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Shen MR, Hammoud MM, Bonham AJ, Aaron B, Ghaferi AA, Varban OA, Carlin AM, Ehlers AP, Finks JF. Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: impact on reflux and weight loss. Surg Obes Relat Dis 2024; 20:738-744. [PMID: 38704333 DOI: 10.1016/j.soard.2024.04.001] [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: 12/18/2023] [Revised: 03/31/2024] [Accepted: 04/02/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Sleeve gastrectomy (SG) is the most commonly performed weight loss operation, and its 2 most common complications are postoperative reflux and weight recurrence. There is limited evidence to guide decision-making in treating these conditions. OBJECTIVES To determine the efficacy of conversion of SG to Roux-en-Y gastric bypass (RYGB) for GERD management and weight loss. SETTING Forty-one hospitals in Michigan. METHODS We conducted a retrospective cohort study examining patients who underwent conversion of SG to RYGB from 2014 to 2022. The primary outcomes were changes in GERD-HRQL scores, anti-reflux medication use, and weight from baseline to 1 year after conversion. Secondary outcomes included 30-day postoperative complications and resource utilization. RESULTS Among 2133 patients undergoing conversion, 279 (13%) patients had baseline and 1-year GERD-HRQL survey data and anti-reflux medication data. GERD-HRQL scores decreased significantly from 24.6 to 6.6 (P < .01). Among these, 207 patients (74%) required anti-reflux medication at baseline, with only 76 patients (27%) requiring anti-reflux medication at 1 year postoperatively (P < .01). Of the 380 patients (18%) with weight loss data, mean weight decreased by 68.4lbs, with a 24.3% decline in total body weight and 51.5% decline in excess body weight. In terms of 30-day complications, 308 (14%) patients experienced any complication and 89 (4%) experienced a serious complication, but there were no leaks, perforations, or deaths. Three-hundred and fifty-five (17%) patients presented to the emergency department and 64 (3%) patients underwent reoperation. CONCLUSIONS This study represents the largest reported experience with conversion from SG to RYGB. We found that conversion to RYGB is associated with significant improvement in GERD symptoms, reduction in anti-reflux medication use, and significant weight loss and is therefore an effective treatment for GERD and weight regain after SG. However, the risks and benefits of conversion surgery should be carefully considered, especially in patients with significant comorbidity burden.
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Affiliation(s)
- Mary R Shen
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Department of Psychiatry, Mass General Brigham, Boston, Massachusetts
| | - Maya M Hammoud
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Aaron J Bonham
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Bryan Aaron
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Amir A Ghaferi
- Department of Surgery, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Oliver A Varban
- Department of Surgery, Henry Ford Health System, Detroit, Michigan
| | - Arthur M Carlin
- Department of Surgery, Henry Ford Health System, Detroit, Michigan
| | - Anne P Ehlers
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jonathan F Finks
- Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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Rapolti DI, Monrabal Lezama M, Manueli Laos EG, Schlottmann F, Masrur MA. Management of Gastroesophageal Reflux Disease after Sleeve Gastrectomy: Effectiveness of Medical, Endoscopic, and Surgical Therapies. J Laparoendosc Adv Surg Tech A 2024; 34:581-602. [PMID: 38568115 DOI: 10.1089/lap.2024.0111] [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] [Indexed: 07/26/2024] Open
Abstract
Introduction: Sleeve gastrectomy (SG) has become the most frequently performed bariatric operation in the United States. One of the main disadvantages of this procedure is the risk of developing gastroesophageal reflux disease (GERD) after the operation. We aimed to analyze different approaches for the treatment of GERD after SG. Methods: A literature review was performed to identify all possible treatment options for post-SG GERD. All the studies were assessed for full eligibility by manual assessment of their aims, methodology, results, and conclusions. Records were individually reviewed by the authors comparing outcomes and complications between procedures. Results: Although some studies have shown improvement or even resolution of GERD symptoms after SG, most patients develop or worsen symptoms. Lifestyle modifications along with medical therapy should be started on patients with GERD after SG. For those who are refractory to medication, endoscopic and surgical therapies can be offered. Conversion to Roux-en-Y gastric bypass (RYGB) is consistently effective in treatment of GERD and is the ideal therapy in patients with associated insufficient weight loss. Endoscopic and alternative surgical procedures are also available and have shown acceptable short-term outcomes. Conclusions: Several treatment options exist for the treatment of GERD after SG. Although conversion to RYGB remains the most effective therapy, other emerging endoscopic and surgical procedures could avoid the potential morbidity of this procedure and should be further evaluated. An evidence-based algorithm for the management of GERD after SG is proposed to guide decision making.
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Affiliation(s)
- Diana I Rapolti
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
| | | | | | - Francisco Schlottmann
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Mario A Masrur
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
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3
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Evans LA, Castillo-Larios R, Cornejo J, Elli EF. Challenges of Revisional Metabolic and Bariatric Surgery: A Comprehensive Guide to Unraveling the Complexities and Solutions of Revisional Bariatric Procedures. J Clin Med 2024; 13:3104. [PMID: 38892813 PMCID: PMC11172990 DOI: 10.3390/jcm13113104] [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: 04/01/2024] [Revised: 05/15/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Revisional metabolic and bariatric surgery (RMBS) presents unique challenges in addressing weight loss failure or complications arising from initial bariatric procedures. This review aims to explore the complexities and solutions associated with revisional bariatric procedures comprehensively, offering insights into the evolving terrain of metabolic and bariatric surgery. A literature review is conducted to identify pertinent studies and expert opinions regarding RMBS. Methodological approaches, patient selection criteria, surgical techniques, preoperative assessments, and postoperative management strategies are synthesized to provide a comprehensive overview of current practices and advancements in the field, including institutional protocols. This review synthesizes key findings regarding the challenges encountered in RMBS, including the underlying causes of primary procedure failure, anatomical complexities, technical considerations, and assessments of surgical outcomes. Additionally, patient outcomes, complication rates, and long-term success are presented, along with institutional approaches to patient assessment and procedure selection. This review provides valuable insights for clinicians grappling with the complexities of RMBS. A comprehensive understanding of patient selection, surgical techniques, preoperative management, and postoperative care is crucial for enhancing outcomes and ensuring patient satisfaction in the field of metabolic bariatric surgery.
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Affiliation(s)
| | | | | | - Enrique F. Elli
- Department of Surgery, Mayo Clinic Florida, 4500 San Pablo Rd., Jacksonville, FL 32224, USA
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4
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Pina L, Parker DM, Wood GC, Smith B, Petrick AT, Obradovic V. Laparoscopic sleeve gastrectomy conversion to gastric bypass: conversion rate over time, predictors of conversion, and weight loss outcomes. Surg Obes Relat Dis 2024; 20:462-466. [PMID: 38155076 DOI: 10.1016/j.soard.2023.11.018] [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: 09/03/2023] [Revised: 11/01/2023] [Accepted: 11/28/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is the most common Bariatric procedure in the United States; however, the frequency of conversion to Roux-en-Y gastric bypass (RYGB) is unknown. OBJECTIVES The primary aim was to determine the conversion rate over time from LSG to RYGB. The secondary objectives were to evaluate factors associated with conversion and postconversion weight loss outcomes. SETTING Single Academic Institution, Center of Bariatric Excellence. METHODS A retrospective analysis of all LSG from 2011 to 2020 was done. Kaplan-Meier analysis was utilized to estimate the conversion rate over time after LSG. Cox regression was utilized to identify predictors of future conversion. RESULTS Of 875 LSGs, 46 were converted to RYGB from 2011 to 2020. Median follow-up was 2.6 years, and 7-year follow-up rate was 59.9%. The 1-year conversion rate was 1.4%, increasing to 3.8%, 9.0%, and 12.6% at 3, 5, and 7 years respectively. Female gender (hazard ratio [HR] = 4.2, P = .05) and age <55 (HR = 3.5, P = .04) were associated with greater chance of conversion. Preoperative asthma (HR = 1.7, P = .14) and gastroesophageal reflux disease (GERD) (HR = 1.5, P = .18) trended toward higher conversion but were not significant. Of those with body mass index (BMI) >35 at time of conversion, the mean total body weight loss (TBWL) was 13.0% at the time of conversion. This subgroup had additional 13.6% of TBWL 1-year after conversion. CONCLUSIONS Conversion of LSG to RYGB increased with time to 12.6% conversion rate at 7-years. Patients with GERD prior to LSG had a nonsignificant trend toward conversion, while younger patients and females had significantly higher rates of conversion. There may be additional weight loss benefit for patients converted to RYGB.
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Affiliation(s)
- Luis Pina
- Division of Bariatric and Foregut Surgery and The Obesity Institute, Geisinger Health System, Danville, Pennsylvania
| | - David M Parker
- Division of Bariatric and Foregut Surgery and The Obesity Institute, Geisinger Health System, Danville, Pennsylvania.
| | - G Craig Wood
- Division of Bariatric and Foregut Surgery and The Obesity Institute, Geisinger Health System, Danville, Pennsylvania
| | - Benjamin Smith
- Division of Bariatric and Foregut Surgery and The Obesity Institute, Geisinger Health System, Danville, Pennsylvania
| | - Anthony T Petrick
- Division of Bariatric and Foregut Surgery and The Obesity Institute, Geisinger Health System, Danville, Pennsylvania
| | - Vladan Obradovic
- Division of Bariatric and Foregut Surgery and The Obesity Institute, Geisinger Health System, Danville, Pennsylvania
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Hany M, Torensma B, Zidan A, Ibrahim M, Abouelnasr AA, Agayby ASS, Sayed IE. Outcomes of primary versus conversional Roux-En-Y gastric bypass after laparoscopic sleeve gastrectomy: a retrospective propensity score-matched cohort study. BMC Surg 2024; 24:84. [PMID: 38448841 PMCID: PMC10919008 DOI: 10.1186/s12893-024-02374-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 02/27/2024] [Indexed: 03/08/2024] Open
Abstract
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.
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Affiliation(s)
- Mohamed Hany
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Alexandria, 21561, Egypt.
- Consultant of bariatric surgery at Madina Women's hospital (IFSO-certified bariatric center), Alexandria, Egypt.
| | - Bart Torensma
- Clinical Epidemiologist, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Ahmed Zidan
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Alexandria, 21561, Egypt
| | - Mohamed Ibrahim
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Alexandria, 21561, Egypt
| | - Anwar Ashraf Abouelnasr
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Alexandria, 21561, Egypt
| | - Ann Samy Shafiq Agayby
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Alexandria, 21561, Egypt
| | - Iman El Sayed
- Biomedical Informatics and Medical Statistics Department, Medical Research Institute, Alexandria University, Alexandria, Egypt
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6
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Ganam S, Tang R, Sher T, Worthey A, Docimo S. Quality of Life in Patients Undergoing Revisional Bariatric Surgery: From Sleeve Gastrectomy to Roux-en-Y Gastric Bypass. Obes Surg 2024; 34:997-1003. [PMID: 38308103 DOI: 10.1007/s11695-024-07082-y] [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: 12/29/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 02/04/2024]
Abstract
Sleeve gastrectomy (SG) is the most performed bariatric surgery worldwide. However, this surgery may be associated with long-term weight regain and severe gastroesophageal reflux disease (GERD), sometimes necessitating conversion to Roux-en-Y gastric bypass (RYGB) to improve quality of life (QoL). We conducted a systematic review on QoL measures following the conversion of SG to RYGB. We searched various databases for studies conducted between January 2005 and September 2023. Four studies, involving 196 participants in total, met the inclusion criteria. Different assessment methods were used to evaluate QoL following the conversion. In the included studies, we observed that GERD symptoms and proton pump inhibitor (PPI) use both decreased following conversion to RYGB. Excess weight loss (EWL) was also observed in all studies.
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Affiliation(s)
- Samer Ganam
- Morsani College of Medicine, University of South Florida, Horatio Street, Tampa, FL, 33609, USA.
- Division of Gastrointestinal Surgery, Tampa General Hospital, Horatio Street, Tampa, FL, 33609, USA.
| | - Ryan Tang
- Morsani College of Medicine, University of South Florida, Horatio Street, Tampa, FL, 33609, USA
| | - Theo Sher
- Morsani College of Medicine, University of South Florida, Horatio Street, Tampa, FL, 33609, USA
| | - Ayana Worthey
- Division of Gastrointestinal Surgery, Tampa General Hospital, Horatio Street, Tampa, FL, 33609, USA
| | - Salvatore Docimo
- Morsani College of Medicine, University of South Florida, Horatio Street, Tampa, FL, 33609, USA
- Division of Gastrointestinal Surgery, Tampa General Hospital, Horatio Street, Tampa, FL, 33609, USA
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7
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Mackey EE, Dore FJ, Kelly JF, Crawford AS, Cohen P, Czerniach D, Perugini R, Kelly JJ, Cherng NB. Ligamentum teres cardiopexy for post vertical sleeve gastrectomy gastroesophageal reflux. Surg Endosc 2023; 37:7247-7253. [PMID: 37407712 DOI: 10.1007/s00464-023-10239-y] [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: 04/04/2023] [Accepted: 06/11/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE Vertical sleeve gastrectomy (VSG) evolved in the early 2000s into the standalone weight loss procedure we see today. While numerous studies highlight VSG's durability for weight loss, and improvements co-morbidities such as type 2 diabetes mellitus and cardiovascular disease, patients with gastroesophageal reflux disease (GERD) have been counseled against VSG due to the concern for worsening reflux symptoms. When considering anti-reflux procedures, VSG patients are unable to undergo traditional fundoplication due to lack of gastric cardia redundancy. Magnetic sphincter augmentation lacks long-term safety data and endoscopic approaches have undetermined longitudinal benefits. Until recently, the only option for patients with a history of VSG with medically refractory GERD has been conversion to roux en Y gastric bypass (RNYGB), however, this poses other risks including marginal ulcers, internal hernias, hypoglycemia, dumping syndrome, and nutritional deficiencies. Given the risks associated with conversion to RNYGB, we have adopted the ligamentum teres cardiopexy as an option for patients with intractable GERD following VSG. METHODS A retrospective chart review was conducted of patients who had prior laparoscopic or robotic VSG and subsequently GERD symptoms refectory to pharmacological management who underwent ligamentum teres cardiopexy between 2017 and 2022. Pre-operative GERD disease burden, intraoperative cardiopexy characteristics, post-operative GERD symptomatology and changes in H2 blocker or PPI requirements were reviewed. RESULTS Of the study's 60 patients the median age was 50 years old, and 86% were female. All patients had a diagnosis of GERD through pre-operative assessments and were taking antisecretory medication. Of the 36 patients who have completed their one year follow up, 81% of patients had either a decrease in dosage or cessation of the antisecretory medication at one year following ligamentum teres cardiopexy. CONCLUSION Ligamentum teres cardiopexy is a viable alternative to RNYGB in patients with a prior vertical sleeve gastrectomy with medical refractory GERD.
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Affiliation(s)
- Emily E Mackey
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Fiona J Dore
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - John F Kelly
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Allison S Crawford
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Philip Cohen
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Donald Czerniach
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Richard Perugini
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - John J Kelly
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Nicole B Cherng
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA.
- Division of Minimally Invasive Surgery, University of Massachusetts Chan Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
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8
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Dirnberger AS, Süsstrunk J, Schneider R, Poljo A, Klasen JM, Slawik M, Billeter AT, Müller-Stich BP, Peterli R, Kraljević M. Mid-Term Outcomes After Conversion Procedures Following Laparoscopic Sleeve Gastrectomy. Obes Surg 2023; 33:2679-2686. [PMID: 37515694 PMCID: PMC10435413 DOI: 10.1007/s11695-023-06734-9] [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: 05/08/2023] [Revised: 07/07/2023] [Accepted: 07/14/2023] [Indexed: 07/31/2023]
Abstract
PURPOSE In the long term, laparoscopic sleeve gastrectomy (SG) may be associated with insufficient weight loss (IWL), gastroesophageal reflux disease (GERD), and persistence or relapse of associated medical problems. This study's objective is to present mid-term results regarding weight loss (WL), evolution of associated medical problems, and reoperation rate of patients who underwent a conversion after SG. METHODS Retrospective single-center analysis of patients with a minimal follow-up of 2 years after conversion. RESULTS In this series of 549 SGs, 84 patients (15.3%) underwent a conversion, and 71 met inclusion criteria. They were converted to short biliopancreatic limb Roux-en-Y gastric bypass (short BPL RYGB) (n = 28, 39.4%), biliopancreatic diversion with duodenal switch (BPD/DS) (n = 19, 26.8%), long biliopancreatic limb Roux-en-Y gastric bypass (long BPL RYGB) (n = 17, 23.9%), and re-sleeve gastrectomy (RSG) (n = 7, 9.9%). Indications were GERD (n = 24, 33.8%), IWL (n = 23, 32.4%), IWL + GERD (n = 22, 31.0%), or stenosis/kinking of the sleeve (n = 2, 2.8%). The mean pre-revisional body mass index (BMI) was 38.0 ± 7.5 kg/m2. The mean follow-up time after conversion was 5.1 ± 3.1 years. The overall percentage of total weight loss (%TWL) was greatest after BPD/DS (36.6%) and long BPL RYGB (32.9%) compared to RSG (20.0%; p = 0.004; p = 0.049). In case of GERD, conversion to Roux-en-Y gastric bypass (RYGB) led to a resolution of symptoms in 79.5%. 16.9% of patients underwent an additional revisional procedure. CONCLUSION In the event of IWL after SG, conversion to BPD/DS provides a significant and sustainable additional WL. Conversion to RYGB leads to a reliable symptom control in patients suffering from GERD after SG.
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Affiliation(s)
- Amanda S Dirnberger
- University Digestive Health Care Center Basel - Clarunis, CH-4002, Basel, Switzerland
| | - Julian Süsstrunk
- University Digestive Health Care Center Basel - Clarunis, CH-4002, Basel, Switzerland
| | - Romano Schneider
- University Digestive Health Care Center Basel - Clarunis, CH-4002, Basel, Switzerland
| | - Adisa Poljo
- University Digestive Health Care Center Basel - Clarunis, CH-4002, Basel, Switzerland
| | - Jennifer M Klasen
- University Digestive Health Care Center Basel - Clarunis, CH-4002, Basel, Switzerland
| | - Marc Slawik
- Interdisciplinary Center of Nutritional and Metabolic Diseases, St. Clara Hospital, CH-4058, Basel, Switzerland
| | - Adrian T Billeter
- University Digestive Health Care Center Basel - Clarunis, CH-4002, Basel, Switzerland
| | - Beat P Müller-Stich
- University Digestive Health Care Center Basel - Clarunis, CH-4002, Basel, Switzerland
- Department of Clinical Research, University of Basel, CH-4031, Basel, Switzerland
| | - Ralph Peterli
- University Digestive Health Care Center Basel - Clarunis, CH-4002, Basel, Switzerland.
- Department of Clinical Research, University of Basel, CH-4031, Basel, Switzerland.
| | - Marko Kraljević
- University Digestive Health Care Center Basel - Clarunis, CH-4002, Basel, Switzerland
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Fehervari M, Banh S, Varma P, Das B, Al-Yaqout K, Al-Sabah S, Khwaja H, Efthimiou E, Ashrafian H. 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. Surg Obes Relat Dis 2023; 19:384-395. [PMID: 36581551 DOI: 10.1016/j.soard.2022.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/03/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Matyas Fehervari
- Department of Bariatric and Metabolic Surgery, Chelsea and Westminster Hospital, London, United Kingdom; Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
| | - Serena Banh
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Piyush Varma
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Bibek Das
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | | | | | - Haris Khwaja
- Department of Bariatric and Metabolic Surgery, Chelsea and Westminster Hospital, London, United Kingdom; Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | | | - Hutan Ashrafian
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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10
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Strauss AL, Triggs JR, Tewksbury CM, Soriano I, Wernsing DS, Dumon KR, Williams NN, Shao JM. Conversion to Roux-En-Y Gastric Bypass: a successful means of mitigating reflux after laparoscopic sleeve gastrectomy. Surg Endosc 2023:10.1007/s00464-023-10024-x. [PMID: 36997653 DOI: 10.1007/s00464-023-10024-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/12/2023] [Indexed: 04/01/2023]
Abstract
INTRODUCTION Laparoscopic sleeve gastrectomy (LSG) has become the most common bariatric procedure due to the technical ease and weight loss success of the operation. However, there has been concern that LSG contributes to gastroesophageal reflux disease (GERD) postoperatively with a proportion of patients requiring conversion to a Roux-En-Y Gastric Bypass (RYGB). The objective of this study was to characterize the patients who underwent revision in our hospital system and to better understand pre-operative predictors of GERD and revision. METHODS After IRB approval, a retrospective review was conducted assessing for patients who had conversion of LSG to RYGB at three hospitals within the University of Pennsylvania Health System from January 2015 to December 2021. The patients' charts were then reviewed to evaluate for demographics, BMI, operative findings, imaging and endoscopic reports, and post-operative outcomes. RESULTS 97 patients were identified who underwent conversion of LSG to RYGB between January 2015 and December 2021. The cohort was predominantly female (n = 89, 91.7%) with an average age of 42.7 ± 10.6 years at the time of conversion. The most common indications for revision were GERD (72.2%) and obesity/insufficient weight loss (24.7%). Patients lost an average of 11.1 ± 12.9 kg after revision to RYGB. Of the patients who underwent revision for GERD, 80.2% noted global symptomatic improvement after revision and 19.4% were able to stop their proton pump inhibitor (PPI) postoperatively, with most patients decreasing the frequency of the PPI use postoperatively. CONCLUSION The majority of patients who underwent conversion from LSG to RYGB due to GERD and saw marked improvements in GERD symptoms and outcomes. These findings illuminate the real-world practices and outcomes of bariatric revisional procedures for reflux and the need for more research on standardized practice.
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Affiliation(s)
- Alexandra L Strauss
- Division of Gastroenterology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | | | - Ian Soriano
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - David S Wernsing
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristoffel R Dumon
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Noel N Williams
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jenny M Shao
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
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11
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Best practice approach for redo-surgeries after sleeve gastrectomy, an expert's modified Delphi consensus. Surg Endosc 2023; 37:1617-1628. [PMID: 36693918 DOI: 10.1007/s00464-023-09879-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 01/08/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Sleeve gastrectomy (SG) is the most common metabolic and bariatric surgical (MBS) procedure worldwide. Despite the desired effect of SG on weight loss and remission of obesity-associated medical problems, there are some concerns regarding the need to do revisional/conversional surgeries after SG. This study aims to make an algorithmic clinical approach based on an expert-modified Delphi consensus regarding redo-surgeries after SG, to give bariatric and metabolic surgeons a guideline that might help for the best clinical decision. METHODS Forty-six recognized bariatric and metabolic surgeons from 25 different countries participated in this Delphi consensus study in two rounds to develop a consensus on redo-surgeries after SG. An agreement/disagreement ≥ 70.0% on statements was considered to indicate a consensus. RESULTS Consensus was reached for 62 of 72 statements and experts did not achieve consensus on 10 statements after two rounds of online voting. Most of the experts believed that multi-disciplinary team evaluation should be done in all redo-procedures after SG and there should be at least 12 months of medical and supportive management before performing redo-surgeries after SG for insufficient weight loss, weight regain, and gastroesophageal reflux disease (GERD). Also, experts agreed that in case of symptomatic GERD in the presence of adequate weight loss, medical treatment for at least 1 to 2 years is an acceptable option and agreed that Roux-en Y gastric bypass is an appropriate option in this situation. There was disagreement consensus on efficacy of omentopexy in rotation and efficacy of fundoplication in the presence of a dilated fundus and GERD. CONCLUSION Redo-surgeries after SG is still an important issue among bariatric and metabolic surgeons. The proper time and procedure selection for redo-surgery need careful considerations. Although multi-disciplinary team evaluation plays a key role to evaluate best options in these situations, an algorithmic clinical approach based on the expert's consensus as a guideline can help for the best clinical decision-making.
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12
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Roach E, Laplante S, Stogryn S, Maeda A, Jackson T, Okrainec A. Weight loss outcomes for patients undergoing conversion to Roux-en-Y-gastric bypass after sleeve gastrectomy. Surg Endosc 2022; 37:3208-3214. [PMID: 35982286 DOI: 10.1007/s00464-022-09506-1] [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: 03/21/2022] [Accepted: 07/23/2022] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Eileen Roach
- Division of General Surgery, University Health Network, Toronto, ON, Canada.
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Division of General Surgery, Toronto Western Hospital, 8MP-325. 399 Bathurst St., Toronto, ON, M5T 2S8, Canada.
| | - Simon Laplante
- Division of General Surgery, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Shannon Stogryn
- Division of General Surgery, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Azusa Maeda
- Division of General Surgery, University Health Network, Toronto, ON, Canada
| | - Timothy Jackson
- Division of General Surgery, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Allan Okrainec
- Division of General Surgery, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
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13
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Outcome of Sleeve Gastrectomy Converted to Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass. Obes Surg 2022; 32:643-651. [PMID: 35028871 PMCID: PMC8866292 DOI: 10.1007/s11695-021-05866-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 12/19/2021] [Accepted: 12/22/2021] [Indexed: 11/19/2022]
Abstract
Purpose Sleeve gastrectomy (SG) is the commonest bariatric procedure worldwide but there is also a high conversion rate mainly due to weight regain and gastroesophageal reflux disease (GERD) reported in studies with long-term follow-up. The aim of this study is to highlight benefits and limitations of converting SG patients to Roux-en-Y gastric bypass (RYGB) and one-anastomosis gastric bypass (OAGB). Setting Retrospective cross-sectional-study, medical university clinic setting. Methods This study includes all patients converted from primary SG to RYGB or OAGB by 12/2018 at the Medical University of Vienna. Patients were examined using gastroscopy, esophageal manometry, 24-h pH-metry, and questionnaires. Results Fifty-eight patients were converted from SG to RYGB (n = 45) or OAGB (n = 13). Total weight loss of patients converted to RYGB and OAGB was 41.5% and 44.8%, respectively, at nadir. Six patients had Barrett’s esophagus (BE) after SG. In four out of these six patients, a complete remission of BE after conversion to RYGB was observed; nevertheless, two patients after RYGB and one after OABG newly developed BE. Clinical GERD improved at a higher rate after RYGB than after OAGB. Both revisional procedures improved associated medical problems. Conclusion Conversion to RYGB is probably the best option for patients with GERD after SG. OAGB has shown a low potential to cure patients from GERD symptoms after SG. In terms of additional weight loss and remission of associated medical problems, both procedures studied were equal. Surveillance gastroscopies every 5 years after SG revisions are recommended. Graphical abstract ![]()
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Gagner M. Comment on: Conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass: patterns predicting persistent symptoms after revision. Surg Obes Relat Dis 2021; 17:1689-1690. [PMID: 34284960 DOI: 10.1016/j.soard.2021.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 06/26/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Michel Gagner
- Hôpital du Sacre Coeur, Montreal, Québec, Canada; Westmount Square Surgical Center, Westmount, Québec, Canada
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15
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Ghanem OM, Badaoui JN. Comment on: Conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass: patterns predicting persistent symptoms after revision. Surg Obes Relat Dis 2021; 17:1690-1691. [PMID: 34275762 DOI: 10.1016/j.soard.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/19/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Omar M Ghanem
- Department of General Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph N Badaoui
- Division of Breast, Endocrine, Metabolic, and GI Surgery, Mayo Clinic, Rochester, Minnesota
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