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

Magnetic single-anastomosis side-to-side duodeno-ileostomy for revision of sleeve gastrectomy in adults with severe obesity: 1-year outcomes

INTRODUCTION

Uncomplicated surgical approaches that minimize anastomotic complications while improving revisional metabolic/bariatric surgical (MBS) outcomes are needed.

METHODS

This prospective single-center study assessed the feasibility, safety, and efficacy of the novel linear magnetic anastomosis system (LMAS [3 cm]) in performing a side-to-side duodeno-ileostomy (MagDI) bipartition to revise clinically suboptimal primary sleeve gastrectomy (SG). Patients with severe obesity with/without type 2 diabetes (T2D) with suboptimal weight loss, regain, and/or T2D recurrence post SG underwent revisional MagDI. A distal and proximal magnet were delivered endoscopically to the ileum and duodenum and aligned via laparoscopic assistance. Gradual magnet fusion formed a DI bipartition.

PRIMARY ENDPOINTS

technical feasibility, safety (Clavien-Dindo [CD] severe adverse event classification) at 1 year. Secondary endpoints: MBS weight and T2D reduction.

RESULTS

July 29, 2022-March 28, 2023, 24 patients (95.8% female, mean age 44.9 ± 1.5 years, and body mass index [BMI] 39.4 ± 1.3 kg/m2) underwent MagDI. Feasibility was attained via correct magnet placement (mean operative time 63.5 ± 3.3 min), patent anastomoses created, and magnet passage per anus in 100.0% of patients. There were 4 CD-III mild or moderate severe AEs, 0.0% associated with the LMAS or MagDI: 0.0% anastomotic leakage, obstruction, bleeding, infection, reintervention, or death. Mean BMI reduction was 2.1 kg/m2 (p < 0.05); total weight loss 5.3%, excess weight loss 16.4%; and the patient with T2D improved.

CONCLUSION

The single-anastomosis MagDI procedure using the novel 3-cm LMAS to revise clinically suboptimal SG was technically straightforward, incurred no major complications, mitigated weight regain, and renewed clinically meaningful weight loss.

CLINICALTRIALS

GOV IDENTIFIER

NCT05322122.

Outcomes of revisional surgery options after inadequate sleeve gastrectomy: A comprehensive network meta-analysis

BACKGROUND

Despite the success of sleeve gastrectomy (SG) in of weight loss and treatment of the medical problems associated with obesity, some concerns have arisen about the need for revisional surgeries after SG in some patients. This study aimed to present an updated and comprehensive comparison among the presently available revisional surgeries employed explicitly in cases of inadequate outcomes after SG, which is the most frequently performed bariatric surgery in contemporary practice.

METHODS

This network meta-analysis included studies that compared the outcomes of different revisional bariatric procedures after an inadequate outcome of SG.

RESULTS

Searching across the electronic databases yielded 31 eligible articles. Re-SG was associated with the highest rate of significant complications. Patients treated with single anastomosis duodenal-ileal bypass (SADI) had a significantly higher percentage of total weight loss (%TWL) than those treated with one anastomosis gastric bypass (OAGB) and Roux-en-Y gastric bypass (RYGB). The percentage of excess weight loss (%EWL) at the end of the follow-up period was significantly higher in patients in the SADI group compared to those in the RYGB group and the OAGB, and re-SG exhibited the least values compared to SADI, biliopancreatic diversion with duodenal switch (BPD/DS), and OAGB. Significantly lower rates of reflux worsening/de novo development were observed in the SADI group compared to the OAGB group and the re-SG group, which showed significantly higher rates than SADI and RYGB.

CONCLUSION

Our comprehensive network meta-analysis highlights SADI as a promising revisional option post-SG, demonstrating superior weight loss outcomes, lower significant complication rates, and a favorable impact on reflux compared to other procedures. While acknowledging the limitations of our study, these findings support the potential efficacy of SADI in addressing the challenges of inadequate weight loss after sleeve gastrectomy.

Fully ambulatory robotic single anastomosis duodeno-ileal bypass (SADI): 40 consecutive patients in a single tertiary bariatric center

BACKGROUND

Single Anastomosis Duodeno-Ileal bypass (SADI) is becoming a key option as a revision procedure after laparoscopic sleeve gastrectomy (LSG). However, its safety as an ambulatory procedure (length of stay < 12 h) has not been widely described.

METHODS

A prospective bariatric study of 40 patients undergoing SADI robotic surgery after LSG with same day discharge (SDD), was undertaken in April 2021. Strict inclusion and exclusion criteria were applied and the enhanced recovery after bariatric surgery protocol was followed. Anesthesia and robotic procedures were standardized. Early follow-up (30 days) analyzed postoperative (PO) outcomes.

RESULTS

Forty patients (37 F/3 M, mean age: 40.3yo), with a mean pre-operative BMI = 40.5 kg/m2 were operated. Median time after LSG was 54 months (21-146). Preoperative comorbidities included: hypertension (n = 3), obstructive sleep apnea (n = 2) and type 2 diabetes (n = 1). Mean total operative time was 128 min (100-180) (mean robotic time: 66 min (42-85)), including patient setup. All patients were discharged home at least 6 h after surgery. There were four minor complications (10%) and two major complications (5%) in the first 30 days postoperative (one intrabdominal abscess PO day-20 (radiological drainage and antibiotic therapy) and one peritonitis due to duodenal leak PO day-1 (treated surgically)). There were six emergency department visits (15%), readmission rate was 5% (n = 2) and reintervention rate was 2.5% (n = 1) There was no mortality and no unplanned overnight hospitalization.

CONCLUSIONS

Robotic SADI can be safe for SDD, with appropriate patient selection, in a high-volume center.

One-Stage Vs. Two-Step One Anastomosis Duodenal Switch (OADS/SADI-S): A Safety and Efficacy Single-Center Propensity-Score Matched Analysis

INTRODUCTION

One Anastomosis Duodenal Switch (OADS/SADI-S) is used both as a one stage and a second-step procedure, either planned or revisional after a failed sleeve gastrectomy. However, there is lack of adjusted comparative evidence validating its use.

MATERIAL AND METHODS

Propensity-score matched comparison between patients submitted to one-stage vs. two-step OADS, adjusted by age, gender, and initial body mass index (BMI).

RESULTS

One hundred ninety-five patients (130 one-stage and 65 two-step OADS) were included, with mean initial BMI 52.4 kg/m2. Overall complication rate was 6.6% in the short-term (3.3% Clavien-Dindo ≥ III), and 7.3% in the long-term, with no differences between groups. Follow-up at 1 and 3 years was 83.6% and 61.5%. After one-stage OADS, total weight loss was 36.6 ± 8.2% at 1 year and 30.4 ± 10.3% at 3 years, vs. 30.2 ± 9.4% and 25.6 ± 10.2% after two-steps OADS (p = 0.021). Resolution rates of diabetes mellitus, hypertension, dyslipidemia, and obstructive sleep apnea were 86.4%, 80.4%, 78.0%, and 73.3%, with no differences between groups.

CONCLUSION

One-stage OADS is a safe and effective bariatric technique for patients with grade III and IV obesity. The two-step strategy does not reduce postoperative risks and may compromise weight loss results at mid-term.

Outcomes of primary versus conversional Roux-En-Y gastric bypass after laparoscopic sleeve gastrectomy: a retrospective propensity score-matched cohort study

BACKGROUND

Conversional surgery is common after laparoscopic sleeve gastrectomy (LSG) because of suboptimal weight loss (SWL) or poor responders and gastroesophageal reflux disease (GERD). Roux-en-Y gastric bypass (RYGB) is the most common conversional procedure after LSG.

METHODS

A retrospective cohort study analyzed patients who underwent primary RYGB (PRYGB) or conversional RYGB (CRYGB) at three specialized bariatric centers between 2008 and 2019 and tested for weight loss, resolution of GERD, food tolerance (FT), early and late complications, and the resolution of associated medical problems. This was analyzed by propensity score matching (PSM).

RESULTS

In total, 558 (PRYGB) and 155 (CRYGB) completed at least 2 years of follow-up. After PSM, both cohorts significantly decreased BMI from baseline (p < 0.001). The CRYGB group had an initially more significant mean BMI decrease of 6.095 kg/m2 at 6 months of follow-up (p < 0.001), while the PRYGB group had a more significant mean BMI decrease of 5.890 kg/m2 and 8.626 kg/m2 at 1 and 2 years, respectively (p < 0.001). Food tolerance (FT) improved significantly in the CRYGB group (p < 0.001), while CRYGB had better FT than PRYGB at 2 years (p < 0.001). A GERD resolution rate of 92.6% was recorded in the CRYGB (p < 0.001). Both cohorts had comparable rates of early complications (p = 0.584), late complications (p = 0.495), and reoperations (p = 0.398). Associated medical problems at 2 years significantly improved in both cohorts (p < 0.001).

CONCLUSIONS

CRYGB is a safe and efficient option in non- or poor responders after LSG, with significant weight loss and improvement in GERD. Moreover, PRYGB and CRYGB had comparable complications, reoperations, and associated medical problem resolution rates.

Revisional Procedures after Sleeve Gastrectomy for Weight Recurrence or Inadequate Weight Loss: An Analysis of the MBSAQIP Database

INTRODUCTION

The safety of conversional bariatric procedures after sleeve gastrectomy (SG) for weight recurrence (WR) or inadequate weight loss (IWL) is debated due to limited evidence. Conversion options include Roux-en-Y gastric bypass (RYGB), single anastomosis duodeno-ileal bypass (SADI), and biliopancreatic diversion with duodenal switch (BPD-DS). We aimed to compare serious complications and mortality rates between these procedures within 30 days.

METHODS

Using the 2020 and 2021 MBSAQIP databases, we identified patients who underwent a conversion from SG to RYGB, SADI, or BPD-DS. We performed a multivariable logistic regression to assess predictors of 30-day complications and mortality.

RESULTS

Among 7388 patients (77.6% RYGB, 8.7% SADI, 13.7% BPD-DS), those undergoing SADI and BPD-DS had higher preoperative body mass index. Conversion reasons included WR (63.0%) and IWL (37.0%). SADI and BPD-DS patients had longer operative times (p < 0.001) and higher leak rates (p = 0.001). Serious complications, reoperations, readmissions, and 30-day mortality were similar across groups. Conversion procedure type was not an independent predictor of complications.

CONCLUSION

RYGB was the most performed conversional procedure after SG. The study indicated a similar safety profile for revisional RYGB, SADI, and BPD-DS, with comparable 30-day complications and mortality rates. However, SADI and BPD-DS patients had longer operative time and higher leak rates.

Weight loss specific to indication, remission of diabetes, and short-term complications after sleeve gastrectomy conversion to Roux-en-Y gastric bypass: a systematic review and meta-analysis

Laparoscopic sleeve gastrectomy (SG) is the most frequently performed bariatric procedure worldwide. Long-term complications such as insufficient weight loss (IWL) and gastroesophageal reflux disease (GERD) may necessitate SG conversion to Roux-en-Y gastric bypass (RYGB). The aim of this review was to determine the indication-specific weight loss and diabetes remission after SG conversion to RYGB (STOBY). Our objective was to extract all available published data on indication for conversion, weight loss, remission of diabetes, and short-term complications after STOBY. A systematic literature search was conducted to identify studies reporting outcomes following STOBY. A random effects model was used for meta-analysis. The search identified 44 relevant studies. Overall short-term (12-mo) excess weight loss (EWL) was 54.6% (95% confidence interval [CI], 46%-63%) in 23 studies (n = 712) and total weight loss (TWL) was 19.9% (95% CI, 14%-25%) in 21 studies (n = 740). For IWL, short-term (12-mo) pooled weight loss outcomes were 53.9% EWL (95% CI, 48%-59%) in 14 studies (n = 295) and 22.7% TWL (95% CI, 17%-28%) in 12 studies (n = 219), and medium-term (2-5 yr) outcomes were 45.8% EWL (95% CI, 38%-53%) in 7 studies (n = 154) and 20.6% TWL (95% CI, 15%-26%) in 9 studies (n = 206). Overall diabetes remission was 53% (95% CI, 33%-72%), and the perioperative complication rate was 8.2% (95% CI, 7.6%-8.7%). Revisional SG conversion to RYGB for IWL can achieve good weight loss outcomes and diabetes remission.

A Comprehensive Review on Bariatric Endoscopy: Where We Are Now and Where We Are Going

Background: Obesity is a chronic disease that impairs quality of life and leads to several comorbidities. When conservative therapies fail, bariatric surgical options such as Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the most effective therapies to induce persistent weight loss. Over the last two decades, bariatric endoscopy has become a valid alternative to surgery in specific settings. Primary bariatric endoscopic therapies: Restrictive gastric procedures, such as intragastric balloons (IGBs) and endoscopic gastroplasty, have been shown to be effective in inducing weight loss compared to diet modifications alone. Endoscopic gastroplasty is usually superior to IGBs in maintaining weight loss in the long-term period, whereas IGBs have an established role as a bridge-to-surgery approach in severely obese patients. IGBs in a minority of patients could be poorly tolerated and require early removal. More recently, novel endoscopic systems have been developed with the combined purpose of inducing weight loss and improving metabolic conditions. Duodenal mucosal resurfacing demonstrated efficacy in this field in its early trials: significant reduction from baseline of HbA1c values and a modest reduction of body weight were observed. Other endoscopic malabsorptive have been developed but need more evidence. For example, a pivotal trial on duodenojejunal bypasses was stopped due to the high rate of severe adverse events (hepatic abscesses). Optimization of these more recent malabsorptive endoscopic procedures could expand the plethora of bariatric patients that could be treated with the intention of improving their metabolic conditions. Revisional bariatric therapies: Weight regain may occur in up to one third of patients after bariatric surgery. Different endoscopic procedures are currently performed after both RYGB and SG in order to modulate post-surgical anatomy. The application of argon plasma coagulation associated with endoscopic full-thickness suturing systems (APC-TORe) and Re-EndoSleeve have shown to be the most effective endoscopic treatments after RYGB and SG, respectively. Both procedures are usually well tolerated and have a very low risk of stricture. However, APC-TORe may sometimes require more than one session to obtain adequate final results. The aim of this review is to explore all the currently available primary and revisional endoscopic bariatric therapies focusing on their efficacy and safety and their potential application in clinical practice.

Comparison of early post-operative complications in primary and revisional laparoscopic sleeve gastrectomy, gastric bypass, and duodenal switch MBSAQIP-reported cases from 2015 to 2019

BACKGROUND

Sleeve gastrectomy (SG) is now the most performed bariatric surgery, though gastric bypass (GB) and duodenal switch (DS) remain common, especially as conversion/revision (C/R) procedures. This analysis compared early postoperative outcomes of primary and C/R laparoscopic SG to DS and GB; and primary procedures of each vs C/R counterparts.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) dataset was queried for SG, GB, and DS cases from 2015 to 2019. Multivariable logistic regression calculated crude and adjusted odds ratios for surgical site infection (SSI), reoperation, and readmission at 30 days in two initial comparisons: (1) primary SG vs DS or GB and (2) C/R SG vs DS or GB. A secondary analysis compared primary GS, GB, or DS with C/R counterparts. Models were adjusted for confounding demographics and comorbidities.

RESULTS

Of 755,968 primary cases, most were SG (72.8%), followed by GB (26.3%), then DS (0.9%). Compared to SG, GB and DS demonstrated higher odds of SSI (aOR 3.02 [2.84, 3.2]), readmission (aOR 1.97 [1.92, 2.03]), and reoperation (aOR 2.74 [2.62, 2.86]), respectively. Of 68,716 C/R cases, SG was most common (43.2%), followed by GB (37.5%), then DS (19.2%). C/R GB and DS demonstrated greater risk of SSI (aOR 2.28 [1.98, 2.62]), readmission (aOR 2.10 [1.94, 2.27]), and reoperation (aOR 2.3 [2.04, 2.59]) vs SG, respectively. C/R SG and DS demonstrated greater risk of SSI (OR 2.09 [1.66, 2.63]; 1.63 [1.24, 2.14), readmission (OR 1.13 [1.02, 1.26]), and reoperation (OR 1.27 [1.06, 1.52]; 1.58 [1.24, 2.0]), vs primary procedures. C/R DS demonstrated greater risk of SSI (OR 1.23 [1.66, 2.63]).

CONCLUSIONS

Early complications are comparable between GB and DS, and greater than SG. In C/R procedures, GB and DS demonstrate greater risk than SG. Overall, C/R procedures demonstrate greater risk of most, but not all, early postoperative complications.

Comparing weight loss outcomes after conversion to Roux-en-Y gastric bypass versus duodenal switch from sleeve gastrectomy in a community hospital

Background

Recidivism after initial sleeve gastrectomy (SG) remains common. Revisional surgery to convert SG to Roux-en-Y gastric bypass (RYGB) or duodenal switch (DS) for additional weight loss is increasing. This study aims to compare the outcomes after conversion of SG to RYGB or DS.

Methods

A retrospective single-institution review was conducted from 2015 to 2021, identifying 75 patients who underwent conversion from prior SG to either RYGB (40) or DS (35). Mean excess body weight loss (EBWL) at 3, 6, 12, and 24 months was assessed and compared. Secondary measures of length of stay (LOS), procedure length, and 30-day readmission rate were also reviewed.

Results

Percentage EBWL for RYGB vs DS was 24.0% vs 18.8% at 3 months (N = 36 vs 26; P < 0.0491), 34.8% vs 29.0% at 6 months (N = 29 vs 17; P < 0.2192), 43.0% vs 40.1% at 12 months (N = 28 vs 12; P < 0.6828), and 36.2% vs 41.7% at 24 months (N = 27 vs 7; P < 0.5553). Average LOS was 2.6 days ± 1.4 for RYGB and 2.8 days ± 1.3 for DS (P < 0.6032). Average procedure length was 134.4 min for RYGB and 189.8 min for DS (P < 0.0001). 30-day readmission rate was 27.5% (N = 11) for RYGB and 14.3% (N = 5) for DS (P < 0.1645). Significant weight loss was observed in both subgroups up to 12 months, with no significant weight loss between 12 and 24 months (RYGB N = 21, P < 0.2961; DS N = 5, P < 0.7233).

Conclusion

Both revisional RYGB and revisional DS procedures had significant and sustained weight loss in the first 12 months. There was no significant excess body weight loss difference between revisional RYGB and revisional DS patients at 6, 12, and 24 months, with only significant greater weight loss for RYGB patients at 3 months. Additionally, procedure length was significantly longer for DS compared to RYGB, with no significant differences in LOS and 30-day readmission rates.

Graphical abstract

Weight loss outcomes for patients undergoing conversion to Roux-en-Y-gastric bypass after sleeve gastrectomy

BACKGROUND

Despite excellent reported outcomes after laparoscopic sleeve gastrectomy (LSG), a percentage of patients go on to have a secondary bariatric surgery to manage side-effects or address weight regain after LSG. Reported weight loss outcomes for patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) after previous LSG are variable. We sought to determine the weight-loss outcomes of patients undergoing LRYGB after LSG in the largest bariatric surgical network in Canada and to determine whether outcomes differ according to indications for conversion.

METHODS

The Bariatric Registry is a multi-center database with prospectively collected standardized data on patients undergoing bariatric surgery at ten Bariatric Centers of Excellence within the Ontario Bariatric Network in Ontario, Canada. A retrospective analysis was performed of patients who underwent LRYGB after previous LSG between 2012 and 2019. Weight loss outcomes were compared between patients who underwent LRYGB for insufficient weight loss/weight regain and those who underwent conversion to LRYGB for other reasons.

RESULTS

Excluding patients with multiple revisions and those without follow-up data, 48 patients were included in the analysis: 33 patients (69%) underwent conversion to LRGYB for insufficient weight loss/weight regain (Group 1) and 15 patients (31%) underwent conversion for other reasons (Group 2). Mean body mass index (BMI) measured pre-LSG, pre-LRYGB, and at mid-term follow-up after LRYGB was 61, 48, and 43 kg/m² in Group 1 and 51, 39, and 34 kg/m² in Group 2, respectively. ΔBMI and %total weight loss (TWL) at mid-term follow-up were not significantly different between the groups.

CONCLUSIONS

Conversion to LRYGB after previous LSG resulted in an additional loss of 4 kg/m² in BMI points at mid-term follow-up. Patients lost a similar number of BMI points and cumulative %TWL was similar regardless of reason for conversion. This can help inform surgical decision-making in the setting of weight regain after LSG.

Bariatric Surgery Conversions in MBSAQIP Centers: Current Indications and Outcomes

BACKGROUND

The demand for revisional bariatric surgery has increased, and bariatric conversions (BC) to a different procedure represent most of the revisional cases. The 2020 Metabolic and Bariatric Surgery Accreditfnation and Quality Improvement Program (MBSAQIP) database was expanded to include additional variables on BC. This study aims to analyze the indications and outcomes of BC.

METHODS

A retrospective analysis of the 2020 MBSAQIP database was performed. Patients who underwent BC were included in the analysis. Index procedures, rates, and indications for BC of the different bariatric operations were described. Outcomes of the most frequent BC were analyzed.

RESULTS

A total of 168,548 bariatric surgeries were done; 20,387 (12.1%) were revisional, and from those 15,031 (73.7%) were BC. The most converted index operations were sleeve gastrectomy (SG) (49.3%) and adjustable gastric banding (AGB) (45.9%). The most frequent conversions were SG to Roux-en-Y gastric bypass (RYGB) (40.3%) for gastroesophageal reflux disease (GERD) (54.2%) and weight loss failure (WLF) (35.8%), AGB to SG (27%) or RYGB (16.2%) for WLF (67% and 61.3%, respectively), and SG to biliopancreatic diversion with duodenal switch (3.2%) or single anastomosis duodeno-ileal bypass (2%) for WLF (91.2% and 92.4%, respectively). Postoperative overall morbidity, serious morbidity, reoperation, and mortality rates ranged from 5.3 to 20.8%, 2.3 to 19.2%, 1.5 to 10%, and 0 to 0.8%, respectively.

CONCLUSIONS

BC represents the most frequent revisional bariatric procedure. GERD and WLF are the main causes for BC. Further research is needed to define the ideal BC according to the index procedure and indication.

Combined Re-sleeve and Single Anastomosis Sleeve Ileal (SASI) Bypass as a Second Stage After Sleeve Gastrectomy (Video Report)

BACKGROUND

In comparison with purely restrictive procedures, combined restrictive and malabsorptive procedures seem to produce better weight loss and comorbidity control in patients with morbid obesity. Two-stage bariatric surgery is popular and is a safe and efficient strategy for patients with super obesity (BMI > 50 kg/m²) and super-super obesity (BMI > 60 kg/m²).

METHODS

The patient in this video was a 36-year-old man with an initial BMI of 53.2 kg/m². Two-stage bariatric surgery was planned. The patient underwent the first stage, laparoscopic sleeve gastrectomy, in 2018. Eighteen months after surgery, his lowest BMI was 38.8 kg/m², and his excess weight loss was 50.9%. In 2021, he regained weight and reached a BMI of 42.4 kg/m². Then, a second-stage bariatric surgery was performed.

RESULTS

As shown in the video, combined re-sleeve and single anastomosis sleeve ileal (SASI) bypass constituted the second stage of bariatric surgery. During the operation, adhesiolysis was first performed, and the stomach was mobilized through a lateral-to-medial approach. Gastric transection was performed with a 36-Fr bougie. Then, the ileocecal junction was identified, and a location 250 cm from the cecum was selected as the anastomosis site. Gastro-ileal anastomosis (3 cm in diameter) was established with a stapler, and the two-layer suture method was used to close the defect. The postoperative period was uneventful, and the patient was discharged 5 days after surgery.

CONCLUSIONS

Combined re-sleeve and SASI bypass has a few surgical morbidities and is promising as an alternative to second-stage duodenal switch in patients with super obesity.

Single Anastomosis Duodeno-ileal Bypass As a Revisional Procedure Following Sleeve Gastrectomy: Review of the Literature

Laparoscopic sleeve gastrectomies (LSGs) can experience weight-loss failure and conversion to another bariatric procedure. An analysis of the bariatric literature concerning the single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) as revisional surgery after LSG in terms of safety and efficacy identified 607 studies. Fifty-nine studies were analyzed for full content review and 9 primary studies (398 patients) were included. Revisional single anastomosis duodeno-ileal bypass (SADI) was performed in 294 patients at a mean interval of 37.7 months (range 11-179). Total weight loss (%) varies from 20.5% to 46.2%. Early complications after surgery occurred in 4.1% surgeries including leak (7 cases -1.9%). Mortality was nil. SADI after LSG, after failed sleeve gastrectomy or as a sequential procedure, offers a satisfactory weight loss result. Both early and late term complications are acceptable.

Robotic Revisional Single Anastomosis Duodenoileal Bypass After Sleeve Gastrectomy

Introduction: Single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) is a metabolic operation emerging as an option for patients with morbid obesity. It is a promising revisional procedure for weight regain or suboptimal weight loss after sleeve gastrectomy (SG). Currently, there is limited literature describing robotic revisional SADI-S. This study describes the safety, feasibility, and early outcomes of robotic revisional SADI-S after previous SG. Methods: This is a retrospective review from May 26 2019 to January 31 2021. Perioperative outcomes were analyzed. Results: A total of 16 patients underwent the procedure. There were 11 females (69%) with a mean age of 39 ± 11 years. Mean body mass index (BMI) was 44.0 ± 5.1 kg/m² and median ASA was two. Comorbidities included hypertension (25%), hyperlipidemia (19%), and obstructive sleep apnea (13%). Mean interval from primary to revisional surgery among patients was 5.5 ± 1.4 years. Median operative console time was 110 minutes (IQR = 103-137). There were no intraoperative complications. The median hospital stay was 2 days (IQR = 2-3). Perioperative outcomes included no reoperations, perioperative complications, or deaths. There were two (12.5%) emergency department visits for wound checks without infection but no readmissions. At a median follow-up of 4.5 months (IQR = 1-10), patients had a mean BMI of 38.3 ± 7.3 kg/m² and a mean percent total body weight loss (%TBW) of 12.7%. Conclusions: Initial outcomes suggest that robotic revisional SADI-S after previous SG is feasible and safe. Future studies are needed to evaluate intermediate- and long-term postoperative outcomes.

The Panoramic View of Revisional Bariatric Surgery

Introduction: Obesity remains a major public chronic disease, and the multifactorial components of its relapse in many patients remain inevitable. Methods: This article provides a panoramic view of the most commonly performed revisional bariatric surgery (RBS). RBS is a complex procedure; thus, primary procedures should be well chosen and performed to avoid the increasing number of RBS cases. Results: Bariatric surgery is the only successful long-term treatment for obesity. However, a proportion of primary bariatric surgeries has failed during the follow-up period. In recent decades, the solution for these complications is by performing RBS. It is mandatory to understand obesity as a chronic disease to appropriately treat patients. Treatment strategies are needed to determine the indications for revision. RBS requires a meticulous evaluation to facilitate good long-term results. Conclusions: Treatment strategies will be a fundamental pillar to wisely determine the indications for revision and identify the factors influencing failure by prudently and rationally evaluating the revisional procedure that the patient will benefit from and acquiring a high level of surgical skills.

A safety study of laparoscopic single-anastomosis duodeno-ileal bypass with gastric plication (SADI-GP) in the management of morbid obesity

Background

Bariatric surgery is more effective in the management of morbid obesity and related comorbidities than is conservative therapy. Pylorus-preserving single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-SG) is a modified duodenal switch technique. Gastric plication (GP) is an alternate to SG.

Methods

Morbidly obese (BMI of > 40, or > 35 in the presence of diabetes or prediabetes) patients were recruited and operated on to perform SADI with GP. Complications related to surgery were recorded to assess the feasibility of the procedure. Weight-loss outcomes were analysed to determine efficacy. Minnesota Multiphasic Personality Inventory 2 (MMPI-2) was recorded after 1 year of follow-up, and test scales were used to describe physiological phenomena.

Results

Seventeen middle-aged (mean: 40 years) patients were involved in our study; 15 of them were females. The mean duration of surgery was 205 min. There were no complications of conversion, death, bleeding, VTE or 30-day readmission to hospital. We did experience CD4a (pulmonary insufficiency due to chronic lung disease) and a CD3b (anastomosis leakage treated laparoscopically) complications. Vomiting occurred in three cases (CD1). Obesity-related comorbidities showed favourable resolution rates (77.8% for hypertension, 81.2% for dyslipidaemia, 100% for diabetes at the 1-year follow-up). Weight-loss outcomes were favourable (53.20 EWL%, and 35.58 TWL% at 1-year follow-up). Greater weight loss caused significantly higher levels of Depression (t(13.958) =  − 2.373; p = 0.00; p < 0.05) and Low Positive Emotions (t(13.301) =  − 2.954; p = 0.00; p < 0.05) and Introversion/Low Positive Emotionality (t(13.408) =  − 1.914; p = 0.02; p < 0.05) in MMPI-2 data.

Conclusion

According to our safety study, SADI-GP is a promising malabsorptive procedure, but a long-term high-volume case series or a randomised controlled trial is necessary to evaluate complication rates and weight-loss outcomes. Emotional dysregulation is common among bariatric surgery patients according to personality inventory data; therefore, psychological follow-up and psychotherapeutic support are necessary for weight-loss maintenance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02276-9.

Indications and Long-Term Outcomes of Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass

PURPOSE

Long-term results on sleeve gastrectomy (SG) with more than 10 years report patients needing sleeve revision for weight loss failure, de novo gastroesophageal reflux (GERD), or sleeve complications. The aim of this study was to analyze the results of laparoscopic conversion of failed SG to Roux-en-Y gastric bypass (RYGB).

MATERIALS AND METHODS

Retrospective review of a prospectively institutional maintained database to identify patients who underwent conversion of SG to RYGB between 2012 and June 2020.

RESULTS

Sixty patients(50 females) underwent conversion to RYGB. Average time to conversion was 5.6 years (2-11). Mean %WL and TWL after SG were respectively 26±8.8% and 33.2±14.1kg. Mean BMI at the time of RYGB was 38.1±7.1 kg/m². Mean follow-up was 30.4±16.8 months (6-84). Available patients at each time of follow-up: 1 year 59 (98.3%); 2 years 47 (78.3%); 3 years 39 (71.6%); and 5 years 33 (55%). Patients were divided according to indication for revision in weight regain/insufficient weight loss (30 patients) group 1 and GERD/complications (25 patients) group 2. Percentage of excess weight loss at 1, 3, and 5 years follow-up after bypass was for group 1 40.3±17.6, 34.3±19.5, and 23.2±19.4 and for group 2 90.4±37, 62.6±28.2, and 56±35.02. Total weight loss at last follow-up since sleeve was respectively 31kg in group 1 and 46.7kg in group 2 (p=0.002). No mortality was observed. Thirty-day complication rate was 3.3%.

CONCLUSION

RYGB after SG is a safe and effective revisional procedure to manage weight regain and de novo GERD, to address complications, and to improve comorbidities.

Obesity, Cancer, and Risk Reduction with Bariatric Surgery

The prevalence of noncommunicable diseases has increased dramatically in North America and throughout the world and is expected to continue increasing in coming years. Obesity has been linked to several types of cancers and is associated with increased morbidity and mortality following cancer diagnosis. Bariatric surgery has emerged as the prominent model to evaluate the effects of intentional weight loss on cancer incidence and outcomes. Current literature, comprising prospective cohort investigations, indicates site-specific reductions in cancer risk with select bariatric procedures. Future research is required to establish evidence-based indications for bariatric surgery in the context of cancer prevention.

Roux-en-Y gastric bypass as revisional surgery

The Roux-en-Y gastric bypass (RYGB) is a worldwide-performed procedure as primary surgery, and as conversional procedure after complications and/or failure of other bariatric procedures. RYGB can be performed as revisional surgery after adjustable gastric banding, vertical banded gastroplasty, sleeve gastrectomy and one anastomosis gastric bypass. Each of these revisional procedures may be technically challenging, and accurate preoperative work-up and operative planning is required. If correctly performed, RYGB as revisional procedure is associated with satisfying outcomes and is indicated in the treatment of insufficient weight loss and postoperative complications of a primary bariatric procedure - such as chronic leak or gastroesophageal reflux after sleeve gastrectomy. The present article analyzes the most important indications, technical points and tips and tricks to safely perform RYGB as a secondary procedure.

Revisional Surgeries of Laparoscopic Sleeve Gastrectomy

Bariatric surgery has become increasingly common due to the worldwide obesity epidemic. A shift from open to laparoscopic surgery, specifically, laparoscopic sleeve gastrectomy (LSG), has occurred in the last two decades because of the low morbidity and mortality rates of LSG. Although LSG is a promising treatment option for patients with morbid obesity due to restrictive and endocrine mechanisms, it requires modifications for a subset of patients because of weight regain and tough complications, such as gastroesophageal reflux, strictures, gastric leak, and persistent metabolic syndrome., Revision surgeries have become more and more indispensable in bariatric surgery, accounting for 7.4% in 2016. Mainstream revisional bariatric surgeries after LSG include Roux-en-Y gastric bypass, repeated sleeve gastrectomy, biliopancreatic diversion, duodenal switch, duodenal-jejunal bypass, one-anastomosis gastric bypass, single anastomosis duodeno-ileal bypass (SAID) and transit bipartition. This review mainly describes the revisional surgeries of LSG, including the indication, choice of surgical method, and subsequent effect.

Management of Leak after Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy

The single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) has been introduced in the past few years for the treatment of morbid obesity. SADI-S has shown good results in terms of long-term results and short-term complications. However, the management of patients undergoing SADI-S and suffering from a leak is a great challenge for surgeons. We present an extensive review of the currently available literature on the management of leak after SADI in morbid obese (MO) patients. We aim at providing objective information regarding the optimal management, including diagnosis, technical options for the different strategies that have been proposed, to facilitate the selection of the best individual approach for each MO patient.

Third bariatric procedure for insufficient weight loss or weight regain: how far should we go?

BACKGROUND

Revisional procedures in bariatric surgery are increasing with several debated failure risk factors, such as super obesity and old age. No study has yet evaluated the outcomes and risks of a third bariatric procedure indicated for weight loss failure or weight regain.

OBJECTIVES

To assess failure risks of a third bariatric procedure according to Reinhold's criteria (percentage excess weight loss [%EWL] ≤50% and/or body mass index [BMI] ≥35 kg/m²).

SETTING

A university-affiliated tertiary care center, France.

METHODS

From 2009 to 2019, clinical data and weight loss results of patients who benefited from 3 bariatric procedures for weight loss failure or weight regain were collected prospectively and analyzed using a binary logistic regression. Weight loss failure was defined according to Reinhold's criteria.

RESULTS

Among 1401 bariatric procedures performed, 336 patients benefited from 2 or more procedures, and 45 had a third surgery. Eleven patients that were reoperated on because of malnutrition or gastroesophageal reflux disease were excluded from the final analysis. Among 34 patients with 3 procedures because of weight loss failure or regain, mean BMI was 48.3 ± 8.3 kg/m², and mean age was 30 ± 10.7 years. Three out of 34 patients (9%) presented a severe complication (Dindo-Clavien IIIb) and 2 (6%) had a minor one. Achieving Reinhold's weight loss criteria after the second bariatric procedure was a significant predictor of success of the third procedure (β = 2.9 ± 1.3 S.E.).

CONCLUSION

Not reaching Reinhold's criteria after a second bariatric procedure was identified as a significant risk factor of failure of a third procedure. A third surgery should be carefully discussed especially in case of primary failure of previous procedures.

Laparoscopic Duodenal Switch Versus Roux-en-Y Gastric Bypass at a High-Volume Community Hospital: a Retrospective Cohort Study from a Rural Setting

BACKGROUND

The classic duodenal switch (DS) represents a minority of bariatric procedures due to its high complexity and potential for complications.

METHODS

A retrospective chart review was conducted on 100 laparoscopic DS cases from 2014 to 2018 at an accredited program in a rural community hospital and compared to 100 laparoscopic Roux-en-Y gastric bypasses (RYGB). Primary outcomes were 30-day morbidity and mortality. Secondary outcomes included anastomotic leak and remission of type 2 diabetes.

RESULTS

There were more demographic risk factors for DS. The 30-day morbidity was higher for DS compared to RYGB (31% vs 13%, respectively; p = 0.0037). There was one mortality for DS and none for RYGB. There were statistically significant longer intraoperative times, greater EBL, and greater decrease in BMI for DS. The DS had a lower incidence of anastomotic ulcers (4% vs 13%, respectively; p = 0.0289), with a higher incidence of subsequent surgery beyond 30 days (21% vs 8%, respectively; p = 0.0160). There were 3 anastomotic leaks for DS and none for RYGB, although not statistically significant (p = 0.2463). The DS was more likely to eradicate hypertension, but the RYGB was more likely to eradicate GERD. There were no statistically significant differences for type 2 diabetes remission (92.1% vs 89.5%, respectively; p = 0.7239).

CONCLUSION

Laparoscopic DS offers greater weight loss and hypertension remission, with lower incidence of anastomotic ulcers, but at the expense of greater morbidity and need for subsequent surgery, with no significant differences in type 2 diabetes remission when compared to RYGB in a rural community hospital program.

SADI-S 250 vs Roux-en-Y Duodenal Switch (RY-DS): Results of 5-Year Observational Study

PURPOSE

There are only a small number of studies providing a comparison between SADI-S and Hess-Marceau's BPD/Duodenal Switch (RY-DS) operations. We aimed to compare 5-year results of SADI-S 250 (common limb 250 cm) with RY-DS.

MATERIAL AND METHODS

Data of patients who underwent open SADI-S (n 226) and RY-DS (n 528) were retrospectively studied. EWL(%), EBMIL(%), TWL(%), antidiabetic effect, complications, and revision rate were compared between the two groups.

RESULTS

After the first 12 months, EWL% (77.0% vs 73.3%) and TWL% (39.4% vs 38.9%) were statistically significantly better after SADI-S (p < 0.01, and p < 0.05 respectively), but not EBMIL% (p > 0.05). At nadir to 24-36 months, EWL, TBWL, and EBMIL after SADI-S was comparable to the RY-DS group. Up to the fourth and fifth year, better weight loss (TBWL, EBMIL, EWL) was observed after RY-DS than after SADI-S. Early complication rate was less (2.65%) in the SADI-S group vs 5.1% in the RY-DS. Protein deficiency and small bowel obstruction rates were also lower after SADI-S. 93.4% of patients achieved total remission of their diabetes. 7.5% of patients in the SADI-S group had symptoms of bile reflux, which was a main indication for revisions.

CONCLUSION

SADI-S has many advantages over RY-DS. However, weight loss and antidiabetic effects after the third year were marginally lower after SADI-S compared to RY-DS. SADI-S is less dangerous in terms of malabsorption and looks to be a reasonable alternative to RY-DS as a metabolic operation. RY-DS could be implemented for weight regain and/or bile reflux after SADI-S.

Bariatric revisional surgery: What are the challenges for the patient and the practitioner?

Bariatric revisional surgery represents an important new issue for obese patients because of the considerable rate of failure and complications following bariatric surgery. As the frequency of bariatric procedures increases, so too does the incidence of revisional surgery, which has become becoming increasingly important. The surgeon must know the indications and the results of the various revisional procedures in order to best guide the therapeutic decision. The current challenge is to correctly select the patients for revisional surgery and to choose the appropriate procedure in each case. Multidisciplinary management is essential to patient re-assessment and to prepare the patient for a re- intervention. The objective of this update, based on data from all the most recent studies concerning revisional surgery, is to guide the surgeon in the choice of the revisional procedure, depending on patient characteristics, co-morbidities, the previously performed procedure, the type of failure or complication observed, but also on the surgeon's own habits and the center's expertise. The collected results show that revisional surgery is difficult, with higher complication rates and weight-loss results that are often lower than those of first-intent surgery. For these reasons, patient selection must be rigorous and multidisciplinary and the management in expert centers of these difficult situations must be encouraged.

Single-anastomosis duodenoileal bypass as a revisional or second-step operation after sleeve gastrectomy

BACKGROUND

One-loop duodenal switch leads to weight loss and improvement or resolution of co-morbidities similar to standard duodenal switch, and it is technically less demanding.

OBJECTIVES

To analyze the weight loss and metabolic improvement after conversion of sleeve gastrectomy to single-anastomosis duodenoileal bypass.

SETTING

University Hospital, Madrid, Spain.

METHODS

This was a retrospective cohort study. Patients submitted to sleeve gastrectomy with insufficient weight loss or programmed for a 2-step surgical approach were included. Single-anastomosis duodenoileostomy was completed if there was no stricture in the stomach and no severe symptoms of gastroesophageal reflux.

RESULTS

Fifty-one patients with a mean initial body mass index of 52 kg/m2 were included. Maximum excess weight loss after the sleeve procedure was 63%. Mean time to the second operation was 36 months. The common channel was 250 cm in 41 patients and 300 cm in 10 patients. The follow-up rate was 77% at 5 years. Excess weight loss and total weight loss were 79% and 39%, respectively, at 1 year from the second surgery and 79% and 41%, respectively, at 5 years. Furthermore, 47% of the patients with diabetes achieved complete remission after sleeve gastrectomy, and 94% achieved remission after conversion to single-anastomosis duodenoileal bypass. Final weight loss was significantly higher in those patients who achieved better weight loss after the sleeve gastrectomy than those who did not.

CONCLUSIONS

Single-anastomosis duodenoileal bypass is a beneficial procedure after sleeve gastrectomy for those who fail to lose weight or those with co-morbidities or as a planned second step.

The Effect of Bariatric Surgery on Oral Antibiotic Absorption: a Systematic Review

PURPOSE

The purpose of this study was to conduct a systematic review of the existing literature to determine the effect of bariatric surgery on various pharmacokinetic parameters of oral antibiotic absorption as well as overall patient outcomes.

MATERIALS AND METHODS

MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched up to February 2020. Outcomes of interest included change in pharmacokinetic parameters of oral antibiotics administered to patients following bariatric surgery, using variables such as maximum plasma concentration (Cmax), time to reach maximum plasma concentration (Tmax), area under the concentration-time curve (AUC), clearance, and volume of distribution. MINORS and Cochrane risk of bias tools were used to assess quality of evidence.

RESULTS

Ten studies with 100 patients assessing 8 oral antibiotics were included. The majority (77%) of patients underwent Roux-en-Y gastric bypass (RYGB), with fewer undergoing ventral banded gastroplasty (VBG) (14%), jejunoileostomy (6%), and jejunoileal bypass (3%). Antibiotic classes investigated included beta-lactams (5 studies), fluoroquinolones (2 studies), macrolides (2 studies), and oxazolidinones (1 study). Heterogeneity between studies precluded meaningful pooling or meta-analysis of data. Overall risk of bias was fair.

CONCLUSION

Patients given oral beta-lactams and macrolides warrant close monitoring due to unpredictable absorption post-bariatric surgery, whereas oral fluoroquinolones and linezolid may not be affected. Several studies also showed decreased absorption following RYGB, as well as lower serum exposure in patients with obesity compared to non-obese controls. Clinicians should monitor patients on a case-by-case basis for signs of antibiotic failure or toxicity and reassess dosing accordingly.

Comparative analysis of weight loss and resolution of comorbidities between laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass: A systematic review and meta-analysis based on 18 studies

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy are the most common procedures performed in bariatric surgery and both have been demonstrated to have significant effectiveness in treating morbid obesity. However, comparative analysis of their effectiveness has not been well studied. This comparative analysis was conducted to determine whether Laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy have the same mid- and long-term outcomes in weight loss, resolution of obesity comorbidities and adverse events (AEs) of treatment.

METHODS

We searched the Cochrane Library, PubMed, Embase and Web of Science databases from the establishment of the database to January 1, 2020 for both randomized control trials and non-randomised interventional studies that studied Laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy with respect to weight loss outcomes, resolution of obesity comorbidities and AEs of treatment. Standardised mean differences, risk ratios and odds ratio with 95% confidence intervals were calculated to compare the outcomes of the groups. Two reviewers assessed the quality of the trials and extracted the data independently. All statistical analyses were performed using the standard statistical procedures in Review Manager 5.2.

RESULTS

We included 20 studies (N = 2917 participants) in this meta-analysis. Our results showed no significant difference in excess weight loss between Laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy, with pooled Standardised mean differences of -0.16 (95% confidence interval: -0.52 to 0.19; P = 0.36) based on randomized control trials and 0.07 (95% confidence interval: -0.10 to 0.24; P = 0.41) based on non-randomised interventional studies. Further, the pooled results showed no significant differences in midterm and long-term weight loss outcomes between the comparative groups. Similarly, no significant difference was found in type 2 diabetes mellitus resolution. The pooled results indicated that patients receiving laparoscopic sleeve gastrectomy experienced fewer postoperative complication and reoperation rates, with pooled risk ratios of 1.66 (95% confidence interval: 1.33 to 2.07; P < 0.00001) and 1.73 (95% confidence interval: 1.14 to 2.62; P = 0.01), respectively. Laparoscopic Roux-en-Y gastric bypass was superior to laparoscopic sleeve gastrectomy in managing dyslipidemia, hypertension and gastroesophageal reflux disease.

CONCLUSIONS

The present meta-analysis indicated that both Laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy had the same effectiveness in resulting in excess weight loss and type 2 diabetes mellitus resolution. However, patients who received laparoscopic sleeve gastrectomy experienced fewer postoperative complication and reoperation rates than those who received Laparoscopic Roux-en-Y gastric bypass. Laparoscopic Roux-en-Y gastric bypass was superior in the management of dyslipidemia, hypertension and gastroesophageal reflux disease.

Bridging interventions before bariatric surgery in patients with BMI ≥ 50 kg/m2: a systematic review and meta-analysis

BACKGROUND

Bariatric surgery on patients with body mass index (BMI) ≥ 50 kg/m², historically known as superobesity, is technically challenging and carries a higher risk of complications. Bridging interventions have been introduced for weight loss before bariatric surgery in this population. This systematic review and meta-analysis aims to assess the efficacy and safety of bridging interventions before bariatric surgery in patients with BMI ≥ 50 kg/m².

METHODS

MEDLINE, EMBASE, Web of Science, and Scopus were searched from database inception to September 2018. Studies were eligible for inclusion if they conducted any bridging intervention for weight loss in patients with BMI greater than 50 kg/m² prior to bariatric surgery. Primary outcome was the change in BMI before and after bridging intervention. Secondary outcomes included comorbidity status after bridging interventions and resulting complications. Pooled mean differences (MD) were calculated using random effects meta-analysis.

RESULTS

13 studies including 550 patients met inclusion criteria (mean baseline BMI of 61.26 kg/m²). Bridging interventions included first-step laparoscopic sleeve gastrectomy (LSG), intragastric balloon (IGB), and liquid low-calorie diet program (LLCD). There was a reduction of BMI by 12.8 kg/m² after a bridging intervention (MD 12.8, 95% CI 9.49-16.1, P < 0.0001). Specifically, LSG demonstrated a BMI reduction of 15.2 kg/m² (95% CI 12.9-17.5, P < 0.0001) and preoperative LLCD by 9.8 kg/m² (95% CI 9.82-15.4, P = 0.0006). IGB did not demonstrate significant weight loss prior to bariatric surgery. There was remission or improvement of type 2 diabetes, hypertension, and sleep apnea in 62.8%, 74.6%, and 74.6% of patients, respectively.

CONCLUSIONS

First-step LSG and LLCD are both safe and appropriate bridging interventions which can allow for effective weight loss prior to bariatric surgery in patients with BMI greater than 50 kg/m².