The technique and early results of high gastric reduction for obesity

Endoscopic reversal of the modified Long vertical gastroplasty

Endoscopic techniques are revolutionizing bariatric surgery because of the significant risks that obesity places on both anaesthesia and surgery. Due to the high number of long-term complications that may be associated with bariatric surgery, and the relative safety of endoscopy compared to operative management, endoscopic methods for reversal of previous bariatric techniques are becoming the favoured approach. We describe the use of an endoscopic stent to assist with endoscopic reversal of a modified Long vertical gastroplasty. The modified Long vertical gastroplasty was a restrictive bariatric procedure that was effective to promote weight loss, but had adverse effects including dysphagia, reflux, indigestion and weight regain. The use of an adjunct stent not only treated the patient's reflux by dilating the stricture but allowed for erosion of the sutures intra-luminally to be removed endoscopically. The endoscopic reversal of this technique is safe and helped to relieve the patient's symptoms of reflux and dysphagia.

Long-Term Outcomes of Revisional Malabsorptive Bariatric Surgery: Do the Benefits Outweigh the Risk?

Purpose

To evaluate the long-term outcomes of revisional malabsorptive bariatric surgery.

Materials and Methods

Malabsorptive bariatric procedures are increasingly performed in the revisional setting. We collated and analysed prospectively recorded data for all patients who underwent a revisional Biliopancreatic diversion + / − duodenal switch (BPD + / − DS) over a 17-year period.

Results

We identified 102 patients who underwent a revisional BPD + / − DS. Median follow-up was 7 years (range 1–17). There were 21 (20.6%) patients permanently lost to follow-up at a median of 5 years postoperatively. Mean total weight loss since the revisional procedure of 22.7% (SD 13.4), 20.1% (SD 10.5) and 17.6% (SD 5.5) was recorded at 5, 10 and 15 years respectively. At the time of revisional surgery, 23 (22.5%) patients had diabetes and 16 (15.7%) had hypercholesterolaemia with remission of these occurring in 20 (87%) and 7 (44%) patients respectively. Nutritional deficiencies occurred in 82 (80.4%) patients, with 10 (9.8%) patients having severe deficiencies requiring periods of parenteral nutrition. Seven (6.9%) patients required limb lengthening or reversal procedures. There were 16 (15.7%) patients who experienced a complication within 30 days, including 3 (2.9%) anastomotic leaks. Surgery was required in 42 (41.2%) patients for late complications.

Conclusion

Revisional malabsorptive bariatric surgery induces significant long-term weight loss and comorbidity resolution. High rates of temporary and permanent attrition from follow-up are of major concern, given the high prevalence of nutritional deficiencies. These data question the long-term safety of malabsorptive bariatric procedures due to the inability to ensure compliance with nutritional supplementation and long-term follow-up requirements.

Graphical abstract

Key points

• Revisional bariatric surgery workload is increasing

• Revisional malabsorptive surgery is efficacious for weight loss and comorbidity resolution

• Revisional malabsorptive surgery is associated with high rates of nutritional deficiencies

• Attrition from follow-up in this specific cohort of patients is of particular concern due to the risk of undiagnosed and untreated nutritional deficiencies

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-022-06019-7.

From the Knife to the Endoscope-a History of Bariatric Surgery

PURPOSE OF REVIEW

This review was conducted to gain insight into the history, present and future of bariatric and/or metabolic surgery and endoscopic treatments of obesity. The challenges that have been overcome, the challenges we still face and our recommendations for the future are discussed.

RECENT FINDINGS

Over the last few decades, a number of treatment strategies have emerged for the treatment of obesity. Both endoscopic and surgical options are available and they lead to significant weight loss and comorbidity reduction. However, to remain a credible treatment alternative to the obesity pandemic, we need to perform these procedures in much larger numbers than we currently do. Even though significant gains have been made in reducing the morbidity and mortality of surgical interventions, there is further room for improvement, especially when it comes to long-term issues. Due to its impact on almost every single organ system in the human body, bariatric surgery has attracted the attention of academics from a variety of medical disciplines. This has led to a rapidly enlarging body of high-quality scientific literature, supporting its wider use and cost-effectiveness.

CONCLUSION

Despite the advances made in bariatric surgery, the criteria determining suitability of patients for bariatric surgery in most parts of the world are still based on a consensus agreed upon in the USA in 1991. There is a need to formulate some new consensus and guidelines that would allow for a significant expansion of the pool of patients that can be offered these procedures.

Future directions in bariatric surgery

Bariatric surgery is a field in rapid evolution, and the speed of this evolution has been accelerating over the last several decades. A thorough understanding of past developments is crucial to anticipating the future intelligently. The trends that have driven evolution historically often persist, and continue to be influential in the future. With this in mind, this article briefly outlines the historical and current trends in bariatric surgery, and follows the trajectory of these trends into the future to anticipate the technologies and techniques that will be most important to the field in the coming years.

The history and evolution of bariatric surgical procedures

The search for the ideal weight loss operation began more than 50 years ago. Surgical pioneers developed innovative procedures that initially created malabsorption, then restricted volume intake, and eventually combined both techniques. Variations, alterations, and modifications of these original procedures, combined with intense efforts to follow and document outcomes, have led to the evolution of modern bariatric surgery. More recent research has focused on the hormonal and metabolic effects of these procedures. These discoveries at the cellular level will help develop possible mechanisms of weight loss and comorbidity reduction beyond the traditional explanation of reduced food consumption and malabsorption.

Functional laparoscopic reversal of a long gastroplasty

Gastroplasty operations for obesity occasionally require surgical reversal. A laparoscopic technique is described for the successful functional reversal of a case who had a Long vertical gastroplasty.

Pre-operative psychiatric assessment of patients presenting for gastric bariatric surgery (surgical control of morbid obesity)

One hundred and fifty-three consecutive patients referred to the Royal Prince Alfred Hospital for consideration of gastric bariatric surgery (surgery for obesity) were assessed pre-operatively by the one psychiatrist, with regard to social, psychological and psychiatric factors. Fifty-one patients (33%) were considered to be uncomplicated from a psychiatric point of view. Eighty-eight patients (58%) had identifiable psychopathology and 14 patients (9%) were of doubtful motivation. Thirty patients (20%) were rejected from the treatment programme after the initial assessment because of overt psychiatric illness, severe situational stress, insufficient motivation or lack of significant support. Six of these patients after further assessment or after responding to psychiatric treatment were reviewed and found suitable for a bariatric operation. Of the 113 patients who had a bariatric procedure performed, 17 patients (15%) required postoperative psychiatric management. while the need for psychiatric assessment of patients presenting for bariatric surgery is disputed by some, our experience would indicate that careful pre-operative screening by a liaison psychiatrist, familiar with morbid obesity and its surgical management, is useful in any bariatric surgical programme. Such screening should identify and enable exclusion of the small number of patients who for psychiatric reasons, are poor risk candidates. A number of other patients in whom identifiable psychopathology will be discerned, will require pre-operative psychiatric management. While such a programme will decrease postoperative psychiatric problems, these will not be eliminated in the morbidly obese, and the assessing liaison psychiatrist will have a valuable role to play in the collaborative postoperative management of such patients.

Modified vertical banded gastroplasty as revision of failed high gastric reduction for morbid obesity

Vertical banded gastroplasty is currently closest to the ideal gastric restrictive procedure for the surgical treatment of obesity. A modification of the technique of vertical banded gastroplasty can be successfully used to revise a failed high gastric reduction for morbid obesity.

Gastroplasty with reinforced greater curve stoma for morbid obesity

Forty-four morbidly obese patients underwent gastroplasty with a transverse double stapled partition forming a 20-30 ml proximal gastric pouch and a 10 mm diameter stoma on the greater curve supported by three non-absorbable imbricating seromuscular inverting suture layers to form a neopylorus. All patients have been followed at approximately 4 weekly intervals for at least 72 weeks and all patients have been submitted to endoscopic assessment at the end of 1 year. There was no mortality and there were no major immediate postoperative complications. Three patients (6.8%) had inadequate weight loss (in two associated with partial staple line failure). The other 41 patients (93.2%) reached final weights less than or equal to 40% above ideal weight. Sixteen patients (36.4%) reached their ideal weight. Six patients (13.6%) developed stomal stenosis (two requiring re-operation, and four requiring endoscopic dilatation).

Gastroplasty for morbid obesity. Roentgen evaluation and spectrum of complications

With the advent of autosuture devices, gastric partitioning procedures have recently become popular surgical treatment of morbid obesity. One such procedure is Gomez gastroplasty. Using an autosuture device a small gastric fundal pouch, having a reservoir capacity of 60 ml and communicating with the remaining stomach through a 12 mm stoma is created along the greater curvature of the stomach. A 3-0 polyprolene internal seromuscular suture is used to reinforce the stoma without incising the stomach. This gastroplasty is extremely attractive because of the disarming simplicity of the procedure and its noninterruption of the normal sequence of the digestive tract. This report is based on a joint review of 280 cases subjected to Gomez gastroplasty to combat morbid obesity. Postoperative radiological evaluation and the spectrum of observed complications are herein described.

The effectiveness of gastric bypass over gastric partition in morbid obesity: consequence of distal gastric and duodenal exclusion

Eighty-seven morbidly obese patients were prospectively randomized to two operations: gastric bypass was performed on 42 and gastric partition on 45. Gastric bypass proved to be more effective; gastric bypass patients lost 15% more of their original weight at 12 months and 21% more at 18 months. There were no failures in the gastric bypass group; 28 of the 45 operations failed in the gastric partition group. An additional 60 patients underwent gastric bypass since the completion of the study. In the total series of 147 patients who underwent gastric bypass or gastric partition, there was no mortality, and the surgical complication rate was 12%. Because the gastric pouches and the anastomoses were similar in the two operations, the superiority of the gastric bypass may well be due to a heretofore unexplained effect of distal gastric and duodenal exclusion.

Gastric bypass for giant morbid obesity

A 35-year-old man, grossly incapacitated by giant morbid obesity, and showing pathological sequelae of it, weighed 225.45 kg at presentation. After gastric bypass, his body weight decreased by 48% over approximately one year. After abdominoplasty and reduction of thigh skin folds, his weight stabilized at 116.36 kg. All sequelae of the morbid obesity had resolved, and the patient was able to resume a normal lifestyle and to re-enter the work force.