypo-caloric diets and prescription drugs has been poor with respect to sustained weight loss. Recent advancements in endoscopic technology and techniques have opened a new field of minimally invasive endoscopic treatment options for combatting obesity both as a first line and adjunctive therapy. Presently, two endoscopic space-occupying devices in the form of intragastric balloons have received FDA approval for 6-month implantation in patients within a BMI range of 30-40 kg/m(2). Furthermore, full-thickness suturing has led to the development of primary endoscopic sleeve gastroplasty and Roux-en-Y gastric bypass revision as viable endoscopic alternatives to surgical approaches. These techniques have the potential to reduce adverse events, cost, and recovery times. Looking forward, a variety of promising and novel medical devices and endoscopic platforms that target obesity and diabetes are in various phases of development and investigation. The present review aims to discuss the current and forthcoming endoscopic bariatric therapies with emphasis on relevant procedural technique and review of available evidence.

Endoscopic Approach for Major Complications of Bariatric Surgery

As lifestyle and diet patterns have become westernized in East Asia, the prevalence of obesity has rapidly increased. Bariatric surgeries, such as Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and laparoscopic adjustable gastric banding (LAGB), are considered the first-line treatment option in patients with severe obesity. However, postoperative complications have increased and the proper management of these complications, including the use of endoscopic procedures, has become important. The most serious complications, such as leaks and fistulas, can be treated with endoscopic stent placement and injection of fibrin glue, and a novel full-thickness closure over-the-scope clip (OTSC) has been used for treatment of postoperative leaks. Stricture at the gastrojejunal (GJ) anastomosis site after RYGB or incisura angularis in SG can be managed using stents or endoscopic balloon dilation. Dilation of the GJ anastomosis or gastric pouch may lead to failure of weight loss, and the use of endoscopic sclerotherapy, novel endoscopic suturing devices, and OTSCs have been attempted. Intragastric migration of the gastric band can be successfully treated using various endoscopic tools. Endoscopy plays a pivotal role in the management of post-bariatric complications, and close cooperation between endoscopists and bariatric surgeons may further increase the success rate of endoscopic procedures.

New endoscopic procedures for diabetes mellitus type 2 and obesity treatment

BACKGROUND

Obesity continues to be a growing epidemic worldwide. Obese patients have severe comorbidities that make risky and technically demanding the execution of bariatric surgery from both surgical and anesthetic point of view; therefore, the focus of bariatric surgeons is increasingly moving towards minimally invasive, endoscopic techniques.

METHODS

The present review presents and discusses recent endoscopic techniques employed in obesity treatment, their features and results.

RESULTS

Endoscopic treatment can be primary or revisional; we can mainly divide the endoscopic devices into five categories: space-occupying devices, restrictive procedures, bypass liner, aspiration therapy and endoscopic revision of gastric bypass for dilated gastric pouch.

CONCLUSIONS

Endoscopic treatments for obesity are promising techniques for selected patients but each procedure should be tailored on the patient in a multimodal approach.

Endoscopy after bariatric surgery

Obesity is a global epidemic with significant morbidity and mortality. Weight loss results in reduction of health risks and improvement in quality of life, thus representing a goal of paramount importance. Bariatric surgery is the most efficacious choice compared to conservative alternatives including diet, exercise, drugs and behavioral modification to treat obese patients. Following bariatric operations, patients may present with upper gastrointestinal tract complaints that warrant endoscopic evaluation and the various bariatric surgery types are often linked to complications. A subset of these complications necessitates endoscopic interventions for accurate diagnosis and effective, minimal invasive treatment. This review aims to highlight the role of upper gastrointestinal endoscopy in patients who have undergone bariatric surgery to evaluate and potentially treat surgery-related complications and upper gastrointestinal symptoms.

Is Endoluminal Bariatric Therapy a New Paradigm of Treatment for Obesity?

The prevalence of obesity has steadily increased throughout recent decades, and along with it, the costs of caring for the associated comorbid conditions has increased as well. Traditional bariatric surgical procedures generally are safe and effective, but patient acceptance, the risk of minor and sometimes serious complications, costs, and insurance coverage have limited the application of these techniques to the treatment of a minority of patients. Endoluminal techniques represent newer approaches to weight loss that can be used independently or in concert with traditional medical and surgical treatments for obesity, with varying degrees of success. It is anticipated that less invasiveness will increase the appeal across a broader representation of patients, perhaps increasing the number of obese patients who choose an intervention over medical management and possibly resulting in a greater total loss of excess body weight across a population; this may reduce costs involved in treating the complications of weight-related comorbidities. Acceptance of endoluminal bariatric procedures and devices will hinge on proving safety, efficacy, and value.

Revisional Laparoscopic Gastric Pouch Resizing for Inadequate Weight Loss After Roux-en-Y Gastric Bypass

Background

Weight regain due to gastric pouch dilatation after Roux-en-Y gastric bypass (RYGB) is seen more frequently after long-term follow-up. We studied the feasibility and safety of laparoscopic pouch resizing (LPR) for dilated gastric pouch after RYGB associated with inadequate weight loss.

Methods

From 1st June 2011 to 1st September 2013, patients who underwent LPR after failed RYGB were retrospectively compared and analyzed. Data included patient demographics, comorbidity, indication for revision, preoperative weight and BMI, operative time, hospital stay, conversion rate, mean follow-up, body mass index (BMI) loss, percentage excess weight loss (%EWL), reoperation rate, morbidity, and mortality.

Results

Out of 170 revisional bariatric procedures, 32 LPR (27/5, F/M) were performed for dilated gastric pouch after RYGB. The mean age, preoperative weight, and BMI were 38.3 ± 9.3 years, 101.7 ± 22.8 kg, 38.8 ± 6.4 kg/m², respectively. The median operative time and hospital stay were 100 min and 2 days, respectively. All pouch resizing procedures were carried out laparoscopically, with none requiring conversion to open surgery. The overall complication and reoperation rates were 15.6 and 3.1 %, respectively. There were no deaths. The mean follow-up was 14.1 ± 6.2 months. The mean postoperative BMI was 32.8 ± 7.3 kg/m², and the median %EWL was 29.1 %.

Conclusions

LPR is safe and can lead to adequate weight loss. However, long-term follow-up is needed to determine the efficiency and durability of this procedure.

Laparoscopic hand-sewn revisional gastrojejunal plication for weight loss failure after Roux-en-Y gastric bypass

BACKGROUND

Revisional surgery has become a widely accepted alternative for weight loss failure/regain after bariatric surgery. However, it is associated to higher morbi-mortality and lesser weight loss than primary bariatric procedure. Our aims are to present a novel technique for weight loss treatment after failed laparoscopic Roux-en-Y gastric bypass (LRYGB) and to report its short-term results.

METHODS

This is a retrospective analysis of patients submitted to a revisional hand-sewn double-layer gastrojejunal plication (GJP) for treatment of weight loss failure/regain after LRYGB. Analysis of demographics, body mass index (BMI), and percentage of excess weight loss (%EWL) at the 6th month complications, and financial costs involved was included.

RESULTS

Four patients were submitted to revisional GJP. Three patients were female and the mean age at revision was 30 ± 9 years (21-44). The median time interval between LRYGB and GJP was 51 months (24-120). The median BMI at the moment of GJP and the 3rd and 6th month was 35.6 kg/m2 (32.0-37.8), 32.2 kg/m2 (29.7-34.1), and 30.7 kg/m2 (28.1-32.1), respectively. The median %EWL at the 3rd and 6th month was 35.4% (13.6-38.9) and 46.2 % (45.1-55.5), respectively, reaching a cumulative (combined surgeries) %EWL of 62.9% (16.5-67.9) and 71.7% (65.1-77.6), respectively. There were no complications or mortality. Financial costs were significantly lower compared to revisional gastrojejunal stapled reduction (US $1400 cheaper).

CONCLUSION

Revisional GJP is a feasible, safe, and cost-effective novel procedure for treatment of weight loss failure/regain after LRYGB. Mid- and long-term results are necessary in order to establish its real effectiveness.

Treatment of weight regain following roux-en-Y gastric bypass: revision of pouch, creation of new gastrojejunostomy and placement of proximal pericardial patch ring

In the literature, weight regain or failure of weight loss has been reported in up to 35% of patients after Roux-en-Y gastric bypass (RYGB). Several revisional procedures have been suggested to reinitiate further weight loss in this group of patients, and placing a silastic ring around the pouch proximal to the gastrojejunostomy is one among those procedures. The aim of our study is to evaluate and compare the safety and efficacy of salvage banding using a pericardial patch after RYGB for further weight loss. Between December 2009 and April 2013, a total of 46 patients underwent revision with pericardial patch ring after RYGB for weight regain/failure of weight loss. A retrospective review of a prospectively collected database was performed, noting the outcomes and complications of the procedure. The mean body mass index at the time of revision was 40.1 ± 6.8 kg/m2. Mean percentage of excess weight loss was 23.4 ± 15.7%, 39.0 ± 27.4%, and 18.9 ± 20.5% at 6, 12 and 24 months after revision, respectively. Eight (17.4%) patients required a total of 11 readmissions due to nausea, vomiting, dysphagia and abdominal pain. Six (13.0%) patients underwent a total of six reoperations, including four patients with laparoscopic removal of the pericardial patch and another revision of RYGB, and two patients with repair of perforated ulcers. Revision with pericardial patch ring after gastric bypass for weight regain or failure of weight loss may not be feasible, safe and effective.

Critical appraisal of salvage banding for weight loss failure after gastric bypass

BACKGROUND

Placement of an adjustable gastric band (AGB) over the gastric pouch after RYGB failure has had varied results. The aim of this study was to evaluate safety and outcomes of AGB after RYGB failure.

METHODS

Twenty-eight patients who underwent laparoscopic placement of an AGB around the gastric pouch as a revisional procedure for inadequate weight loss or recidivism after RYGB between 2008-2011 were identified.

RESULTS

Twenty-four (86%) patients had a dilated gastric pouch and/or stoma. The mean operative and adhesiolysis times were 137.9±52.3 minutes and 83±51 minutes, respectively. History of a previous open RYGB was associated with a longer adhesiolysis time (P = .03). Three (11%) major intraoperative and 5 (18%) early postoperative complications occurred. Late complications (all requiring band removal) were observed in 6 (21%) patients and included ineffectiveness (n = 2), dysphagia/esophageal dilation (n = 2), band erosion (n = 1), and peritonitis (n = 1). In all 4 patients with a normal-sized pouch and stoma at the time of band placement, the band was removed. After a mean follow-up of 38.3±14.8 months, the mean body mass index (BMI) change and median excess weight loss (EWL) after salvage banding were -3.6±4.5 kg/m(2) and 12.7%, respectively. In the subset of patients with a dilated pouch/stoma, BMI less than 42 kg/m(2) at the time of band placement was associated with a significantly higher EWL (41.4%±37.0%) compared with a baseline BMI>42 kg/m(2) (12.1%±7.2%, P = .03).

CONCLUSIONS

Salvage banding is technically challenging due to dense adhesions, carries significant morbidity, and is associated with only 13% additional EWL. However, this approach may still be an option in carefully selected patients, such as those with previous laparoscopic RYGB who have a dilated pouch and/or stoma and lower BMI.

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.

Relationship between gut hormones and glucose homeostasis after bariatric surgery

Type 2 diabetes mellitus (T2D) is emerging as a worldwide public health problem, and is mainly associated with an increased incidence of obesity. Bariatric surgery is currently considered the most effective treatment for severely obese patients. After bariatric surgery, T2D patients have shown a significant improvement in glycemic control, even before substantial weight loss and often discontinuation of medication for diabetes control. A central role for enteroendocrine cells from the epithelium of the gastrointestinal tract has been speculated in this postoperative phenomenon. These cells produce and secrete polypeptides - gut hormones - that are associated with regulating energy intake and glucose homeostasis through modulation of peripheral target organs, including the endocrine pancreas. This article reviews and discusses the biological actions of the gut hormones ghrelin, cholecystokinin, incretins, enteroglucagon, and Peptide YY, all of which were recently identified as potential candidates for mediators of glycemic control after bariatric surgery. In conclusion, current data reinforce the hypothesis that T2D reversion after bariatric surgery may be related to glycemic homeostasis developed by the intestine.

Emerging technologies and procedures: results of an online survey and real-time poll

BACKGROUND

Many new techniques and bariatric endoluminal procedures are being developed and used for the treatment of obesity. Clear guidelines or opinions of the new techniques are not readily available. The aim of this study was to gauge the level of interest and opinions of bariatric surgeons regarding these new techniques, using online and real poll surveys.

METHODS

The American Society for Metabolic and Bariatric Surgery (ASMBS) Emerging Technologies committee developed a questionnaire that was distributed among the membership and conducted a live poll of attendees at Obesity Week 2013. Opinions of new technologies and techniques by practitioners were assessed.

RESULTS

A total of 134 responses to the questionnaire were returned. Most responses (79%) expressed the belief that new bariatric techniques are needed to improve the practice of bariatric and metabolic surgery. The responses describing the effects of new procedures and technology as beneficial were (1) increased interest from patients or referring physicians (94%), (2) expanded indications for intervention (93%), and (3) lower risk intervention (96%). Nearly all respondents (90.2%) identified value in informational guidelines on new technologies and procedures, and most (88.7%) agreed that the ASMBS should coordinate clinical trials or registries to evaluate these therapies.

CONCLUSION

Although most bariatric and metabolic surgeons agree that new endoluminal surgical techniques are beneficial, most also are unable to offer the procedures to their patients without more clinical evidence and clear guidelines from the society.

The cooperation between endoscopists and surgeons in treating complications of bariatric surgery

The results of lifestyle interventions and pharmacotherapy are disappointing in severe obesity which is characterised by premature death and many obesity-associated co-morbidities. Only surgery may achieve significant and durable weight losses associated with increased life expectancy and improvement of co-morbidities. Bariatric surgery involves the gastrointestinal tract and may therefore increase gastrointestinal complaints. Bariatric surgery may also result in complications which in many cases can be solved by endoscopic interventions. This requires a close cooperation between surgeons and endoscopists. This chapter will concentrate on the most commonly performed operations such as the Roux-en-Y gastric bypass, the adjustable gastric banding and the sleeve gastrectomy, in the majority of cases performed by laparoscopy. Operations such as the vertical banded gastroplasty and the biliopancreatic diversion with or without duodenal switch will not be discussed at length as patients with these operations will not be encountered frequently and their management can be found under the headings of the other operations.

Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force

BACKGROUND

Reoperative bariatric surgery has become a common practice in many bariatric surgery programs. There is currently little evidence-based guidance regarding specific indications and outcomes for reoperative bariatric surgery. A task force was convened to review the current evidence regarding reoperative bariatric surgery. The aim of the review was to identify procedure-specific indications and outcomes for reoperative procedures.

METHODS

Literature search was conducted to identify studies reporting indications for and outcomes after reoperative bariatric surgery. Specifically, operations to treat complications, failed weight loss, and weight regain were evaluated. Abstract and manuscript reviews were completed by the task force members to identify, grade, and categorize relevant studies.

RESULTS

A total of 819 articles were identified in the initial search. After review for inclusion criteria and data quality, 175 articles were included in the systematic review and analysis. The majority of published studies are single center retrospective reviews. The evidence supporting reoperative surgery for acute and chronic complications is described. The evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. Procedure-specific outcomes are described. Complication rates are generally reported to be higher after reoperative surgery compared to primary surgery.

CONCLUSION

The indications and outcomes for reoperative bariatric surgery are procedure-specific but the current evidence does support additional treatment for persistent obesity, co-morbid disease, and complications.