Gastrogastric fistulas. A complication of divided gastric bypass surgery

The risk and benefit of revisional vs. primary metabolic- bariatric surgery and drug therapy - A narrative review

Metabolic and bariatric surgery (MBS) leads to long-term weight loss, reduced risk of cardiovascular events and cancer, and reduced mortality. Sleeve gastrectomy and Roux-en-Y gastric bypass are currently the most common surgical techniques. Weight loss after MBS was previously believed to work through restriction and malabsorption, however, mechanistic studies show that MBS techniques with long term efficacy instead alter physiological signaling between the gut and the brain. In revisional MBS, the initial surgical technique is corrected, modified, or converted to a new one. The indication for revisional MBS can be to achieve further weight loss or improvement in obesity comorbidity, but it may be necessary due to complications (e.g., gastroesophageal reflux or obstruction). Revisional MBS is associated with an increased risk of surgical complications and often less weight loss compared to the results following primary surgery. This narrative review summarizes data from revisional MBS where information is often presented with inconsistent definitions for indications and outcomes, making comparison between strategies difficult. In summary, we suggest careful weighing of potential benefits and risks with revisional MBS, bearing in mind the option of add-on therapy with new anti-obesity drugs.

Weight Regain after Metabolic Surgery: Beyond the Surgical Failure

Patients undergoing metabolic surgery have factors ranging from anatomo-surgical, endocrine metabolic, eating patterns and physical activity, mental health and psychological factors. Some of the latter can explain the possible pathophysiological neuroendocrine, metabolic, and adaptive mechanisms that cause the high prevalence of weight regain in postbariatric patients. Even metabolic surgery has proven to be effective in reducing excess weight in patients with obesity; some of them regain weight after this intervention. In this vein, several studies have been conducted to search factors and mechanisms involved in weight regain, to stablish strategies to manage this complication by combining metabolic surgery with either lifestyle changes, behavioral therapies, pharmacotherapy, endoscopic interventions, or finally, surgical revision. The aim of this revision is to describe certain aspects and mechanisms behind weight regain after metabolic surgery, along with preventive and therapeutic strategies for this complication.

Endoscopic closure versus surgical revision in the management of gastro-gastric fistula following Roux-en-Y gastric bypass

Background and study aims  Gastro-gastric fistulae (GGF) occur in 1.3 % to 6 % of Rouxy-en-Y gastric bypass (RYGB) patients and can be associated with abdominal pain, reflux, weight regain and onset of diabetes. Endoscopic and surgical treatments are available without prior comparisons. The study aim was to compare endoscopic and surgical treatment methods in RYGB patients with GGF. Patients and methods  A retrospective matched cohort study of RYGB patients who underwent endoscopic closure (ENDO) or surgical revision (SURG) for GGF. One-to-one matching was performed based on age, sex, body mass index and weight regain. Patient demographics, GGF size, procedural details, symptoms and treatment-related adverse events (AEs) were collected. A comparison of symptom improvement and treatment-related AEs was performed. Fisher's Exact, t -test and Wilcoxon Rank Sum tests were performed. Results  Ninety RYGB patients with GGF (45 ENDO, 45 matched SURG) were included. GGF symptoms included weight regain (80 %), gastroesophageal reflux disease (71 %) and abdominal pain (67 %). At 6 months, the ENDO and SURG groups experienced 0.59 % and 5.5 % total weight loss (TWL) ( P  = 0.0002). At 12 months, the ENDO and SURG groups experienced 1.9 % and 6.2 % TWL ( P  = 0.007). Abdominal pain improved in 12 (52.2 %) ENDO and 5 (15.2 %) SURG patients at 12 months ( P  = 0.007). Diabetes and reflux resolution rates were similar between groups. Treatment-related AEs occurred in four (8.9 %) ENDO and 16 (35.6 %) SURG patients ( P  = 0.005), of which none and eight (17.8%), respectively, were serious ( P  = 0.006). Conclusions  Endoscopic GGF treatment produces greater improvement in abdominal pain and fewer overall and serious treatment-related AEs. However, surgical revision appears to yield greater weight loss.

Bariatric revisional surgery for gastrogastric fistula following Roux-en-Y gastric bypass positively impacts weight loss

BACKGROUND

Gastrogastric fistula (GGF) is a rare complication from Roux-en-Y gastric bypass (RYGB). It is a known risk factor associated with weight recidivism and an indication for Bariatric Revisional Surgery (BRS).

OBJECTIVES

The primary outcome of this study is to evaluate perioperative outcomes and the long-term total body weight loss (TBWL) outcomes following revision.

SETTING

Single Academic Institution, Center of Bariatric Excellence.

METHODS

We selected patients who had primary bariatric surgery and BRS from 2003 to 2020, followed by BRS for GGF. Patients' demographics, perioperative outcomes, and TBWL were analyzed.

RESULTS

One hundred five patients underwent BRS for GGF. Mean body mass index (BMI) at index operation and revision was 51.6 ± 10.1, and 42.4 ± 11.2 respectively. Ninety percent of patients had open primary RYGB, and 69% had open revisional surgery. The median length of stay after BRS was 3 days. The 30-day reintervention rate was 19%. The 30-day readmission rate was 34%. Of the 77 patients included for weight loss analysis, the mean %TBWL after primary RYGB was 34% ± 14. The total mean %TBWL at the time of revision was 18.8%, translating into a weight regain of 13.6% ± 9.5. The total mean %TBWL after revision was 37.6% ± 11.4, translating into TBWL of 18.8% ± 9.4 after revision when compared to TBWL at revision time.

CONCLUSIONS

Our results demonstrate that revision for GGF can be safely performed, however is associated with higher morbidity than primary bariatric surgery. Revision for GGF results in significant long-term weight loss.

"Innocent as a LAMS": Does Spontaneous Fistula Closure (Secondary Intention), After EUS-Directed Transgastric ERCP (EDGE) via 20-mm Lumen-Apposing Metal Stent, Confer an Increased Risk of Persistent Fistula and Unintentional Weight Gain?

BACKGROUND AND AIMS

Persistent gastrogastric or jejunogastric fistula is theoretically a concerning sequela of EUS-directed transgastric ERCP/EUS (EDGE), as it may functionally reverse the malabsorptive mechanism of Roux-en-Y gastric bypass (RYGB). Prior EDGE studies, using predominantly 15-mm (diameter) lumen-apposing metal stents (LAMS) and fistula closure by primary intent, collectively report 9% persistent fistula rate, without a clear weight gain association. Our study determines the incidence of persistent fistula, and its association with unintentional weight gain, among recipients of EDGE via 20-mm LAMS followed by spontaneous fistula closure (secondary intent).

METHODS

We conducted a dual-center prospective cohort study of 22 RYGB patients who underwent EDGE using 20-mm between 3/2018 and 10/2019. After LAMS extraction, all GGFs/JGFs were allowed to heal spontaneously. Objective testing for persistent fistula and total body weight (TBW) occurred a minimum of 8 weeks after LAMS extraction.

RESULTS

Persistent fistula was identified in 9 patients (41%). Longer LAMS dwell time (median 77-days) was observed in the persistent fistula group, compared to those with durable spontaneous fistula closure (median 35-days) (p = 0.03). Weight gain of ≥ 5% TBW occurred in 56% (n = 5) of patients with persistent fistula, compared to 15% (n = 2) of patients with spontaneous fistula closure (p = 0.128). Four patients with symptomatic persistent fistulas underwent attempted endoscopic fistula closure a median 7.5 months after LAMS extraction. Durable fistula closure occurred in the single patient who received argon plasma coagulation plus endoscopic suturing, whereas fistula dehiscence occurred in 3/3 (100%) patients with endoscopic suturing monotherapy.

CONCLUSIONS

Larger LAMS diameter (20-mm), longer LAMS dwell time, and spontaneous fistula closure may be technical factors that increase the likelihood of post-EDGE persistent fistula. Post-EDGE persistent fistula has not been shown by ours or other studies to be significantly associated with unintentional weight gain; however, this may be due to small sample size. We question the utility of routine fistula closure by primary intent and suggest a personalized approach to post-EDGE fistula management.

Over-the-Scope Clip in the Treatment of Gastrointestinal Leaks and Perforations

While perforations, postoperative fistulas, and leaks have traditionally led to surgical or interventional radiology consultation for management, the introduction of the over-the-scope clip has allowed increased therapeutic possibilities for endoscopists. While primarily limited to case reports and series, the over-the-scope clip successfully manages gastrointestinal bleeding, perforations, as well as postoperative leaks and fistulas. Retrospective studies have demonstrated a relatively high success rate and a low complication rate. Given the similarity to variceal banding equipment, the learning curve with the over-the-scope clip is rapid. However, given the higher risk of procedures involving the use of the over-the-scope clip, it is essential to obtain the scope in a stable position and grasp sufficient tissue with the cap using a grasping tool and/or suction. From our experience, while closure may be successful in lesions sized up to 3 cm, successful outcomes are obtained for lesions sized <1 cm. Ultimately, given the limited available data, prospective randomized trials are needed to better evaluate the utility of the over-the-scope clip in various clinical scenarios, including fistula and perforation management.

Test Characteristics of Abdominal Computed Tomography for the Diagnosis of Gastro-gastric Fistula in Patients with Roux-en-Y Gastric Bypass

INTRODUCTION

Gastrogastric fistulae (GGF) occur in 1-6% of Roux-en-Y gastric bypass (RYGB) patients. Many patients undergo abdominal computed tomography (CT) as an initial test owing to its wide availability; however, CT diagnostic accuracy for GGF is unclear. Our aim was to evaluate test characteristics of abdominal CT compared to upper gastrointestinal series (UGI) and esophagogastroduodenoscopy (EGD) for diagnosing GGF using surgery as a gold standard.

METHODS

Retrospective review of RYGB patients who underwent abdominal CT with oral contrast within 1 year. Demographics, weight parameters, and symptoms were collected. Surgery within 1 year of the diagnostic tests was included as the gold standard comparison. Primary outcomes included CT sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy (DA) for GGF.

RESULTS

One hundred thirty-seven patients were included, where 42 (30.1%) had positive CT and 95 (69.3%) had negative CT for GGF. Compared to surgical confirmation, CT abdomen with PO contrast had sensitivity of 73.1% (59-84.4), specificity of 95.2% (88.3-98.7), PPV 90.5% (77.4-97.3), NPV of 85.1% (76.3-91.2), and DA 89.7%. UGI series had sensitivity of 58.5% (42.1-73.7), specificity of 98.8% (93.5-99.9), PPV of 96% (79.7-99.9), NPV of 82.8% (73.9-89.7), and diagnostic accuracy (DA) of 85.4%. EGD had sensitivity of 78.3% (63.6-89.1), specificity of 98.8% (93.5-99.9), PPV 97.3 (85.8-99.9), and DA 91.5%. There were no significant differences in diagnostic test characteristics among modalities.

CONCLUSIONS

Abdominal CT with oral contrast has similar diagnostic test characteristics to UGI and EGD at detecting GGF when using surgical diagnosis as a gold standard.

Value of contrast-enhanced multidetector computed tomography in imaging of symptomatic patients after laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy

Background

To assess the role of contrast-enhanced multidetector computed tomography (MDCT) in the assessment of symptomatic patients following laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy.

Results

We reviewed the studies of 129 cases and found complications in 113 patients: 55 early complications and 48 late complications. All of these complications were diagnosed with intravenous contrast-enhanced MDCT. Statistically significant difference was found between UGIS and MDCT in the diagnosis of many cases.

Conclusion

The rate of complications in bariatric surgery is high and the associated mortality is not negligible. The interpreting radiologists should know the normal postoperative findings and be aware of possible complications.

Endoscopic Closure of Gastro-gastric Fistula After Gastric Bypass: a Technically Feasible Procedure but Associated with Low Success Rate

BACKGROUND

Gastro-gastric fistulas (GGF) are reported to be as high as 12% after gastric bypass for treatment of morbid obesity. While different endoscopic methods are described, the management traditionally consists of surgical revision with high associated morbidity. The aim of the study was to assess feasibility, safety and success rate of endoscopic closure using an endoscopic suturing device.

METHODS

From January 2016 to March 2018, we reviewed the electronic records of all patients undergoing endoscopic closure of a GGF with the Apollo Overstitch system (Apollo Endosurgery, Austin, Texas, USA). Demographic details, procedure details, and outcome variables were recorded.

RESULTS

A total of six patients (M:F = 5:1) underwent endoscopic fistula closure. Five patients (83.3%) had a prior banded gastric bypass (with subsequent band removal). The median number of prior abdominal surgeries was 3, the mean time from bypass to endoscopic fistula closure was 5 years (range 1.1-10.4). While immediate complete endoscopic fistula closure was possible in 10 of 12 attempts in those six patients (83%), all patients had recurrent (persistent) fistulas at follow-up. After a mean follow-up time of 12 months, 83.3% had further laparoscopic converted to open (n = 2) or laparoscopic (n = 3) revisions with complete fistula closure. One patient is refusing further intervention.

CONCLUSION

Endoscopic gastro-gastric fistula closure with an endoscopic suturing device is feasible and safe. Unfortunately, due to the nature of gastro-gastric fistulas, permanent successful closure is rare. Therefore, the approach should be reserved for patients in whom a laparoscopic or open surgical attempt is impossible due to prior abdominal revisions.

Surgical Management of Gastrogastric Fistula After Roux-en-Y Gastric Bypass: 10-Year Experience

BACKGROUND

Gastrogastric fistula (GGF) occurs in 1-6% of patients who undergo Roux-en-Y gastric bypass (RYGB) for morbid obesity. The pathophysiology may be related to gastric ischemia, fistula, or ulcer.

OBJECTIVES

The purposes of the study are to describe the principles of management and to review the literature of this uncommon complication.

SETTING

The setting of this study is University Hospital, France.

MATERIALS AND METHODS

We conducted a retrospective review of all patients' records with a diagnosis of GGF after RYGB between January 2004 and November 2014.

RESULTS

During the study period, 1273 patients had RYGB for morbid obesity. Fifteen patients presented with a symptomatic GGF (1.18%). The average interval from surgery to presentation was 28 months (22-62). A history of marginal ulcer or anastomotic leak was present in nine patients (60%). The most common presentation was weight regain (80%), followed by pain (73.3%). Two types of fistulas were identified, an exclusively GGF (high) and a gastro-jejuno-gastric fistula (low). High GGF, frequently associated with dilatation of the gastric pouch, was treated by a sleeve of the pouch and sleeve resection of the remnant stomach (nine patients). Low GGF was treated with gastric resection coupled with a revision of the gastrojejunal anastomosis (six patients). All patients were treated laparoscopically with no conversion to laparotomy. The average length of postoperative hospital stay was 5.2 days (range 3-10).

CONCLUSION

GGF after RYGB is a rare complication. Its pathophysiology remains unclear. Surgical management is the definitive treatment.

Metabolic Effect of Foregut Exclusion Demonstrated by the Impact of Gastrogastric Fistula on Recurrence of Diabetes

BACKGROUND

Type 2 diabetes mellitus (T2DM) resolves in >80% of patients after Roux-en-Y gastric bypass (RYGB). It has been hypothesized that foregut exclusion is mechanistically important to this observation. This study aimed to determine whether gastrogastric (GG) fistula, with a loss of foregut exclusion, is associated with T2DM relapse, and to assess whether closure of GG fistula is associated with T2DM resolution.

STUDY DESIGN

A matched cohort study of patients who experienced T2DM remission after RYGB. Cases (patients with GG fistula) were matched to controls (patients without GG fistula) based on age, BMI, weight regain, and duration from RYGB. Primary end point was T2DM relapse. Time-to-event analysis was performed to identify an association between GG fistula and time to T2DM resolution.

RESULTS

One hundred and twenty-six patients (42 cases and 84 controls) were included. Cases experienced a higher rate of T2DM relapse than controls (48% vs 13%; odds ratio 18; p < 0.0001). On multivariable analysis, GG fistula remained a significant predictor of T2DM relapse after controlling for sex and insulin use (odds ratio 6.3; p = 0.02). Of the 42 cases, 20 experienced T2DM relapse, with 1 spontaneous resolution. Of 19, thirteen underwent fistula revision and experienced a higher rate of T2DM resolution than the nonrevision group (69% vs 0%; odds ratio 27; p = 0.036). Time to T2DM resolution was shorter in the revision group compared with the nonrevision group (p = 0.006).

CONCLUSIONS

The RYGB patients with GG fistula have a higher rate of T2DM relapse, compared with those without GG fistula with similar BMI and weight regain. Successful fistula revision is associated with resolution of T2DM.

Double Pigtail Stent Insertion for Healing of Leaks Following Roux-en-Y Gastric Bypass. Our Experience (with Videos)

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is complicated by a leak in 0-4.3% of cases. Treatment by fully covered stents has been reported to be associated with some life-threatening complications. We report our experience of insertion of double pigtail stents.

METHODS

Thirty-three patients (20M, 43 years-20/65), presenting with a leak at an average of 10 days after RYGB (4-35), were treated by double pigtail stent insertion and a nasojejunal feeding tube. Sixty percent of these patients had undergone surgical drainage prior to stenting for control of sepsis. Thirty leaks were located at the top of staple line and three at the gastro-jejunal anastomosis. At a 4-weekly follow-up, ablation or re-stenting was performed depending on status of fistula closure and patients were placed on normal diet.

RESULTS

At the first follow-up, 10/33 fistulae healed, one patient presented with clinical failure (3%) and needed surgery, and 22/33were re-stented. Twenty-one out of these 22 developed a secondary sub-clinical gastro-gastric fistula and one, instead, developed complex (gastro-gastric, gastro-colic) fistula. All (22) primary fistulae healed following four more weeks of treatment. Average treatment duration was of 61 days (28-99). Thirty-two patients (97%) at a follow-up of 1-33 months are asymptomatic.

CONCLUSIONS

Leaks following RYGB can be successfully and safely managed by double pigtail stents. Upper gastric staple line leaks are responsible for the formation of a secondary sub-clinic gastro-gastric fistula which needs no additional treatment.

Effect of Gastrogastric Fistula Closure in Type 2 Diabetes

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) has been shown to significantly improve glucose control in patients with type 2 diabetes (T2DM). The formation of a gastrogastric fistula (GGF) allows nutrients to pass through the native route, rather than bypassing the duodenum in typical RYGB configuration. We sought to evaluate the effect of revisional bariatric surgery for known GGF on control of diabetes.

METHODS

A retrospective chart review of a single academic institution was performed to identify patients who had T2DM at the time of corrective surgery for a GGF. Baseline characteristics, and postoperative outcomes including changes in body mass index (BMI), glycated hemoglobin, fasting blood glucose (FBG), and diabetes medications were assessed.

RESULTS

Ten patients were identified with GGF who had T2DM at the time of corrective surgery. Patients had a male-to-female ratio of 2:3, a mean age of 59.2 ± 10 years, a mean baseline BMI of 38.1 ± 17.6 kg/m², and a median duration of 9 years (interquartile range 6-14) from initial RYGB to revision. At a mean follow-up of 14.9 ± 8.5 months, a mean reduction in BMI of 4.9 ± 6 kg/m² was associated with a significant mean reduction in FBG (167.1 ± 88.2 vs. 106.1 ± 20.4 mg/dL, p = 0.04) and number of diabetes medications (1.4 ± 0.8 vs. 0.7 ± 0.7, p = 0.04).

CONCLUSION

In patients with diabetes and GGF, a corrective surgery for closure of fistula and restoration of bypass anatomy results in improvement of glucose control and status of diabetes medications. This finding can highlight the potential metabolic significance of duodenal exclusion.

Successful laparoscopic repair of gastro-gastric fistula following Roux-en-Y gastric bypass at Harlem Community Hospital

Gastro-gastric fistula is a communication between the gastric remnant and gastric pouch. It is a rare complication of Roux-en-Y gastric bypass. It is caused by anastomotic leak, marginal ulcers, distal obstruction or erosion from foreign body. In this case report, we are presenting a successful laparoscopic repair of gastro-gastric fistula in a patient who presented with weight gain after initial loss.

Over-the-scope clip for endoscopic closure of gastrogastric fistulae

BACKGROUND

Gastrogastric fistulae (GGF) are a well-known complication of Roux-en-Y gastric bypass (RYGB). Endoscopic approaches for closure of GGF have gained popularity, but with limited data and efficacy.

OBJECTIVES

The primary arm of the study was to evaluate the safety and efficacy of the endoscopic closure of GGF using the over-the-scope clip (OTSC) device.

SETTING

University hospital, United States METHODS: This is a retrospective review of consecutive patients at a single academic center from September 2013 to December 2014 who underwent upper endoscopy with attempted OTSC placement for closure of GGF related to RYGB. Preprocedural, procedural, and postprocedural data were collected. Outcome measures included technical success, primary success, and long-term success.

RESULTS

A total of 14 patients underwent attempted GGF closure using OTSC. Twelve of the 14 patients (85.7%) had technical success. Four patients were lost to follow-up. Primary success was achieved in 5 of the 10 patients (50%) in which it was assessed, either by upper gastrointestinal series or endoscopy. One of the 5 patients who had primary success was then lost to follow-up. Of the 4 patients in whom primary success was achieved and had long-term follow up, 75% (n = 3) achieved long-term success at a mean follow-up of 6.6 months from initial OTSC placement (range, 3-9), making for a long-term success rate of 33% (3/9). There were no reported complications.

CONCLUSION

OTSC closure of small GGF is feasible, safe, and offers a reasonable alternative to surgical revision. Large GGF may undergo attempted endoscopic closure, acknowledging a high failure rate.

Laparoscopic Transgastric Repair of a Gastrogastric Fistula After Gastric Bypass

Gastrogastric fistulas are an uncommon complication following laparoscopic Roux-Y gastric bypass surgery (LRYGB) and may be caused by staple-line dehiscence or leak. Described here is a novel technique to treat these fistulae via a laparoscopic transgastric approach and closure of the fistulous tract with an Endo Stitch™ device. The 33-year-old patient, post LRYGB in 2002, with documented gastrogastric fistula, had failed non-operative management. A transoral endoscope was passed into the cephalad portion of the gastrogastric fistula; a glidewire was passed from the gastric pouch into the gastric remnant. Laparoscopically, 2 gastrotomies were made and a “pneumogastrium” created with carbon dioxide. Under direct, transgastric visualization, the distal portion of the gastrogastric fistula was closed using an Endo Stitch™ device. This technique is safe and reproducible when performed by an experienced laparoscopic surgeon and could be modified for other scenarios requiring alternate access to the stomach.

Place of upper endoscopy before and after bariatric surgery: A multicenter experience with 3219 patients

AIM: To study the preoperative and postoperative role of upper esophagogastroduodenoscopy (EGD) in morbidly obese patients.

METHODS: This is a multicenter retrospective study by reviewing the database of patients who underwent bariatric surgery (laparoscopic sleeve gastrectomy, laparoscopic Roux en Y gastric bypass, or laparoscopic minigastric bypass) in the period between 2001 June and 2015 August (Jahra Hospital-Kuwait, Hafr Elbatin Hospital and King Saud Medical City-KSA, and Mansoura University Hospital - Egypt). Patients with age 18-65 years, body mass index (BMI) > 40, or > 35 with comorbidities after failure of many dietetic regimen and acceptable levels of surgical risk were included in the study after having an informed signed consent. We retrospectively reviewed the medical charts of all morbidly obese patients. The patients’ preoperative data included clinical history including upper digestive symptoms and preoperative full workup including EGD. Only patients whose charts revealed weather they were symptomatic or not were studied. We categorized patients accordingly into two groups; with (group A) or without (group B) upper digestive symptoms. The endoscopic findings were categorized into 4 groups based on predetermined criteria. The medical record of patients who developed stricture, leak or bleeding after bariatric surgery was reviewed. Logestic regression analysis was used to identify preoperative predictors that might be associated with abnormal endoscopic findings.

RESULTS: Three thousand, two hundred and nineteen patients in the study period underwent bariatric surgery (75% LSG, 10% LRYDB, and 15% MGB). Mean BMI was 43 ± 13, mean age 37 ± 9 years, 79% were female. Twenty eight percent had presented with upper digestive symptoms (group A). EGD was considered normal in 2414 (75%) patients (9% group A vs 66% group B, P = 0.001). The abnormal endoscopic findings were found high in those patients with upper digestive symptoms. Abnormal findings (one or more) were found in 805 (25%) patients (19% group A vs 6% group B, P = 0.001). Seven patients had critical events during conscious sedation due to severe hypoxemia (< 60%). Rate of stricture in our study was 2.6%. Success rate of endoscopic dilation was 100%. One point nine percent patients with gastric leak were identified with 75% success rate of endoscopic therapy. Three point seven percent patients developed acute upper bleeding. Seventy-eight point two percent patients were treated by conservative therapy and EGD was performed in 21.8% with 100% success and 0% complications.

CONCLUSION: Our results support the performance of EGD only in patients with upper gastrointestinal symptoms. Endoscopy also offers safe effective tool for anastomotic complications after bariatric surgery.

COMPLICATIONS RELATED TO GASTRIC BYPASS PERFORMED WITH DIFFERENT GASTROJEJUNAL DIAMETERS

Background:

Among the options for surgical treatment of obesity, the most widely used has been the Roux-en-Y gastric bypass. The gastrojejunal anastomosis can be accomplished in two ways: handsewn or using circular and linear stapled. The complications can be divided in early and late.

Aim:

To compare the incidence of early complications related with the handsewn gastrojejunal anastomosis in gastric bypass using Fouchet catheter with different diameters.

Method:

The records of 732 consecutive patients who had undergone the bypass were retrospectively analyzed and divided in two groups, group 1 with 12 mm anastomosis (n=374), and group 2 with 15 mm (n=358).

Results:

The groups showed anastomotic stenosis with rates of 11% and 3.1% respectively, with p=0.05. Other variables related to the anastomosis were also analyzed, but without statistical significance (p>0.05).

Conclusion:

The diameter of the anastomosis of 15 mm was related with lower incidence of stenosis. It was found that these patients had major bleeding postoperatively and lower surgical site infection, and in none was observed presence of anastomotic leak.

Gastrogastric fistulae following gastric bypass surgery-clinical recognition and treatment

Gastrogastric fistula (GGF) formation is an uncommon but well-recognized complication following Roux-en-Y gastric bypass for morbid obesity. Patients with GGF may be asymptomatic or have nonspecific problems of abdominal pain, weight regain, or ulcer formation at the gastrojejunal anastomosis. Maintaining a high index of suspicion is the key to diagnosis. Flexible upper endoscopy and upper gastrointestinal fluoroscopy are complementary imaging modalities for securing the diagnosis of GGF. Surgical repair of GGF is generally the most definitive management but is invasive and has the potential for morbidity. Endoscopic methods of closure have gained favor in recent years due to their noninvasive nature despite the lack of long-term data regarding their success. Novel methods of endoscopic closure, including endoscopic suturing, more closely resemble the surgical paradigm and will likely supplant traditional surgical methods for the management of GGF.

Late surgical complications after gastric by-pass: a literature review

INTRODUCTION

Gastric bypass is today the most frequently performed bariatric procedure, but, despite of it, several complications can occur with varied morbimortality. Probably all bariatric surgeons know these complications, but, as bariatric surgery continues to spread, general surgeon must be familiarized to it and its management. Gastric bypass complications can be divided into two groups: early and late complications, taking into account the two weeks period after the surgery. This paper will focus the late ones.

METHOD

Literature review was carried out using Medline/PubMed, Cochrane Library, SciELO, and additional information on institutional sites of interest crossing the headings: gastric bypass AND complications; follow-up studies AND complications; postoperative complications AND anastomosis, Roux-en-Y; obesity AND postoperative complications. Search language was English.

RESULTS

There were selected 35 studies that matched the headings. Late complications were considered as: anastomotic strictures, marginal ulceration and gastrogastric fistula.

CONCLUSION

Knowledge on strategies on how to reduce the risk and incidence of complications must be acquired, and every surgeon must be familiar with these complications in order to achieve an earlier recognition and perform the best intervention.

Weight recidivism post-bariatric surgery: a systematic review

Obesity is considered a worldwide health problem of epidemic proportions. Bariatric surgery remains the most effective treatment for patients with severe obesity, resulting in improved obesity-related co-morbidities and increased overall life expectancy. However, weight recidivism has been observed in a subset of patients post-bariatric surgery. Weight recidivism has significant medical, societal and economic ramifications. Unfortunately, there is a very limited understanding of how to predict which bariatric surgical patients are more likely to regain weight following surgery and how to appropriately treat patients who have regained weight. The objective of this paper is to systematically review the existing literature to assess the incidence and causative factors associated with weight regain following bariatric surgery. An electronic literature search was performed of the Medline, Embase and Cochrane library databases along with the PubMed US national library from January 1950 to December 2012 to identify relevant articles. Following an initial screen of 2,204 titles, 1,437 abstracts were reviewed and 1,421 met exclusion criteria. Sixteen studies were included in this analysis: seven case series, five surveys and four non-randomized controlled trials, with a total of 4,864 patients for analysis. Weight regain in these patients appeared to be multi-factorial and overlapping. Aetiologies were categorized as patient specific (psychiatric, physical inactivity, endocrinopathies/metabolic and dietary non-compliance) and operation specific. Weight regain following bariatric surgery varies according to duration of follow-up and the bariatric surgical procedure performed. The underlying causes leading to weight regain are multi-factorial and related to patient- and procedure-specific factors. Addressing post-surgical weight regain requires a systematic approach to patient assessment focusing on contributory dietary, psychologic, medical and surgical factors.

Variation in utilization of acid-reducing medication at 1 year following bariatric surgery: results from the Michigan Bariatric Surgery Collaborative

BACKGROUND

Morbidly obese patients undergoing bariatric surgery have high rates of gastroesophageal reflux and are often treated with acid-reducing medications (ARM) such as proton pump inhibitors or H2-blockers. The objective of this study was to evaluate the effect of bariatric procedures on the utilization of ARM. We analyzed data from the clinical registry of the Michigan Bariatric Surgery Collaborative on 35,477 patients undergoing bariatric surgery between January 2006 and October 2012 who completed both baseline and 1-year follow-up surveys. Procedures included laparoscopic adjustable gastric banding (LAGB, n=2,627), Roux-en-Y gastric bypass (RYGB, n=6,410), sleeve gastrectomy (SG, n=1,567), and biliopancreatic diversion with duodenal switch (BPD/DS, n=162).

METHODS

Rates of ARM at 1 year by procedure type were compared using logistic regression analysis. Models were adjusted for patient characteristics, baseline co-morbidities, weight loss, and hiatal hernia repair.

RESULTS

Overall ARM use at baseline was 37.7% and declined to 29.6% at 1 year after bariatric surgery. The proportion of patients starting an ARM at 1 year when they were not using one at baseline by procedure was LAGB (13.9%), RYGB (19.2%), SG (21.6%), and BPD/DS (26.7%). The proportion of patients discontinuing an ARM at 1 year when they were using one at baseline by procedure was LAGB (55.6%), RYGB (56.2%), SG (37.3%), and BPD/DS (42.1%). Compared with LAGB on multivariable analysis, the likelihood of ARM use at 1 year was higher for SG (OR 1.70, 95% CI 1.45-1.99) and BDP/DS (OR 1.53, CI .97-2.40) but not different for RYGB (OR 1.02, CI .90-1.16).

CONCLUSION

Overall ARM use decreases after bariatric surgery; however, it is not uniform and depends on procedure type. SG is a significant predictor for ARM use at 1 year.

Effects of gastrogastric fistula repair on weight loss and gut hormone levels

BACKGROUND

Weight regain after gastric bypass (GBP) can be associated with a gastrogastric fistula (GGF), in which a channel forms between the gastric pouch and gastric remnant, allowing nutrients to pass through the "old route" rather than bypassing the duodenum. To further understand the mechanisms by which GGF may lead to weight regain, we investigated gut hormone levels in GBP patients with a GGF, before and after repair.

MATERIALS AND METHODS

Seven post-GBP subjects diagnosed with GGF were studied before and 4 months after GGF repair. Another cohort of 22 GBP control subjects without GGF complication were studied before and 1 year post-GBP. All subjects underwent a 50-g oral glucose tolerance test and blood was collected from 0-120 min for glucose, insulin, ghrelin, PYY3-36, GIP, and GLP-1 levels.

RESULTS

Four months after GGF repair subjects lost 6.0 ± 3.9 kg and had significantly increased postprandial PYY3-36 levels. After GGF repair, fasting and postprandial ghrelin levels decreased and were strongly correlated with weight loss. The insulin response to glucose also tended to be increased after GGF repair, however no concomitant increase in GLP-1 was observed. Compared to the post-GBP group, GLP-1 and PYY3-36 levels were significantly lower before GGF repair; however, after GGF repair, PYY3-36 levels were no longer lower than the post-GBP group.

CONCLUSIONS

These data utilize the GGF model to highlight the possible role of duodenal shunting as a mechanism of sustained weight loss after GBP, and lend support to the potential link between blunted satiety peptide release and weight regain.

Endoscopic management of complications after gastrointestinal weight loss surgery

As more patients undergo bariatric surgery, gastroenterologists will increasingly encounter variant postsurgical anatomies and postoperative complications. We discuss the diagnosis and management of bleeding, ulcers, foreign bodies, stenoses, leaks, fistulas, pancreaticobiliary diseases, weight regain, and dilated outlets.

Managing complications associated with laparoscopic Roux-en-Y gastric bypass for morbid obesity

Obesity has become a major health concern in Canada. This has resulted in a steady rise in the number of bariatric surgical procedures being performed nationwide. The laparoscopic Roux-en-Y gastric bypass (LRYGB) is not only the most common bariatric procedure, but also the gold standard to which all others are compared. With this in mind, it is imperative that all gastrointestinal surgeons understand the LRYGB and have a working knowledge of the common postoperative complications and their management. Early postoperative complications following LRYGB that demand immediate recognition include anastomotic or staple line leak, postoperative hemorrhage, bowel obstruction and incorrect Roux limb reconstructions. Later complications may be challenging to differentiate from other gastrointestinal disorders and include anastomotic stricture, marginal ulceration, fistula formation, weight gain and nutritional deficiencies. We discuss the principles involved in the management of each complication and the timing of referral to specialist bariatric centres.

Endoscopic management of gastrogastric fistulae does not increase complications at bariatric revision surgery

BACKGROUND

Gastrogastric fistula (GGF) is a challenging complication of primary obesity surgery that often leads to revision surgery. The impact of prior endoscopic intervention on subsequent surgical revisional outcomes remains unknown. We present the largest series of Roux-en-Y gastric bypass GGF with subsequent surgical revision of fistulae to date.

METHODS

A database of bariatric surgical revisions performed at a single institution was collected. The cohort was divided between patients with and without attempted endoscopic fistula closure prior to surgical revision. Thirty-day morbidity and mortality was the primary outcome.

RESULTS

Thirty-five cases of revision were performed for GGF. Of the 35 cases, 22 patients had attempted endoscopic closure prior to surgical revision while 13 patients went directly to surgical revision. In the endoscopy group, two minor complications and seven major complications occurred (total 9 of 22; 40.9%). In the surgery only group, three minor complications and three major complications occurred (total 6 of 13; 46.1%). No deaths occurred.

CONCLUSION

Prior attempts at endoscopic fistula closure do not lead to increased surgical complications at the time of surgical revision.

Bariatric surgical anatomy and mechanisms of action

Because bariatric surgery is becoming increasingly common, gastroenterologists need to be familiar with the surgical and endoscopic anatomy of the operations in use today. This review focuses on the 4 most commonly performed bariatric operations in the United States: Roux-en-Y gastric bypass, adjustable gastric band, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch. The anatomy and mechanism of action of each procedure is discussed and illustrated. Emphasis is placed on the endoscopic anatomy, with review of the commonly encountered complications. Emerging techniques and devices are reviewed.

Endoscopic management of common bariatric surgical complications

The primary role of endoscopic intervention in the care of bariatric surgery patients is in the management of late bariatric surgical complications and non-operative revision of the surgical anatomy. In the future, indications for therapeutic endoscopy will involve the gastroenterologist in primary weight loss interventions as cutting edge technology is currently undergoing rigorous scientific evaluation. Endoscopists caring for these patients should become familiar with post-bariatric surgical anatomy, potential complications, common presenting symptoms, anticipated luminal/extra-luminal findings, and endoscopic management of common bariatric complications; this review addresses these issues. This review will discuss common presenting symptoms, luminal as well as extra-luminal findings and endoscopic management of common bariatric complications.

Laparoscopic resectional gastric bypass in patients with morbid obesity: experience on 112 consecutive patients

INTRODUCTION

Gastric bypass, without gastric resection of the distal excluded stomach, is the surgical treatment more frequently performed for morbid obesity. Several postoperative complications related to the “in situ” distal stomach have been described, and few cases of undetected gastric carcinoma located in this segment of stomach have been published. In this paper, we present our early postoperative results in patients submitted to laparoscopic gastric bypass with resection of distal stomach in patients with morbid obesity.

METHODS

One hundred twelve consecutive patients were included in this study. The mean body weight was 112.15±5.1 (range 78–145), and BMI was 40.5±6.9 kg/m2 (32.9–50.3). Patients were submitted to resectional gastric bypass by laparoscopic approach. The operative time was 133.7±29.1 min (range 120–240).

RESULTS

Postoperative complications occurred in 12 patients (10.7%) without any mortality. Early complications were observed in 11 patients while one patient presented a late complication, four patients were re-hospitalized, three of them without operation and other four of them were re-operated due to early (three patients) or late complication (one patient). One hundred patients (89.2%) were discharged at fourth postoperative day, seven patients remained in hospital between 5 and 10 days, and four patients after the tenth day due to complications. Leaks were observed in three patients. The histological study of the resected specimen was normal in only 8.9%.

CONCLUSIONS

Laparoscopic resectional gastric bypass presents very similar results compared to classic gastric bypass, without significant increase of morbidity, mortality, early and late postoperative results, and therefore, it is an option for the surgical treatment of morbid obesity in countries with high risk of gastric carcinoma.

Endoscopic repair of small symptomatic gastrogastric fistulas after gastric bypass surgery: a single center experience

Gastrogastric fistula (GGF) is a known complication of gastric bypass surgery. Revisional surgery for GGF repair can be technically challenging. We describe our experience with endoscopic repair of small GGFs. A retrospective review was performed to identify patients in whom symptomatic GGF was repaired endoscopically at our institution between September 2004 and September 2008. At endoscopy, the fistulous margins were debrided using cold biopsy forceps or ablated using Argon Plasma Coagulation (APC). The fistula was then repaired with endoclips. Status of GGF repair was assessed intra-operatively, at 2 weeks by upper gastrointestinal (UGI) series, and at regular follow-up thereafter. GGF repair was attempted in eight female patients (mean age = 47 years). The average time interval between gastric bypass surgery and GGF presentation was 81 months. The presenting symptoms included nausea, vomiting, abdominal pain, and weight regain. The average duration of endoscopic procedure was 55 min. All GGFs were small (<20 mm). Endoscopic repair of GGF was successful intra-operatively in all patients. Two patients had failure of GGF repair at 2 weeks. Other two patients experienced recurrent symptoms after several weeks and had a delayed failure of GGF repair diagnosed by UGI series. Endoscopic repair has remained successful in four patients at 8-46 months follow-up. Endoscopic repair of small GGFs using endoclips is feasible. It must be considered as an option for management of small GGFs, given its safety, and ease of performance compared to revisional surgery.

Gastrogastric fistula following Roux-en-Y bypass is attributed to both surgical technique and experience

BACKGROUND

The stomach can either be divided or undivided in performing Roux-en-Y gastric bypass (RGB) for morbid obesity. We evaluated whether surgical technique is the sole contributing factor to the formation of gastrogastric fistula (GGF).

METHODS

A retrospective analysis of 1,036 consecutive patients was evaluated. RGB was performed as open undivided, open divided, and laparoscopic (divided). Incidence of GGF was identified for each technique and its relationship to surgical experience was assessed.

RESULTS

Overall incidence of GGF was 1.3%. All fistulae occurred in patients who received undivided open RGB. There was a significant difference between the undivided open group and the divided open+laparoscopic groups (2.1% vs 0%, P<.01). Incidence of GGF decreased over time with increasing open undivided RGB volume.

CONCLUSIONS

GGF was only identified in undivided RGB. The occurrence decreased with increasing surgical experience. Together, overall surgical technique in addition to gastric division must play a role in fistula formation.

Endoscopic closure of gastrogastric fistulas by using a tissue apposition system (with videos)

BACKGROUND

Gastrogastric fistulas (GGFs) are seen in 1.5% to 12.5% of patients after Roux-en-Y gastric bypass (RYGB) bariatric surgery, often leading to failure to lose adequate weight.

OBJECTIVE

The aim of this study was to assess the feasibility, safety, and percentage of successful primary endoluminal closures of GGFs by using a recently developed tissue apposition system in combination with local mucosectomy.

DESIGN

A feasibility and outcome study following institutional review board protocol.

SETTING

Tertiary referral teaching hospital, Legacy Health System, Portland, Oregon.

INTERVENTIONS

A combination of mucosectomy and nonresorbable tissue apposition is used to achieve a permanent closure of the GGF.

PATIENTS

Four patients with 5 GGFs after RYGB; the mean fistula diameter of was 18.6 mm (range 10-30 mm).

RESULTS

Primary closure rate (1 endoscopic session) of 5 GGFs was 100%. The mean procedure time was 88.5 minutes. One to 4 pairs of tissue anchors were used to close the fistulas. The mean time for performing mucosectomy was 21.6 minutes (range 8-42 minutes) and 39.6 minutes (range 12-58 minutes) for fistula closure. Estimated blood loss was on average 2 mL (range 0-5 mL). No complications were recorded. Early success (3 months), as evidenced by early satiety and weight loss, was noted for 3 of 4 patients. After 3 months, only the smallest fistula (10 mm) was still completely closed, and after 6 months, it also showed a pinhole opening.

CONCLUSION

It was feasible to close all fistulas endoscopically without complications. Permanent closure of GGFs could not be achieved.

Endoscopic repair of gastrogastric fistula after Roux-en-Y gastric bypass: a less-invasive approach

BACKGROUND

Gastrogastric fistulas (GGFs) are a well-known complication of Roux-en-Y gastric bypass. Surgical repair of such fistulas is technically difficult, with significant associated morbidity. The aim of the present study was to evaluate the efficacy of endoscopic GGF closure at a university hospital in the United States.

METHODS

Patients with Roux-en-Y gastric bypass and confirmed GGFs on esophagogastroduodenoscopy or barium study. Endoscopic repair was performed with the EndoCinch suturing system (group 1) or clips (group 2). All patients were followed up in the outpatient clinic or interviewed by telephone at 1, 6, and 18 months after the procedure, then as indicated by symptoms.

RESULTS

A total of 95 patients were included in the present series (group 1, n = 71, 75%; group 2, n = 24, 25%). The mean GGF size was significantly larger in group 1 than in group 2 (14.5 +/- 8.7 versus 7.7 +/- 6, P = .01). An average of 2.2 sutures or 3 clips (range 2-7) was used. Complete initial GGF closure was achieved in 90 patients (95%), with reopening in 59 (65%) an average of 177 +/- 202 days. The average follow-up was 395 +/- 49 days, with 22 patients lost to follow-up. Two significant complications were reported (bleeding and an esophageal tear). None of the GGFs with an initial size >20 mm remained closed during the follow-up period compared with 10 (32%) of the 31 fistulas <or=10 mm in diameter remained closed.

CONCLUSION

Peroral endoscopic repair of postbariatric GGFs is technically feasible and safe but with limited durability. The fistula size predicted for long-term outcomes, with the best results seen in fistulas <or=10 mm in diameter.

Analysis of factors associated with durable remission of diabetes after Roux-en-Y gastric bypass

BACKGROUND

Data on the durability of remission of type 2 diabetes mellitus (T2DM) after gastric bypass are limited. Our purpose was to identify the rate of long-term remission of T2DM and the factors associated with durable remission.

METHODS

A total of 177 patients with T2DM who had undergone Roux-en-Y gastric bypass from 1993 to 2003 had 5-year follow-up data available. T2DM status was determined by interview and evaluation of the diabetic medications. Patients with complete remission or recurrence of T2DM were identified.

RESULTS

Follow-up ranged from 5 to 16 years. Of the 177 patients, 157 (89%) had complete remission of T2DM with a decrease in their mean body mass index from baseline (50.2 +/- 8.2 kg/m(2)) to 31.3 +/- 7.2 kg/m(2) postoperatively (mean percentage of excess weight loss 70.0% +/- 18.6%). However, 20 patients (11.3%) did not have T2DM remission despite a mean percentage of excess weight loss of 58.2% +/- 12.3% (P <.0009). Of the 157 patients with initial remission of their T2DM, 68 (43%) subsequently developed T2DM recurrence. Remission of T2DM was durable in 56.9%. Durable (>5-year) resolution of T2DM was greatest in the patients who originally had either controlled their T2DM with diet (76%) or oral hypoglycemic agents (66%). The rate of T2DM remission was more likely to be durable in men (P = .00381). Weight regain was a statistically significant, but weak predictor, of T2DM recurrence.

CONCLUSION

Early remission of T2DM occurred in 89% of patients after Roux-en-Y gastric bypass. T2DM recurred in 43.1%. Durable remission correlated most closely with an early disease stage at gastric bypass.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist health-care professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Estudo da gastrinemia pré e pós-operatória em pacientes submetidos à gastroplastia vertical com banda e reconstrução em Y de Roux por obesidade mórbida

OBJETIVO: Avaliar as concentrações pré e pós-operatória da gastrina sérica, hormônio fundamental na produção do ácido clorídrico gástrico, correlacionando-as com as complicações cloridropépticas pós-cirúrgicas, em pacientes submetidos à gastroplastia vertical com banda e reconstrução em Y de Roux (GVBYR). MÉTODO: Foram incluídos neste estudo, 20 pacientes com Índice de Massa Corpórea (IMC) superior a 40 Kg/m² selecionados após rigorosa avaliação psicológica. A dosagem da gastrina foi realizada no pré e no pós-operatório. Neste mesmo período todos os pacientes forma também submetidos a exame endoscópico com biópsia para estudo histopatológico. RESULTADOS: As quantidades de gastrina produzidas antes e após o tratamento cirúrgico não diferiram significativamente (p= 0,4281). Nenhum paciente apresentou alteração endoscópica ou histológica até o 2º mês de pós-operatório. CONCLUSÃO: Após a realização da GVBYR ocorre uma adaptação do tubo digestivo, de modo a manter a sua fisiologia, conduzindo-nos à convicção da segurança dessa técnica no tratamento da obesidade mórbida.

Revisional operations for marginal ulcer after Roux-en-Y gastric bypass

BACKGROUND

Marginal ulcer is a potentially serious complication of Roux-en-Y gastric bypass (RYGB). This study reviewed 1 surgeon's experience with 39 revisional operations for intractable marginal ulcer after primary RYGB.

METHODS

A total of 2282 consecutive patients underwent RYGB by 1 surgeon from 1984 to 2006, of which 1621 were open and 661 laparoscopic. The stomach was transected in laparoscopic RYGB and was left undivided in the open group. All revisions included ulcer excision, revision of the gastrojejunostomy with gastric transection as needed. Six patients underwent vagotomy.

RESULTS

Of the 2282 patients, 122 (5.3%) developed marginal ulcers (88 and 34 from the open and laparoscopic group, respectively). Of these 122 patients, 39 (32%) underwent revision for intractability (35 open and 4 laparoscopic). Of these 39 patients, 28 (71.7%) had gastrogastric fistulas. Risk factors for ulcer (medication, smoking) were present in 26 patients (66.6%). The primary indications of intractability included abdominal pain (66.6%), gastrointestinal bleeding (20.5%), stomal obstruction (10.2%), and perforation (2.5%). Early postoperative complications included 2 leaks (5.1%) and 2 wound infections (5.1%). Three smokers (7.7%) developed recurrent ulcers postoperatively. One patient died of acute respiratory distress syndrome 5 months postoperatively. Of the 39 patients, 34 (87%) remained asymptomatic after revision. The revision rate was significantly less after laparoscopic RYGB (.6%) than after open RYGB (2.1%; P < or =.0025).

CONCLUSION

The results of our study have shown that operations for intractable marginal ulcer after RYGB are highly successful in nonsmokers. Patients who undergo laparoscopic RYGB with gastric transection are less likely to require revision than patients who undergo RYGB with an incontinuity gastric partition. The rate of reoperation for marginal ulcer was greater than anticipated.