Laparoscopic conversion of Roux-en-Y gastric bypass to sleeve gastrectomy for intractable marginal ulcer

Challenges in Bariatric Surgery: Outcomes in Patients Having Three or More Bariatric Procedures

INTRODUCTION

Over the last two decades, a progressive increase in failure rate of bariatric surgery (BS) has occurred in conjunction with an exponential increase in BS worldwide. Bariatric surgeons are confronted with challenging situations in patients with a complex bariatric history. In this study, we aim to evaluate the feasibility and outcomes of revisional BS in patients with at least two or more previous bariatric procedures.

METHODS

Data were retrospectively retrieved from a prospectively held database of bariatric procedures performed at our tertiary referral bariatric center and included procedures done from February 2013 up to April 2019 by a single center.

RESULTS

Thirty patients underwent a third bariatric procedure. The median age was 40 (18-57) and 54 (27-69) years at the time of the first and the last procedures, respectively. Laparoscopic adjustable gastric banding was the first procedure in 26 patients. The complication rate was 33%; no patient required additional surgery because of postoperative complications. A total weight loss of 29.6% and an excess loss of 53.4% were obtained at a mean follow-up of 61 months after the last redo bariatric procedure.

CONCLUSION

This study indicates that redo BS either conversional or revisional is feasible and effective in patients with a complex bariatric history including two or more previous procedures. Careful patients' selection is mandatory and extensive information should be given on the increased risk of postoperative complications.

Considerations regarding sarcoidosis in the bariatric surgical patient

The sarcoidosis patient who seeks surgical management for obesity presents many challenges. The interaction between sarcoidosis and obesity complicates both disorders and creates special issues to consider when contemplating surgery. This manuscript will review the approach to pre- and postoperative management of the sarcoidosis patient undergoing bariatric surgery.

One-Anastomosis Jejunal Interposition with Gastric Remnant Resection (Branco-Zorron Switch) for Severe Recurrent Hyperinsulinemic Hypoglycemia after Gastric Bypass for Morbid Obesity

BACKGROUND

The anatomical and physiological changes after Roux-en-Y gastric bypass for morbid obesity can lead to severe hyperinsulinemic hypoglycemia with neuroglycopenia in a small percentage of patients. The exact physiologic mechanism is not completely understood. Surgical reversal to the original anatomy and distal or total pancreatectomy are current therapeutic options to reverse the hypoglycemic effect, with substantial associated morbidity. Our group reports a pilot clinical series of a novel surgical technique using one-anastomosis jejunal interposition with gastric remnant resection (Branco-Zorron Switch).

METHODS

Patients with severe symptomatic hyperinsulinemic hypoglycemia refractory to conservative therapy were treated using the technique. The procedure started with resection of the remnant stomach close to pylorus. The alimentary limb was sectioned at 20 cm from the gastrojejunal anastomosis, and the rest of the alimentary limb was resected until the Y-Roux anastomosis. A hand-sutured anastomosis was then performed with the proximal alimentary limb and the remnant antrum.

RESULTS

Four patients were successfully submitted to the procedure with reversal of the symptomatology and normalization of insulin levels, postprandial glucose levels, and oral glucose tolerance test, with a mean follow-up of 24.3 months. Mean operative time was 188 min, and patients recovered without postoperative complications.

CONCLUSION

Patients suffering from severe hyperinsulinemic hypoglycemia after gastric bypass may be efficiently treated by this innovative procedure, avoiding extreme surgical therapy such as pancreatectomy or restoring the gastric anatomy, while still maintaining sustained weight loss. Studies with larger series and longer follow-up are still needed to define the role of this therapy in managing this entity.