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Bastos ELS, Salgado W, Dantas ACB, Onzi TR, Silva LB, Albano Á, Tristão LS, Dos Santos CL, Silvinato A, Bernardo WM. Medium and Long-Term Weight Loss After Revisional Bariatric Surgery: A Systematic Review and Meta-Analysis. Obes Surg 2024; 34:1917-1928. [PMID: 38573390 DOI: 10.1007/s11695-024-07206-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 03/23/2024] [Accepted: 03/28/2024] [Indexed: 04/05/2024]
Abstract
Despite the current increase in revisional bariatric surgery (RBS), data on the sustainability of weight loss remain unclear. A systematic review and meta-analysis were performed to assess weight loss outcomes in adult patients undergoing RBS with follow-up > 2 years. Twenty-eight observational studies (n = 2213 patients) were included. The %TWL was 27.2 (95%CI = 23.7 to 30.6), and there was a drop in BMI of 10.2 kg/m2 (95%CI = - 11.6 to - 8.7). The %EWL was 54.8 (95%CI = 47.2 to 62.4) but with a high risk of publication bias (Egger's test = 0.003). The overall quality of evidence was very low. Our data reinforce that current evidence on RBS is mainly based on low-quality observational studies, and further higher-quality studies are needed to support evidence-based practice.
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Affiliation(s)
- Eduardo L S Bastos
- Department of Gastrointestinal Surgery, Marília School of Medicine, Marília, Brazil.
| | - Wilson Salgado
- Department of Surgery and Anatomy, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Anna C B Dantas
- Bariatric and Metabolic Surgery Unit, University of São Paulo, São Paulo, Brazil
| | - Tiago R Onzi
- Department of Surgery, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Lyz B Silva
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Álvaro Albano
- Bariatric and Metabolic Service, Santa Casa de Misericórdia de Itabuna, Bahia, Brazil
| | - Luca S Tristão
- Department of Evidence Based Medicine, Lusíada University Center, Santos, Brazil
| | - Clara L Dos Santos
- Department of Evidence Based Medicine, Lusíada University Center, Santos, Brazil
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2
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Aleassa EM, Papasavas P, Augustin T, Khorgami Z, Benson-Davies S, Ghiassi S, Carter J, Nimeri A. American Society for Metabolic and Bariatric Surgery literature review on the effect of Roux-en-Y gastric bypass limb lengths on outcomes. Surg Obes Relat Dis 2023; 19:755-762. [PMID: 37268517 DOI: 10.1016/j.soard.2023.04.298] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 04/02/2023] [Indexed: 06/04/2023]
Abstract
This literature review is issued by the American Society for Metabolic and Bariatric Surgery regarding limb lengths in Roux-en-Y gastric bypass (RYGB) and their effect on metabolic and bariatric outcomes. Limbs in RYGB consist of the alimentary and biliopancreatic limbs and the common channel. Variation of limb lengths in primary RYGB and as a revisional option for weight recurrence after RYGB are described in this review.
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Affiliation(s)
- Essa M Aleassa
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.
| | | | - Toms Augustin
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Zhamak Khorgami
- Department of Surgery, University of Oklahoma College of Community Medicine, Tulsa, Oklahoma
| | - Sue Benson-Davies
- Department of Surgery, Sanford School of Medicine, University of South Dakota, Vermillion, South Dakota
| | - Saber Ghiassi
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jonathan Carter
- Department of Surgery, University of California, San Francisco, California
| | - Abdelrahman Nimeri
- Department of Surgery, Carolinas Medical Center, University of North Carolina, Charlotte, North Carolina
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3
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Lee MH, Almalki OM, Lee WJ, Soong TC, Chen SC. Outcomes of laparoscopic revisional conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: Diff erent strategies for obese and non-obese Asian patients. Asian J Surg 2023; 46:761-766. [PMID: 35843822 DOI: 10.1016/j.asjsur.2022.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 05/05/2022] [Accepted: 07/06/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Sleeve gastrectomy (SG) is the most performed bariatric procedure now. Some patients would necessitate a revision to Roux-en-Y gastric bypass (RYGB) as a salvage procedure for intractable gastroesophageal reflux disease (GERD). However, outcome of the revision in Asians with co-existed obesity and those non-obese is not clear. METHODS We retrospectively reviewed the data of patients who underwent revisional laparoscopic RYGB after SG between 2007 and 2019 for intractable GERD with data of one year follow-up. Pre-operative clinical data, perioperative outcomes, GERD symptoms, weight loss and medication details were analyzed. Patients were classified into those with body mass index (BMI) ≥ 25 and < 25 kg/m2. RESULTS Fifty-five patients (44 women, 11 men; mean age 42.5 years) were included. Mean interval from the initial SG to revision surgery was 51.2 months (range, 5-132). Mean body mass index before SG was 34.6 kg/m2, whereas that before revision surgery was 27.6 kg/m2. All the patients required continue proton pump inhibitor (PPI) to control the GERD symptoms before surgery. Among them, 36 (65.4%) patients in the obese group received long BP limb (>100 cm) RYGB for associated obesity but the common channel was assured to ≥ 400 cm or 70% of small bowel length, the other 19 (34.6%) patients in the non-obese group received standard BP limb (<100 cm) RYGB. There was no difference in basic characters between the two groups before revision surgery except a higher mean BMI (30.0 vs. 22.2 kg/m2, p < 0.001), blood pressure and triglyceride in obese group. One year after revision surgery, all the patients had improved GERD symptoms but only 33 (60%) can completely wave PPI, without difference between the 2 groups. Obese group with a long BP limb RYGB had a significant higher % total weight loss (TWL) than non-obese group (%TWL 9.1% vs. -3.1%, p = 0.005). CONCLUSION Laparoscopic revision to RYGB is a safe and effective treatment for patients with intractable GERD after SG but some patients may still have residual GERD symptoms. Using a modified RYGB technique in revision surgery may help in weight reduction for obese Asian patients.
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Affiliation(s)
- Ming-Hsien Lee
- Metabolic & Bariatric Surgical Department, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taiwan, ROC
| | - Owaid M Almalki
- Department of Surgery, College of Medicine, Taif University, Saudi Arabia
| | - Wei-Jei Lee
- Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan, ROC; Department of Asia Obesity Medical Research Center, E-DA Hospital, Taiwan, ROC.
| | - Tien-Chou Soong
- Department of Asia Obesity Medical Research Center, E-DA Hospital, Taiwan, ROC; Department of Weight Loss and Health Management Center, E-DA Dachang Hospital, Kaohsiung, Taiwan, ROC; College of Medicine, I-Shou University, Kaohsiung, Taiwan, ROC
| | - Shu-Chun Chen
- Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan, ROC
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4
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Hort A, Cheng Q, Morosin T, Yoon P, Talbot M. Optimal common limb length in
Roux‐en‐Y
gastric bypass surgery: is it important for an ideal outcome? – a systematic review. ANZ J Surg 2022; 93:851-858. [PMID: 36480354 DOI: 10.1111/ans.18192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/07/2022] [Accepted: 11/27/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND In Roux-en-Y gastric bypass (RYGB) surgery the common limb length (CLL) is thought to significantly impact on nutritional and metabolic outcomes. However, there has been little focus on establishing routine standardized CLL measurements and its subsequent effect on weight loss and nutritional status. This review aimed to determine the effect of variations of CLL in RYGB surgery on post-operative outcomes, particularly nutritional status, while considering the need for routine CLL measurements in addition to measuring biliopancreatic limb and alimentary limb lengths. METHODS A systematic review was performed in accordance with the PRISMA guidelines. All English language articles addressing CLL and impact on weight loss, nutritional and metabolic outcomes were retrieved and reviewed. RESULTS Thirteen relevant studies were identified with CLLs varying from 76 to >600 cm. No significant difference in total body weight loss or excess weight loss was observed. Significant metabolic improvements occurred with shorter CLLs. Nutritional deficiencies were more severe when the CLL was <400 cm. CONCLUSION The data from this systematic review suggests that reasonable weight loss and positive impacts on metabolic outcomes can be achieved with CLLs of >400 cm.
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Affiliation(s)
- Amy Hort
- Department of Surgery Westmead Hospital Sydney New South Wales Australia
- Department of Surgery, The School of Medicine The University of Sydney Sydney New South Wales Australia
| | - Qiuye Cheng
- Department of Surgery Westmead Hospital Sydney New South Wales Australia
- UNSW St George and Sutherland Clinical School Sydney New South Wales Australia
| | - Tia Morosin
- Department of Surgery Westmead Hospital Sydney New South Wales Australia
| | - Peter Yoon
- Department of Surgery Westmead Hospital Sydney New South Wales Australia
| | - Michael Talbot
- UNSW St George and Sutherland Clinical School Sydney New South Wales Australia
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De Luca M, Piatto G, Sartori A, Zese M, Lunardi C, Targa S, Giardiello C, Gentileschi P, Himpens J. 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. Obes Surg 2022; 32:3194-3204. [PMID: 35763129 DOI: 10.1007/s11695-022-06174-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 03/13/2022] [Accepted: 03/18/2022] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Maurizio De Luca
- Chief Department of General and Metabolic Surgery, Rovigo Hospital, Rovigo, Italy.
| | - Giacomo Piatto
- Department of Surgery, San Valentino Montebelluna Hospital, Treviso, Italy
| | - Alberto Sartori
- Department of Surgery, San Valentino Montebelluna Hospital, Treviso, Italy
| | - Monica Zese
- Department of General and Metabolic Surgery, Rovigo Hospital, Rovigo, Italy
| | - Cesare Lunardi
- Department of Surgery, San Valentino Montebelluna Hospital, Treviso, Italy
| | - Simone Targa
- Department of Surgery, Adria Hospital, Rovigo, Italy
| | - Cristiano Giardiello
- Department of Emergency and Metabolic Surgery, Pineta Grande Hospital, Caserta, Italy
| | - Paolo Gentileschi
- Department of Bariatric and Metabolic Surgery, San Carlo Nancy Hospital, Rome, Italy
| | - Jacques Himpens
- Metabolic & Obesity Unit, Chirec Delta Hospital, Brussels, Belgium
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Tourky M, Issa M, Salman MA, Salman A, Shaaban HED, Safina A, Elias AAK, Elewa A, Noureldin K, Mahmoud AA, Dorra A, Farah M, Gebril M, Gasemelseed Fadlallah Elhaj M, Barbary H. Nutritional Complications After Laparoscopic Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass: A Comparative Systematic Review and Meta-Analysis. Cureus 2022; 14:e21114. [PMID: 35036236 PMCID: PMC8752406 DOI: 10.7759/cureus.21114] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 12/29/2022] Open
Abstract
A systematic review and meta-analysis were carried out involving studies that compared the nutritional complications of Roux-en-Y gastric bypass (RYGB) and one-anastomosis gastric bypass (OAGB); these included the incidence of malnutrition as well as deficiencies of other nutritional elements, such as total protein, albumin, calcium and iron. A comprehensive search strategy was implemented in PubMed, Embase, and the Cochrane Library. Effect sizes included the pooled odds ratios (ORs) and 95% confidence intervals (95% CIs), as well as mean differences (MDs) and 95% CIs of the percentage total weight loss (%TWL) and excess weight loss percentage (%EWL). Thirteen studies were included (12,964 patients, 66.27% females, 53.82% underwent OAGB). At the longest follow-up period (≥3 years), OAGB was associated with significantly higher %TWL (MD=5.41%, 95%CI, 1.52 to 9.29) and %EWL (MD=13.81%, 95%CI, 9.60 to 18.02) compared to RYGB. However, OAGB procedures were associated with malnutrition (OR=3.00, 95%CI, 1.68 to 5.36, p<0.0001), hypoalbuminemia (OR=2.38, 95%CI, 1.65 to 3.43, p<0.0001), hypoproteinemia (OR=1.85, 95%CI, 1.09 to 3.14, p=0.022), anemia (OR=1.38, 95%CI, 1.08 to 1.77, p=0.011), and hypocalcemia (OR=1.78, 95%CI, 1.01 to 3.12, p=0.046). On subgroup analyses, the proportions of anemia and hypoalbuminemia remained significantly higher at longer follow-up periods and in studies published in Asia. Despite the favorable weight loss profile, the unfavorable nutritional consequences of OAGB merits further investigations to explore the malabsorptive element, ethnic variation, and the role of biliopancreatic limb length.
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Affiliation(s)
- Mohamed Tourky
- General Surgery, Great Western Hospital, NHS Foundation Trust, Swindon, GBR
| | - Mohamed Issa
- Surgery, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, GBR
- Surgery, Prince Charles Hospital, Myrther Tydfil, GBR
| | - Mohamed A Salman
- Surgery, KasrAlainy School of Medicine, Cairo University, Cairo, EGY
| | - Ahmed Salman
- Internal Medicine, KasrAlainy School of Medicine, Cairo University, Cairo, EGY
| | - Hossam El-Din Shaaban
- Gastroenterology and Hepatology, National Hepatology and Tropical Medicine Research Institute, Cairo, EGY
| | - Ahmed Safina
- General Surgery, KasrAlainy School of Medicine, Cairo University, Cairo, EGY
| | - Abd Al-Kareem Elias
- General Surgery, Faculty of Medicine, Al-Azhar University, Assuit Branch, Kafr El-Sheikh, EGY
| | - Ahmed Elewa
- General Laparoscopic and Hepato-Pancreatico-Biliary (HBP) Surgery, National Hepatology and Tropical Medicine Research Institute, Cairo, EGY
| | - Khaled Noureldin
- General Surgery, KasrAlainy School of Medicine, Cairo University, Cairo, EGY
- Colorectal Surgery, Southend University Hospital, Mid and South Essex NHS Foundation Trust, Essex, GBR
| | | | - Ahmed Dorra
- Surgery, Leighton Hospital, Mid Cheshire Hospitals NHS Foundation Trust, Crewe, GBR
| | - Mohamed Farah
- Urology, Sunderland Royal Hospital, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, GBR
| | - Mahmoud Gebril
- General and Laparoscopic Surgery, Al Qabary Specialized Oncology Center, Alexandria, EGY
| | | | - Hesham Barbary
- General and Laparoscopic Surgery, El Zaitoun Specialized Hospital, Cairo, EGY
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7
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Hamed H, Ali M, Elmahdy Y. Types, Safety, and Efficacy of Limb Distalization for Inadequate Weight Loss After Roux-en-Y Gastric Bypass: A Systematic Review and Meta-analysis With a Call for Standardized Terminology. Ann Surg 2021; 274:271-280. [PMID: 32941271 DOI: 10.1097/sla.0000000000004485] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Comprehensive classification and evaluation of the outcome of limb distalization (LD) for inadequate weight loss after roux-en-y gastric bypass (RYGB). BACKGROUND Limb distalization is a revisional malabsorptive procedure for the management of inadequate weight loss after RYGB. Multiple studies with small sample sizes reported the outcome of LD. This meta-analysis aims to reach a higher level of evidence regarding the safety and efficacy of the procedure. METHODS A systematic search, including all studies on LD for management of inadequate weight loss after RYGB. The search engines included were PubMed, Embase, Web of Science, Cochrane Library, Scopus, and EBSCOhost. RESULTS Fourteen studies were included. The pooled estimates of the mid-term percentage of excess weight loss (%EWL), diabetic, and hypertension remission were 50.8%, 69.9%, and 59.8%, respectively. The rate of surgical revision for the management of protein-energy malnutrition (PEM) was 17.1%. The %EWL was significantly higher with older age and good response to index surgery (P = 0.01, 0.04, respectively). Less total alimentary limb length was not associated with better %EWL (P = 0.9), but it was significantly associated with severe PEM (P = 0.01). CONCLUSIONS LD has an encouraging rate of resolution of comorbidities. A judicious patient selection is essential for better weight loss after LD. Type I LD with total alimentary limb length ≥350 cm was associated with less risk of malnutrition. PEM is a life-threatening complication that may require revisional surgery years after LD. Future studies on LD, adopting standardized surgical practice and terminology, will allow a more conclusive assessment of the outcome of the procedure.
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Affiliation(s)
- Hosam Hamed
- Gastrointestinal surgical center (GISC), Faculty of Medicine, Mansoura University, Mansoura, Egypt
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8
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Kraljević M, Köstler T, Süsstrunk J, Lazaridis II, Taheri A, Zingg U, Delko T. Revisional Surgery for Insufficient Loss or Regain of Weight After Roux-en-Y Gastric Bypass: Biliopancreatic Limb Length Matters. Obes Surg 2021; 30:804-811. [PMID: 31863410 DOI: 10.1007/s11695-019-04348-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Weight regain after laparoscopic Roux-en-Y gastric bypass (RYGB) occurs in up to 35% of patients. Revisional surgery may be applied. Conversion from RYGB to a long biliopancreatic limb (BPL) RYGB is a potential option for revisional surgery and short-term results are promising. METHODS All patients who underwent conversion to long BPL RYGB due to weight loss failure, defined as excess weight loss (EWL) < 50% or body mass index (BMI) > 35 kg/m2, were assessed. Proximal RYGB or very very long limb RYGB (VVLL RYGB) was modified by shortening of the total alimentary limb length (TALL) to create a long BPL. RESULTS A total of 28 patients received revisional surgery from either PRYGB (n = 22) or VVLL RYGB (n = 6). Mean age at operation was 45.3 ± 10.4 years, with 78% females. Mean prerevisional BMI was 41.7 ± 4.4 kg/m2. Mean time to revision was 76.5 ± 38.5 months. Limb lengths were 150 cm (95% CI 133-156 cm) for RL and 100 cm (95% CI 97-113 cm) for CC, thus providing a total median alimentary limb length of 250 (95% CI 238-260 cm). Additional %EWL and TWL improved significantly in long-term. Five years postoperatively, all patients (n = 9) had an EWL% > 50%. Six patients (21.4%) required reoperation due to severe malnutrition during the postoperative course. CONCLUSION Conversion from RYGB to BPL RYGB leads to significant additional weight loss in the long term. However, the morbidity is relevant, especially severe protein malnutrition and the frequency of revisional surgery. Therefore, this type of surgery should not be done routinely.
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Affiliation(s)
- Marko Kraljević
- Department of General Surgery, Limmattal Hospital, 8952, Zurich-Schlieren, Switzerland
| | - Thomas Köstler
- Department of General Surgery, Limmattal Hospital, 8952, Zurich-Schlieren, Switzerland
| | - Julian Süsstrunk
- Department of General Surgery, Limmattal Hospital, 8952, Zurich-Schlieren, Switzerland
| | - Ioannis I Lazaridis
- Clarunis, University Center for Gastrointestinal and Liver Diseases, 4002, Basel, Switzerland
| | - Amy Taheri
- Institute of Clinical Chemistry, University Hospital Zurich, 8952, Zurich-Schlieren, Switzerland
| | - Urs Zingg
- Department of General Surgery, Limmattal Hospital, 8952, Zurich-Schlieren, Switzerland
| | - Tarik Delko
- Clarunis, University Center for Gastrointestinal and Liver Diseases, 4002, Basel, Switzerland.
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Abstract
Revisional bariatric surgery is a growing subset of all bariatric procedures. Although revisions can be associated with higher morbidity rates and less optimal outcomes than those seen with primary procedures, they can be safely performed, with excellent outcomes and improved quality of life for patients. Facility and familiarity with revisional principles and techniques are necessary components of bariatric surgical practice.
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Affiliation(s)
- Katelin Mirkin
- Minimally Invasive and Bariatric Surgery, Penn State Hershey Medical Center
| | - Vamsi V Alli
- Minimally Invasive and Bariatric Surgery, Penn State Hershey Medical Center
| | - Ann M Rogers
- Minimally Invasive and Bariatric Surgery, Penn State Hershey Medical Center.
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10
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Bariatric Surgery-How Much Malabsorption Do We Need?-A Review of Various Limb Lengths in Different Gastric Bypass Procedures. J Clin Med 2021; 10:jcm10040674. [PMID: 33578635 PMCID: PMC7916324 DOI: 10.3390/jcm10040674] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/06/2021] [Accepted: 02/07/2021] [Indexed: 12/18/2022] Open
Abstract
The number of obese individuals worldwide continues to increase every year, thus, the number of bariatric/metabolic operations performed is on a constant rise as well. Beside exclusively restrictive procedures, most of the bariatric operations have a more or less malabsorptive component. Several different bypass procedures exist alongside each other today and each type of bypass is performed using a distinct technique. Furthermore, the length of the bypassed intestine may differ as well. One might add that the operations are performed differently in different parts of the world and have been changing and evolving over time. This review evaluates the most frequently performed bariatric bypass procedures (and their variations) worldwide: Roux-en-Y Gastric Bypass, One-Anastomosis Gastric Bypass, Single-Anastomosis Duodeno-Ileal Bypass + Sleeve Gastrectomy, Biliopancreatic Diversion + Duodenal Switch and operations due to weight regain. The evaluation of the procedures and different limb lengths focusses on weight loss, remission of comorbidities and the risk of malnutrition and deficiencies. This narrative review does not aim at synthesizing quantitative data. Rather, it provides a summary of carefully selected, high-quality studies to serve as examples and to draw tentative conclusions on the effects of the bypass procedures mentioned above. In conclusion, it is important to carefully choose the procedure and small bowel length excluded from the food passage suited best to each individual patient. A balance has to be achieved between sufficient weight loss and remission of comorbidities, as well as a low risk of deficiencies and malnutrition. In any case, at least 300 cm of small bowel should always remain in the food stream to prevent the development of deficiencies and malnutrition.
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11
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Almalki OM, Soong TC, Lee WJ, Chen JC, Wu CC, Lee YC. Variation in Small Bowel Length and Its Influence on the Outcomes of Sleeve Gastrectomy. Obes Surg 2020; 31:36-42. [PMID: 32914323 DOI: 10.1007/s11695-020-04958-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/28/2020] [Accepted: 09/02/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Small bowel length is drawing attention in the development of gastrointestinal bariatric/metabolic surgery, but the importance of the length of the small bowel in bariatric/metabolic is not clear. The present study was conducted to investigate variations in small bowel length and their clinical significance in patients undergoing laparoscopic sleeve gastrectomy (LSG). MATERIALS AND METHODS Small bowel length was measured in 620 patients diagnosed with obesity who underwent LSG between March 2014 and August 2018. Prospectively obtained demographic and clinical data were investigated, focusing on the association between small bowel length and weight loss. RESULTS Small bowel length varied widely among patients (mean 739.8 + 115.7 cm, range 380-1050 cm). Linear regression analysis revealed a significant association between small bowel length and body height, body weight, waist circumference, and serum levels of low-density lipoprotein cholesterol, hemoglobin, C-peptide, glycated hemoglobin (A1C), and gamma-glutamyl transferase (r-GT). Multivariate analysis confirmed that body height and serum A1C% levels independently predicted small bowel length in bariatric patients, strongly with body height (p < 0.001) but weakly with A1C%(p = 0.021). One-year follow-up rate was 75.3% (467/620), and small bowel length did not influence weight loss or the reduction of obesity related cardiovascular risk factors after LSG. CONCLUSION In this study, small bowel length varied widely among bariatric patients and was strongly associated with body height and weakly with serum A1C levels. Small bowel length has no significant role in weight loss or the resolution of cardiovascular risk factors after LSG.
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Affiliation(s)
- Owaid M Almalki
- Department of Surgery, College of Medicine, Taif University, Ta'if, Saudi Arabia.,Department of Surgery, Min-Sheng General Hospital, No. 168, Ching Kuo Road, Taoyuan, Taiwan
| | - Tien-Chou Soong
- Department of Weight Loss and Health Management Center, E-DA Dachang Hospital, Kaohsiung, Taiwan.,Department of Asia Obesity Medical Research Center, E-DA Hospital, Kaohsiung, Taiwan.,College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Wei-Jei Lee
- Department of Surgery, Min-Sheng General Hospital, No. 168, Ching Kuo Road, Taoyuan, Taiwan.
| | - Jung-Chien Chen
- Department of Surgery, Min-Sheng General Hospital, No. 168, Ching Kuo Road, Taoyuan, Taiwan
| | - Chun-Chi Wu
- Department of Surgery, Min-Sheng General Hospital, No. 168, Ching Kuo Road, Taoyuan, Taiwan
| | - Yi-Chih Lee
- Department of International Business, Chien Hsin University, Taoyuan, Taiwan
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Biobaku F, Ghanim H, Monte SV, Caruana JA, Dandona P. Bariatric Surgery: Remission of Inflammation, Cardiometabolic Benefits, and Common Adverse Effects. J Endocr Soc 2020; 4:bvaa049. [PMID: 32775937 PMCID: PMC7402590 DOI: 10.1210/jendso/bvaa049] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 08/03/2020] [Indexed: 02/07/2023] Open
Abstract
Obesity is associated with increased mortality as a result of several comorbidities which occur in tandem with the obese state. Chronic inflammation is well documented in obesity, and evidence from numerous studies support the notion that the increased inflammation in individuals with obesity accentuates the comorbidities seen in this condition. The remission of comorbidities such as metabolic, cardiovascular, and neurological complications occurs following bariatric procedures. Bariatric surgery significantly reduces mortality and results in remarkable weight loss and reversal in several obesity-related comorbidities. There is indisputable evidence that the resolution of inflammation that occurs after bariatric surgery mitigates some of these comorbidities. With the increasing use of bariatric surgery for the treatment of severe obesity, it is pivotal to elucidate the underlying mechanisms responsible for the notable improvements seen after the procedure. This review summarizes underlying mechanisms responsible for the remission of obesity-related abnormalities and discusses the common adverse effects of bariatric surgery. Well-stratified, large-scale studies are still needed for a proper evaluation of these underlying mechanisms.
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Affiliation(s)
- Fatimo Biobaku
- Division of Endocrinology, Diabetes and Metabolism, State University of New York at Buffalo, New York
| | - Husam Ghanim
- Division of Endocrinology, Diabetes and Metabolism, State University of New York at Buffalo, New York
| | - Scott V Monte
- Synergy Bariatrics (Erie County Medical Center), Williamsville, NY
| | - Joseph A Caruana
- Synergy Bariatrics (Erie County Medical Center), Williamsville, NY
| | - Paresh Dandona
- Division of Endocrinology, Diabetes and Metabolism, State University of New York at Buffalo, New York
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Ortega-Serrano J, Kraus-Fischer G, Alfonso-Ballester R, Cassinello-Fernández N. Shortening of the Common Channel as a Rescue Surgery After Gastric Bypass Failure. Obes Surg 2020; 30:4760-4767. [PMID: 32691399 DOI: 10.1007/s11695-020-04854-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND After Roux-en-Y gastric bypass (RYGB), up to 30% failures in weight loss have been reported. Among multiple solutions available, we report our experience with shortening of the common channel (SCC) by performing a limb distalization of the alimentary or the biliopancreatic limb. SETTINGS University Hospital. METHODS We reviewed data from 23 patients that underwent limb distalization between 2001 and 2019 due to inadequate weight loss after an initial RYGB in our center. All patients who failed to achieve an excess weight loss reduction of > 50% or maintained a body mass index (BMI) above 35 kg/m2 were included. Multiple variables were analyzed during the follow-up at five time points: initial, after RYGB, before SCC, after SCC, and current. RESULTS The mean BMI prior to the RYGB was 51.8 kg/m2, after RYGB was 37.6 kg/m2, before SCC was 43.6 kg/m2, after SCC was 36.1 kg/m2, and the final BMI was 36.3 kg/m2. No morbidity was seen after SCC. Long-term associated nutritional deficiencies were only identified in 3 patients which had iron deficiency and 1 patient with vitamin D deficiency. Patients with associated comorbidities significantly improved or were withdrawn from medications after the RYGB, with minor variations after SCC. CONCLUSIONS Limb distalization with SCC is a safe and effective technique for patients who failed to achieve an adequate weight loss after RYGB. There is a slight increase in excess of weight loss after the SCC compared with RYGB. In addition, no further weight regain was documented.
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Affiliation(s)
- Joaquin Ortega-Serrano
- Endocrine and Bariatric Surgery Unit, Hospital Clinico Universitario, Valencia, Spain. .,Department of Surgery, University of Valencia, Av. Blasco Ibanez, 17, 46010, Valencia, Spain.
| | - Gabriel Kraus-Fischer
- Endocrine and Bariatric Surgery Unit, Hospital Clinico Universitario, Valencia, Spain
| | - Raquel Alfonso-Ballester
- Endocrine and Bariatric Surgery Unit, Hospital Clinico Universitario, Valencia, Spain.,Department of Surgery, University of Valencia, Av. Blasco Ibanez, 17, 46010, Valencia, Spain
| | - Norberto Cassinello-Fernández
- Endocrine and Bariatric Surgery Unit, Hospital Clinico Universitario, Valencia, Spain.,Department of Surgery, University of Valencia, Av. Blasco Ibanez, 17, 46010, Valencia, Spain
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One Anastomosis Gastric Bypass–Mini-Gastric Bypass (OAGB-MGB) Versus Roux-en-Y Gastric Bypass (RYGB)—a Mid-Term Cohort Study with 612 Patients. Obes Surg 2019; 30:1230-1240. [DOI: 10.1007/s11695-019-04250-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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15
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Alvarez R, Sandoval DA, Seeley RJ. A rodent model of partial intestinal diversion: a novel metabolic operation. Surg Obes Relat Dis 2019; 16:270-281. [PMID: 31874737 DOI: 10.1016/j.soard.2019.10.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 10/15/2019] [Accepted: 10/28/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Metabolic surgery is safe and the most effective therapy for obesity and its co-morbidities. New procedures may allow for better tailoring of metabolic surgery to the individual patient. OBJECTIVE To evaluate the impact, comparative effectiveness, and mechanisms of the partial intestinal diversion (PID), vertical sleeve gastrectomy (VSG), and the combination of PID and VSG on weight and glucose regulation. SETTING University research facility, United States. METHODS Three cohorts of high-fat diet-induced obese male rats were randomized to distal PID (DPID), proximal PID (PPID), VSG, VSG and DPID (VSG/DPID), or sham operation (Sham). Animals were followed for 11 (cohort 1) or 10 (cohorts 2 and 3) weeks. Outcomes included weight and composition, food intake, glucose metabolism, lipids, bile acids, and energy balance. Statistical comparisons were performed using Tukey's multiple comparison test applied to analysis of variance. RESULTS DPID and not PPID resulted in significant weight and body fat reductions relative to Sham. Improved glucose tolerance was seen in all surgical groups though this reached statistical significance for only DPID and VSG compared with Sham. Improvements in baseline glucose and insulin, corresponding insulin resistance, and plasma lipids were noted in DPID compared with Sham. Though the magnitude of weight and body composition changes and metabolic benefit tended to be larger for VSG relative to DPID, it only reached statistical significance for lipids. VSG and VSG/DPID resulted in similar outcomes. Markedly reduced food intake occurred after VSG and more modestly after DPID. Stool caloric content was higher in DPID relative to all groups. CONCLUSIONS DPID is an effective metabolic operation resulting in notable weight and fat loss and metabolic improvement relative to sham-operated rodents. Interestingly, combining VSG with DPID added little additional benefit to the effects of VSG.
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Affiliation(s)
- Rafael Alvarez
- Department of Surgery, University of Michigan, Ann Arbor, Michigan.
| | | | - Randy J Seeley
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Ren Q, Duan J, Cao J. Rapid Improvement in Diabetes After Simple Side-to-side Jejunoileal Bypass Surgery: Does It Need a Ligation or Not? Obes Surg 2019; 28:1974-1979. [PMID: 29392631 DOI: 10.1007/s11695-018-3122-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Dual-path side-to-side jejunoileal bypass (SSJIB) can markedly ameliorate diabetes and obesity. However, whether SSJIB requires the ligation of the bypassed loop (single-path) and what is the most appropriate length of the bypassed small bowel remain unknown. The aim of this study was to evaluate the role of ligation and the length of the bypassed small bowel in mediating changes in glucose homeostasis after SSJIB in streptozotocin (STZ)-induced diabetic rats. METHODS Fourteen STZ-induced diabetic rats were randomized into two groups: one group was subjected to 50% SSJIB (SSJIB-50 group) and one group was subjected to sham surgery (sham group). Three weeks later, the SSJIB-50 group was re-operated, and the bypassed segment was ligated (SSJIBL-50 group). Three weeks later, the SSJIBL-50 group was operated again, and 60% of the length of the proximal small intestine was bypassed (SSJIBL-60 group). The measured primary outcomes were body weight, food intake, fasting blood glucose (FBG), and oral glucose tolerance test (OGTT). RESULTS Body weight in the SSJIBL-60 group was lower than that in the sham group. Food intakes in the SSJIBL-50 and SSJIBL-60 groups were lower than that in the sham group. FBG and OGTT were not improved in the SSJIB-50 group compared with the sham group. However, FBG and OGTT were improved in the SSJIBL-50 group and were further improved in the SSJIBL-60 group. CONCLUSIONS Ligation of the first portion of the bypassed loop is essential to SSJIB, and bypassing approximately 60% of the small intestine length may be appropriate in SSJIBL.
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Affiliation(s)
- Quan Ren
- Department of General Surgery, Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Nanchang University, No.1 Minde Road, Nanchang, 330006, Jiangxi Province, People's Republic of China
| | - Jinyuan Duan
- Department of General Surgery, Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Nanchang University, No.1 Minde Road, Nanchang, 330006, Jiangxi Province, People's Republic of China.
| | - Jiaqing Cao
- Department of General Surgery, Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Nanchang University, No.1 Minde Road, Nanchang, 330006, Jiangxi Province, People's Republic of China
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Soong TC, Almalki OM, Lee WJ, Ser KH, Chen JC, Wu CC, Chen SC. Measuring the small bowel length may decrease the incidence of malnutrition after laparoscopic one-anastomosis gastric bypass with tailored bypass limb. Surg Obes Relat Dis 2019; 15:1712-1718. [PMID: 31558409 DOI: 10.1016/j.soard.2019.08.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 06/07/2019] [Accepted: 08/09/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopic one (single)-anastomosis gastric bypass (OAGB) is an effective and durable treatment for morbidly obese patients. However, the ideal length of the small bowel bypass remains controversial. OBJECTIVES The study aimed to report the clinical results of using a tailored bypass based on the total length of the small bowel. SETTING Academic medical center. METHODS Since 2005, we have performed OAGB with tailored limb according to preoperative body mass index. From July 2014, we modified our technique, measuring the whole small bowel length to keep the common channel at least 400-cm long. Data from 470 patients treated with the new technique (Group II) were compared with those of a matched group treated with tailored bypass only (Group I). The preoperative clinical data and outcomes were analyzed. All clinical data were prospectively collected and stored. RESULTS Both groups had similar clinical profiles at baseline. All procedures were completed laparoscopically. Group II had a significant longer operation time (161.9 versus 122.6 min; P < .001), but shorter hospital stay (2.9 versus 5.3 d; P < .001) and lower complication rate (.2% versus 1.5%; P = .002) than Group I. One year after surgery, the mean body mass index (27.4 versus 26.8 kg/m2; P = .244), percent total weight loss (32.0% versus 34.0%; P = .877), and diabetes remission rate (84.7% versus 84.1%; P = .876) were comparable between the 2 groups. However, Group II patients had a significantly lower incidence of anemia (5.9% versus 11.1%; P < .001), secondary hyperparathyroidism (21.7% versus 33.8%; P < .001) and hypoalbuminemia (1.5% versus 2.8%; P < .001) than did Group I. CONCLUSION Routine measurement of the whole bowel length to keep the common channel at least 400-cm long may reduce the incidence of malnutrition after OAGB with tailored limb bypass, without compromising efficacy in weight loss and diabetes resolution.
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Affiliation(s)
- Tien-Chou Soong
- Center for Weight Loss and Health Management, E-DA Dachang Hospital, Kaohsiung, Taiwan; Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Owaid M Almalki
- Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan; Department of Surgery, College of Medicine, Taif University, Saudi Arabia
| | - Wei-Jei Lee
- Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan.
| | - Kong-Han Ser
- Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Jung-Chien Chen
- Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Chun-Chi Wu
- Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Shu-Chun Chen
- Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan
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Surgical therapy of weight regain after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2019; 15:1719-1728. [PMID: 31474525 DOI: 10.1016/j.soard.2019.07.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/28/2019] [Accepted: 07/03/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is a well-established surgical method for morbid obesity; however, weight regain (WR) after initially good results may be considered an issue, the treatment of which has found no consensus yet. OBJECTIVES The aim of this study was to compare the different surgical methods treating WR after RYGB that are used at the Vienna Medical University in a larger number of patients, concerning further weight loss, complications, and reoperations. SETTING University hospital, Austria. METHODS This study includes all patients with RYGB who were reoperated due to WR at the Vienna Medical University by December 2016 (n = 84). The follow-up rate was 93%. The following 4 approaches to treating WR after RYGB were taken: (1) pouch resizing, (2) pouch banding, (3) pouch resizing plus pouch banding, and (4) common limb shortening (i.e., distalization). RESULTS The mean maximum excess weight loss referring to the WR procedure in the 4 groups was as follows: group 1: 69.0% ± 35.2%, group 2: 62.8% ± 39.5%, group 3: 83.1% ± 30.9%, and group 4: 81.5% ± 41.6%. Reoperations occurred in the following different groups: group 1 had 2 balloon dilations (20%), groups 2 (n = 13) and 3 (n = 29) had 5 (38% and 17%) band removals each, and group 4 had 9 reversal procedures due to malnutrition (30%). CONCLUSIONS There are nonsignificant differences in terms of additional weight loss between the different methods. However, differences lay in the areas of adverse symptoms and further reoperations. While there was no risk of malnutrition with pouch resizing, there was with distalization. Pouch banding (with or without resizing) poses a higher risk of dysphagia.
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Kassir R, Nunziante M. Protein deficiency after gastric bypass: the role of common limb length in revision surgery. Surg Obes Relat Dis 2019; 15:e31-e32. [PMID: 31253508 DOI: 10.1016/j.soard.2019.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/29/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Radwan Kassir
- Department of Bariatric Surgery, CHU Félix Guyon, La réunion, Saint Denis, France
| | - Marco Nunziante
- Department of Bariatric Surgery, CHU Félix Guyon, La réunion, Saint Denis, France
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20
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Neichoy BT, Schniederjan B, Cottam DR, Surve AK, Zaveri HM, Cottam A, Cottam S. Stomach Intestinal Pylorus-Sparing Surgery for Morbid Obesity. JSLS 2018; 22:JSLS.2017.00063. [PMID: 29398898 PMCID: PMC5779797 DOI: 10.4293/jsls.2017.00063] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background and Objective: The Roux-en-Y duodenal switch (RYDS) is one of the most efficient forms of bariatric surgery. However, diarrhea, malnutrition, ulcers, and internal hernias have hampered its widespread adoption. The stomach intestinal pylorus-sparing (SIPS) procedure was developed to alleviate these sequelae while retaining the same weight loss as the RYDS. In this study, we report our midterm experience with this novel technique. Methods: Retrospective analysis was performed on data from 225 patients who underwent a primary SIPS procedure by 2 surgeons at a single center from October 2013 through December 2016. Results: Two hundred twenty-five patients were identified for analysis. The mean preoperative body mass index (BMI) was 52.4 ± 9.1 kg/m2. Forty-eight patients were beyond 2 years after surgery, with data available for 30 patients (62.5% follow-up). Three patients were lost to follow-up. At 2 years, the patients had an average change in BMI of 26.6 U (kg/m2) with an average of 88.7% of excess weight loss. Three deaths were related to the surgery. The most common short-term complication was a leak (2.2%), whereas the most common long-term complication was diarrhea (2.2%). Conclusion: In conclusion, SIPS surgery is a safe procedure with favorable weight loss outcomes at 2 years.
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Affiliation(s)
- Bo T Neichoy
- PanHandle Weight Loss Center, Amarillo, Texas, USA
| | | | | | - Amit K Surve
- Bariatric Medicine Institute, Salt Lake City, Utah, USA
| | | | - Austin Cottam
- Bariatric Medicine Institute, Salt Lake City, Utah, USA
| | - Samuel Cottam
- Bariatric Medicine Institute, Salt Lake City, Utah, USA
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Laparoscopic gastric bypass for the treatment of type 2 diabetes: a comparison of Roux-en-Y versus single anastomosis gastric bypass. Surg Obes Relat Dis 2018; 14:509-515. [DOI: 10.1016/j.soard.2017.12.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 12/04/2017] [Accepted: 12/18/2017] [Indexed: 12/28/2022]
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Pal A, Rhoads DB, Tavakkoli A. Customization of biliopancreatic limb length to modulate and sustain antidiabetic effect of gastric bypass surgery. Am J Physiol Gastrointest Liver Physiol 2018; 314:G287-G299. [PMID: 29097359 PMCID: PMC5866424 DOI: 10.1152/ajpgi.00276.2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Although Roux-en-Y Gastric Bypass (RYGB) remains the most effective treatment for obesity and type 2 diabetes (T2D), many patients fail to achieve remission, or relapse. Increasing intestinal limb lengths of RYGB may improve outcomes, but the mechanistic basis for this remains unclear. We hypothesize biliopancreatic (BP) limb length modulates the antidiabetic effect of RYGB. Rats underwent RYGB with a 20-cm (RYGB-20cm) or 40-cm (RYGB-40cm) BP limb and were compared with control animals. After 2 and 4 wk, portal and systemic blood was sampled during intestinal glucose infusion. Portosystemic gradient was used to calculate intestinal glucose utilization (Gutil), absorption (Gabsorp), and hormone secretion. Intestinal morphology and gene expression were assessed. At 2 wk, Gabsorp progressively decreased with increasing BP limb length; this pattern persisted at 4 wk. Gutil increased ≈70% in both RYGB-20cm and -40cm groups at 2 wk. At 4 wk, Gutil progressively increased with limb length. Furthermore, Roux limb weight, and expression of hexokinase and preproglucagon, exhibited a similar progressive increase. At 4 wk, glucagon-like peptide-1 and -2 levels were higher after RYGB-40cm, with associated increased secretion. We conclude that BP limb length modulates multiple antidiabetic mechanisms, analogous to the dose-response relationship of a drug. Early postoperatively, a longer BP limb reduces Gabsorp. Later, Gutil, Roux limb hypertrophy, hormone secretion, and hormone levels are increased with longer BP limb. Sustained high incretin levels may prevent weight regain and T2D relapse. These data provide the basis for customizing BP limb length according to patient characteristics and desired metabolic effect. NEW & NOTEWORTHY Biliopancreatic limb length in gastric bypass modulates multiple antidiabetic mechanisms, analogous to the dose-response relationship of a drug. With a longer biliopancreatic limb, Roux limb hypertrophy, increased glucose utilization, reduced glucose absorption, and sustained high incretin levels may prevent weight regain and diabetes relapse.
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Affiliation(s)
- A. Pal
- 1Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts,2Harvard Medical School Boston, Massachusetts
| | - D. B. Rhoads
- 2Harvard Medical School Boston, Massachusetts,3Pediatric Endocrinology, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - A. Tavakkoli
- 1Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts,2Harvard Medical School Boston, Massachusetts,4Center for Weight Management and Metabolic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
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15-year experience of laparoscopic single anastomosis (mini-)gastric bypass: comparison with other bariatric procedures. Surg Endosc 2018; 32:3024-3031. [PMID: 29313123 DOI: 10.1007/s00464-017-6011-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/13/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic single anastomosis (mini-)gastric bypass (LSAGB) has been validated as a safe and effective treatment for morbid obesity. However, data of the long-term outcome remain lacking. METHODS Between October 2001 and December 2015, 1731 morbidly obese patients who received LSAGB as primary bariatric procedure at the Min-Sheng General Hospital were recruited. Surgical outcome, weight loss, resolution of comorbidities, and late complications were followed, then compared with groups of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). All data derived from a prospective bariatric database and a retrospective analysis were conducted. RESULTS The average patient age was 33.8 ± 10.4 years with a mean body mass index (BMI) of 40.4 ± 7.7 kg/m2. Of them, 70.0% were female while 30.0% were male. Mean operating time, intraoperative blood, and hospital stay of LSAGB were 124.6 ± 38.8 min, 39.5 ± 38.7 ml, and 5.0 ± 4.1 days, respectively. The 30-day post-operative major complication occurred in 30 (1.7%) of LSAGB patients, 16 (2.0%) of LRYGB, and 15 (1.4%) of LSG patients. The follow-up rates at 1, 5, and 10 years were 89.3, 52.1, and 43.6%, respectively. At postoperative 1, 5, and 10 years, the mean percentage of weight loss (%WL) of LSAGB patients were 32.7, 32.2, and 29.1%, and mean BMI became 27, 26.9, and 27 kg/m2, respectively. The LSAGB had a higher weight loss than LRYGB and LSG at 2-6 years after surgery. LSG had a lower remission rate in dyslipidemia comparing to LSAGB and LRYGB. The overall revision rate of LSAGB is 4.0% (70/1731) which was lower than the 5.1% in LRYGB and 5.2% in the LSG. CONCLUSION LSAGB is an effective procedure for treating morbid obesity and metabolic disorders, which results in sustained weight loss and a high resolution of comorbidities.
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Contribution of Malabsorption to Weight Loss After Roux-en-Y Gastric Bypass: a Systematic Review. Obes Surg 2017; 27:2194-2206. [DOI: 10.1007/s11695-017-2762-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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25
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Making sense of gastric/intestinal bypass surgeries: forget the name and remember the degree of restriction and malabsorption the surgeries provide. Surg Obes Relat Dis 2017; 13:716-719. [DOI: 10.1016/j.soard.2017.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 01/03/2017] [Indexed: 12/23/2022]
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26
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Small Intestinal Bypass Induces a Persistent Weight-Loss Effect and Improves Glucose Tolerance in Obese Rats. Obes Surg 2017; 27:1859-1866. [DOI: 10.1007/s11695-017-2571-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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27
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Maleckas A, Gudaitytė R, Petereit R, Venclauskas L, Veličkienė D. Weight regain after gastric bypass: etiology and treatment options. Gland Surg 2016; 5:617-624. [PMID: 28149808 DOI: 10.21037/gs.2016.12.02] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Roux-en-Y gastric bypass (RYGB) is one of the most common operations performed for the patients with morbid obesity. Weight regain (WR) is a complication that may decrease efficiency of the surgical treatment and demand further interventions. Different factors including lifestyle, mental health, hormonal/metabolic and surgical plays role in WR after RYGB. Various treatment options have been proposed for WR. Conservative treatment is less effective than surgery. Endoscopic refashioning of gastric pouch/stoma fails to achieve sustainable weight loss. Surgical reduction of pouch has acceptable short-term results, but WR after 3 years is substantial. Banded gastric bypass achieves good short-term results, but long-term follow-up data are needed. Distalization of RYGB has a high risk of protein calorie malnutrition (PCM) and conversion to BP diversion (BPD)/duodenal switch (DS) is a technically demanding procedure. Both procedures achieve sustainable long-term weight loss. More studies are needed to explore long-term results of various surgical interventions for WR after RYGB.
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Affiliation(s)
- Almantas Maleckas
- Department of Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania;; Department of Gastrosurgical Research and Education, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Rita Gudaitytė
- Department of Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rūta Petereit
- Department of Gastroenterology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Linas Venclauskas
- Department of Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Džilda Veličkienė
- Institute of Endocrinology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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Surve A, Zaveri H, Cottam D, Belnap L, Medlin W, Cottam A. Mid-term outcomes of gastric bypass weight loss failure to duodenal switch. Surg Obes Relat Dis 2016; 12:1663-1670. [PMID: 27396548 DOI: 10.1016/j.soard.2016.03.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/16/2016] [Accepted: 03/19/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND The Roux-en-Y gastric bypass (RYGB) is a very effective treatment for obesity and its related co-morbidities. However, some patients fail to achieve>50% of their excess weight loss (EWL), and others regain much of the weight that they lost. OBJECTIVE The purpose of this study was to analyze early outcomes after conversion of RYGB to duodenal switch (DS) in terms of weight loss, change in co-morbidities, and complications. SETTING This is a retrospective analysis from 1 surgeon at a single private institution. METHODS We analyzed data from 32 obese patients retrospectively who underwent revision for failed RYGB. Nine patients underwent DS with Roux-en-Y reconstruction (RYDS), and 23 patients underwent single anastomosis DS between October 2012 and December 2015. Regression analyses were performed for all follow-up weight-loss data. RESULTS The patients experienced mean EWL of 16.2% over an average of 16 years (range: 0-38) with their primary RYGB surgery. Of 32 patients who underwent revision DS, 22 patients are beyond the 1-year postoperative mark (follow-up 81.8%), and 15 patients are beyond the 2-year postoperative mark (follow-up 73.3%). One patient was lost to follow-up. The patients experienced mean EWL of 31.2%, 45.1%, 51%, 54.2%, 56%, and 56.4% at 3, 6, 9, 12, 18, and 24 months, respectively, after their revisional surgery. Mean total weight loss achieved at 12 and 24 months was 27.7% and 29.2%, respectively. There was no statistical significant difference in mean %EWL at 12 months (P = .468) and 24 months (P = .266) between RYDS and single anastomosis DS. CONCLUSION A laparoscopic revision from RYGB to DS is an effective weight-loss operation with midterm follow-up of 2 years. Though long-term follow-up is warranted to measure recidivism, the initial data seem favorable.
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Affiliation(s)
- Amit Surve
- Bariatric Medicine Institute, Salt Lake City, Utah
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Chaux F, Bolaños E, Varela JE. Lengthening of the biliopancreatic limb is a key step during revisional Roux-en-Y gastric bypass for weight regain and diabetes recurrence. Surg Obes Relat Dis 2015; 11:1411. [DOI: 10.1016/j.soard.2015.08.511] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 08/17/2015] [Indexed: 10/23/2022]
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