FROM COMPLEX EVOLVING TO SIMPLE: CURRENT REVISIONAL AND ENDOSCOPIC PROCEDURES FOLLOWING BARIATRIC SURGERY

Mid-term Results of Laparoscopic Conversion of Gastric Bypass to Duodenal Switch for Weight Regain: the Review of the Literature and Single-Center Experience

BACKGROUND

Weight regain after Roux-en-Y gastric bypass (RYGB) is a nightmare for the patients and the surgeons and is mostly regarded as "irreversible." However, conversions to duodenal switch (DS) have been done previously with promising success. The current paper reports a single center's mid-to-long-term follow-up outcomes.

METHODS

The data from all patients undergoing a conversion of RYGB (and one anastomosis gastric bypass (OAGB)) to DS were reviewed retrospectively. The demographic, operative, and weight loss parameters were analyzed, including age, duration of surgery, weight loss, body mass index (BMI), and morbidity/mortality.

RESULTS

Seventeen patients were operated on between January 2013 and December 2021. The mean BMI was 45 kg/m2 (33-70) before conversion. The overall average %EWL was 74.4%, the least was 52% at 6 months, and the most was 91% at 24 and 36 months. All comorbidities resolved after conversion. One patient had a gastro-gastrostomy leak needing prompt surgical repair on the same day of diagnosis. Three patients had other complications: a duodenal stump leak, an intrabdominal abscess, and an ileus. All resolved without surgery. One sudden death happened on the 5th postoperative day.

CONCLUSION

Laparoscopic conversion of gastric bypass operations to DS is a complicated procedure that may have severe complications despite excessive patience and expertise but can be performed in a single step. The mid-to-long-term outcomes are promising for weight loss and control of associated co-morbidities.

CRITICAL ANALYSIS OF SURGICAL TREATMENT TECHNIQUES OF MORBID OBESITY

INTRODUCTION

Obesity is a disease of high prevalence in Brazil and in the world, and bariatric surgery, with its different techniques, is an alternative treatment.

OBJECTIVE

To compare techniques: adjustable gastric band (AGB), sleeve gastrectomy), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) analyzing leaks, bleeding, death, weight loss, resolution of type 2 diabetes, systemic arterial hypertension, dyslipidemia and obstructive sleep apnea.

METHODS

Were selected studies in the PubMed database from 2003 to 2014 using the descriptors: obesity surgery; bariatric surgery; biliopancreatic diversion; sleeve gastrectomy; Roux-en-Y gastric bypass and adjustable gastric banding. Two hundred and forty-four articles were found with the search strategy of which there were selected 116 studies through the inclusion criteria.

RESULTS

Excess weight loss (EWL) after five years in AGB was 48.35%; 52.7% in SG; 71.04% in RYGB and 77.90% in BPD. The postoperative mortality was 0.05% in the AGB; 0.16% on SG; 0.60% in RYGB and 2.52% in BPD. The occurrence of leak was 0.68% for GBA; 1.93% for SG; 2.18% for RYGB and 5.23% for BPD. The incidence of bleeding was 0.44% in AGB; 1.29% in SG; 0.81% in RYGB and 2.09% in BPD. The rate of DM2 resolved was 46.80% in AGB, 79.38% in SG, 79.86% in RYGB and 90.78% in BPD. The rate of dyslipidemia, apnea and hypertension resolved showed no statistical differences between the techniques.

CONCLUSION

The AGB has the lowest morbidity and mortality and it is the worst in EWL and resolution of type 2 diabetes. The SG has low morbidity and mortality, good resolution of comorbidities and EWL lower than in RYGB and BPD. The RYGB has higher morbidity and mortality than AGB, good resolution of comorbidities and EWL similar to BPD. The BPD is the worst in mortality and bleeding and better in EWL and resolution of comorbidities.

FUNDOPLICATION CONVERSION IN ROUX-EN-Y GASTRIC BYPASS FOR CONTROL OF OBESITY AND GASTROESOPHAGEAL REFLUX: SYSTEMATIC REVIEW

Introduction:

Obesity is related with higher incidence of gastroesophageal reflux disease. Antireflux surgery has inadequate results when associated with obesity, due to migration and/or subsequent disruption of antireflux wrap. Gastric bypass, meanwhile, provides good control of gastroesophageal reflux.

Objective:

To evaluate the technical difficulty in performing gastric bypass in patients previously submitted to antireflux surgery, and its effectiveness in controlling gastroesophageal reflux.

Methods:

Literature review was conducted between July to October 2016 in Medline database, using the following search strategy: (“Gastric bypass” OR “Roux-en-Y”) AND (“Fundoplication” OR “Nissen ‘) AND (“Reoperation” OR “Reoperative” OR “Revisional” OR “Revision” OR “Complications”).

Results:

Were initially classified 102 articles; from them at the end only six were selected by exclusion criteria. A total of 121 patients were included, 68 women. The mean preoperative body mass index was 37.17 kg/m² and age of 52.60 years. Laparoscopic Nissen fundoplication was the main prior antireflux surgery (70.58%). The most common findings on esophagogastroduodenoscopy were esophagitis (n=7) and Barrett’s esophagus (n=6); the most common early complication was gastric perforation (n=7), and most common late complication was stricture of gastrojejunostomy (n=9). Laparoscopic gastric bypass was performed in 99 patients, with an average time of 331 min. Most patients had complete remission of symptoms and efficient excess weight loss.

Conclusion:

Although technically more difficult, with higher incidence of complications, gastric bypass is a safe and effective option for controlling gastroesophageal reflux in obese patients previously submitted to antireflux surgery, with the added benefit of excess weight loss.

NEW TECHNIQUE FOR OBESITY SURGERY: INTERNAL GASTRIC PLICATION TECHNIQUE USING INTRAGASTRIC SINGLE-PORT (IGS-IGP) IN EXPERIMENTAL MODEL

Background:

Bariatric surgery is currently the most effective method to ameliorate co-morbidities as consequence of morbidly obese patients with BMI over 35 kg/m². Endoscopic techniques have been developed to treat patients with mild obesity and ameliorate comorbidities, but endoscopic skills are needed, beside the costs of the devices.

Aim:

To report a new technique for internal gastric plication using an intragastric single port device in an experimental swine model.

Methods:

Twenty experiments using fresh pig cadaver stomachs in a laparoscopic trainer were performed. The procedure was performed as follow in ten pigs: 1) volume measure; 2) insufflation of the stomach with CO2; 3) extroversion of the stomach through the simulator and installation of the single port device (Gelpoint Applied Mini) through a gastrotomy close to the pylorus; 4) performance of four intragastric handsewn 4-point sutures with Prolene 2-0, from the gastric fundus to the antrum; 5) after the performance, the residual volume was measured. Sleeve gastrectomy was also performed in further ten pigs and pre- and post-procedure gastric volume were measured.

Results:

The internal gastric plication technique was performed successfully in the ten swine experiments. The mean procedure time was 27±4 min. It produced a reduction of gastric volume of a mean of 51%, and sleeve gastrectomy, a mean of 90% in this swine model.

Conclusion:

The internal gastric plication technique using an intragastric single port device required few skills to perform, had low operative time and achieved good reduction (51%) of gastric volume in an in vitro experimental model.