Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force. Surg Obes Relat Dis. 2014;10:952-972. [PMID: 24776071 DOI: 10.1016/j.soard.2014.02.014]

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.

Gastric interventional endoscopy

PURPOSE OF REVIEW

To review new advances in gastric interventional endoscopy.

RECENT FINDINGS

Implementation of gastric endoscopy as a therapeutic option in obesity, gastric cancer, and gastroparesis.

SUMMARY

Less invasive new gastric endoscopic procedures can potentially replace currently offered laparoscopic approaches in many fields. In this article, we will review the use of endoscopic sleeve gastroplasty as a weight loss procedure, endoscopic submucosal dissection in treatment of early gastric cancer, and gastric per-oral endoscopic myotomy in treatment of refractory gastroparesis. These procedures can increase access to bariatric weigh loss procedures, provide an organ-saving curative option for early gastric cancer, and offer a new modality to improve refractory gastroparesis.

Depressive Symptoms in Bariatric Surgery Patients with Multiple Sclerosis

BACKGROUND

Bariatric surgery has been shown to be a safe and effective intervention for patients with comorbid obesity and multiple sclerosis (MS); however, this sub-population may be at heightened risk for pre- and postoperative depressive symptoms.

OBJECTIVE

This current exploratory study aims to describe the prevalence and nature of depressive symptoms in a sample of patients with MS who undergo bariatric surgery.

METHODS

Medical records were retrospectively reviewed to identify patients who received bariatric surgery and had a diagnosis of MS (n = 31) and a control sample of non-surgical MS patients with severe obesity (n = 828). Longitudinal outcome measures included the Patient Health Questionnaire-9 (PHQ-9) and Multiple Sclerosis Performance Scale (MSPS).

RESULTS

There were no significant differences in PHQ-9 total and item scores between groups at baseline. PHQ-9 scores significantly improved at years 1 (p < 0.01) and 2 (p = 0.03) post-bariatric surgery when compared to non-surgical controls. Higher BMI (p = 0.03) and worse overall quality of life (p < 0.01) were associated with worsening of PHQ-9 scores in the bariatric group. When compared to controls, the bariatric group demonstrated improved MSPS scores on a trend level 1 year post-surgery (p = 0.08).

CONCLUSIONS

Consistent with the literature on more general bariatric surgery populations, current findings highlight the possible early benefits of bariatric surgery for reducing depressive symptoms in this population when compared to controls. Importantly, results should be viewed as preliminary and additional research is needed to examine bariatric surgery and associations with depressive symptoms and performance in the MS population.

Weight regain after Roux-en-Y gastric bypass has a large negative impact on the Bariatric Quality of Life Index

BACKGROUND

Despite initial successful weight loss, some patients may experience weight regain following Roux-en-Y gastric bypass (RYGB).

OBJECTIVE

To assess the impact of weight regain on bariatric patients' quality of life (QoL).

METHODS

This was a prospective cross-sectional study. Fifty-six consecutive RYGB patients were recruited and divided into weight-regain and weight-stable cohorts. QoL was assessed using the Bariatric Quality of Life (BQL) questionnaire. The BQL Index scores of the weight-regain and weight-stable groups were compared using Student's t-test. Additionally, the BQL Index score of the weight-regain group was compared with that of historical prebariatric patients. Predictors of BQL were assessed using univariate and multivariate linear regression analyses.

RESULTS

Of 56 RYGB patients, 41 (73%) had weight regain. On average, patients had body mass index (BMI) of 37 ±7.5 kg/m2 and gained 34 ±26% of maximal weight initially lost. Weight-regain patients had lower BQL Index scores than weight-stable patients (44.8±6 vs 53±7, p<0.001). Patients with weight regain had similar BQL Index scores as the prebariatric patients despite lower BMI (BMI of 39.7±6.8 vs 47.2±7.6, p<0.05; BQL Index of 44.8±6 vs 41.6±10.4, p=0.144, respectively). Years from RYGB, BMI and amount of weight regain were associated with BQL Index on a univariate analysis (β=-0.55,-0.52, -0.7; p<0.0001). Only weight regain was a significant predictor of BQL on a multivariate analysis (β =-0.56; p=0.001).

CONCLUSION

Weight regain had a negative impact on bariatric patients' QoL. Patients who regained at least 15% of maximal weight lost appeared to have as low QoL as those who had not undergone bariatric surgery despite a lower BMI.

Revisional Surgery Following Laparoscopic Gastric Plication

BACKGROUND

The laparoscopic gastric plication (LGP) is a relative new bariatric procedure that has gained popularity over the last few years, but no real consensus exists and the evidence is unclear, especially in its real efficacy, safety, and durability.

METHODS

Retrospective study analyzing the records patients submitted to LGP between 2009 and 2010. The primary objective was to describe the characteristics and outcomes of patients submitted to revisional surgery. Baseline data and evolution were obtained and analyzed. Surgical analysis included revision cause, perioperative outcome, type of surgery, complications, and weight loss after 18 months. A comparison between gastric bypass and sleeve gastrectomy was performed.

RESULTS

One hundred LGP were performed. After a mean time of 13.5 months, 42 patients presented an overall excess weight loss (EWL) <50 % and 38 had severe symptoms. Thirty patients accepted revisional surgery with BMI before conversion of 38.6 ± 4.2 kg/m². There were 17 laparoscopic sleeve gastrectomy (LSG) and 13 laparoscopic gastric bypass (LGBP) with comparable preoperative characteristics. The LSG group had lower pneumoperitoneum time and less hospital stay. At 18 months, the LGBP group had lower BMI (24.1 ± 1.1 vs. 25.8 ± 1.3 kg/m² for the LSG; p = 0.006) and higher %EWL (75.7 ± 16.1 vs. 61.4 ± 14.5 % for the LSG; p = 0.008).

CONCLUSION

In our series, LGP presented a high failure rate and an increased number of symptomatic patients. Revisional surgery proved to be safe and effective. Revision to LSG was faster and had less hospital stay. Revision to LGBP showed better %EWL at 18 months.

A comparison of revisional and primary bariatric surgery

BACKGROUND

Revisional surgery is an important component of addressing weight regain and complications following primary bariatric surgery. Owing to provincial need and the complexity of this patient population, a specialized multidisciplinary revision clinic was developed. We sought to characterize patients who undergo revision surgery and compare their outcomes with primary bariatric surgery clinic data.

METHODS

We completed a retrospective chart review of bariatric revision clinic patients compared with primary bariatric surgery patients from December 2009 to June 2014.

RESULTS

We reviewed the charts of 2769 primary bariatric clinic patients, 886 of whom had bariatric surgery, and 534 revision bariatric clinic patients, 83 of whom had revision surgery. Fewer revision clinic patients underwent surgery than primary clinic patients (22% v. 32%). The mean preoperative body mass index (BMI) was 44.7 ± 9.5 in revision patients compared with 45.7 ± 7.6 in primary bariatric surgery patients. Most revision patients had a prior vertical banded gastroplasty (VBG; 48%) or a laparoscopic adjustable gastric band (LAGB; 24%). Bands were removed in 36% of all LAGB patients presenting to clinic. Of the 134 procedures performed in the revision clinic, 83 were bariatric weight loss surgeries, and 51 were band removals. Revision clinic patients experienced a significant decrease in BMI (from 44.7 ± 9.5 to 33.8 ± 7.5, p < 0.001); their BMI at 12-month follow-up was similar to that of primary clinic patients (34.5 ± 7.0, p = 0.7). Complications were significantly more frequent in revision patients than primary patients (41% v. 15%, p < 0.001).

CONCLUSION

A bariatric revision clinic manages a wide variety of complex patients distinct from those seen in a primary clinic. Operative candidates at the revision clinic are chosen based on favourable medical, anatomic and psychosocial factors, keeping in mind the resource constraints of a public health care system.

Does Bariatric Surgery Improve Obesity Associated Comorbid Conditions

Obesity is a constantly growing health problem which reduces quality of life and life expectancy. Bariatric surgery for obesity is taken into account when all other conservative treatment modalities have failed. Comparison of the multidisciplinary programs with bariatric surgery regarding to weight loss showed that substantial and durable weight reduction have been achieved only with bariatric surgical treatments. However, the benefits of weight loss following bariatric procedures are still debated regarding the pro-inflammatory and metabolic profile of obesity.

Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy as Revisional Procedures after Adjustable Gastric Band: 5-Year Outcomes

INTRODUCTION

In 2013, a worldwide bariatric surgery survey showed that laparoscopic adjustable gastric banding (LAGB) has been abandoned in favor of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-y gastric bypass (LRYGBP).

PURPOSE

The aim of this study was to compare results of LRYGBP and LSG performed as a revisional procedure after LAGB.

MATERIALS AND METHODS

All patients converted from LAGB to LSG or to LRYGBP from January 2007 to December 2011 were included in the study. Clinical data collected were age, gender, indications for revision, complications, body mass index (BMI), and body weight at revisional procedures. Weight loss was calculated at 1, 3, and 5 years after conversion.

RESULTS

Fifty-one patients were included in this study, 43 females and 8 males. Twenty-four patients were converted to LRYGBP (LRYGBP group) and 27 to LSG (LSG group). Indication for conversion was weight loss failure in 34 (67%) patients and band complications in 17 (33%) patients. No significant difference in age, BMI, and body weight in the two groups was found at the time of revision. One patient converted to LRYGBP had an internal hernia; one patient initially scheduled for LSG was intraoperatively converted to LRYGBP due to staple line leak. No other major perioperative complication was observed. Follow-up rate at 5 years was 84.3% (43 patients out of 51 patients) Delta-BMI and percentage of excess weight loss (%EWL) were not significantly different in the two groups at 1, 3, and 5 years (p > 0.05).

CONCLUSION

LRYGBP or LSG are feasible and effective surgical options after LAGB. Satisfactory weight loss was achieved after both procedures.

Revisional Bariatric Surgery: Focus on Quality of Life

Bariatric surgery is considered to be the most effective treatment for morbid obesity. At present, revisional surgery is considered in patients who experience complications, or in whom the intended weight loss is not achieved. However, as there is no consensus on what constitutes failure of primary surgery, there are no guidelines on who should receive revisional surgery. Physical parameters alone may be insufficient and quality of life has emerged as an alternative to provide a holistic appraisal of the outcome of primary surgery and the need for further revisional surgery in bariatric patients. Quality of life surveys such as short form health survey (SF-36) or Moorehead-Ardelt II (MA-II) assess the patients’ perception of their weight and can also be used to assess the impact of post-operative complications such as gastro-esophageal reflux disease or dysphagia. However, unrealistic expectations of weight loss have been shown to be prevalent in bariatric patients and patients who seek revisional surgery on the basis of disappointment with the primary outcome are unlikely to be satisfied with the revisional outcome. Indications for re-operative surgery must be tailored to improve the quality and longevity of each individual patient’s life. Long term studies are required to investigate and validate quality of life as an indication for revisional surgery.

Revisional Bariatric/Metabolic Surgery: What Dictates Its Indications?

Bariatric/metabolic surgery is currently the only effective long-term treatment for morbid obesity- and obesity-related diseases such as diabetes, heart disease, hypertension, obstructive sleep apnea, and dyslipidemia. In addition, bariatric/metabolic surgery has been shown to significantly reduce the incidence of diabetes and cancer and prolong life when compared to non-surgical therapies. However, as obesity is a chronic disease, recidivism of weight and comorbid conditions can occur. In addition, the surgical construct can lead to long-term consequences such as marginal ulceration, bowel obstruction, reflux, and nutritional deficiencies. Despite these drawbacks, prospective randomized controlled studies and long-term longitudinal population-based comparative studies greatly favor surgical intervention as opposed to traditional lifestyle, diet, and exercise programs. Revisional surgery can be quite complex and technically challenging and may offer the patient a wide variety of solutions for treatment of weight recidivism and complications after primary operations. Given the paucity of high quality published data, we have endeavored to provide indications for revisions after bariatric surgery.

Revisional Bariatric Surgery

Revisional bariatric procedures are increasingly common. With more primary procedures being performed to manage severe obesity and its complications, 5% to 8% of these procedures will fail, requiring revisional operation. Reasons for revisional bariatric surgery are either primary inadequate weight loss, defined as less than 25% excess body weight loss, or weight recidivism, defined as a gain of more than 10 kg based on the nadir weight; however, each procedure also has inherit specific complications that can also be indications for revision. This article reviews the history of each primary bariatric procedure, indications for revision, surgical options, and subsequent outcomes.

Can We Selectively Reduce Appetite for Energy-Dense Foods? An Overview of Pharmacological Strategies for Modification of Food Preference Behavior

Excessive intake of food, especially palatable and energy-dense carbohydrates and fats, is largely responsible for the growing incidence of obesity worldwide. Although there are a number of candidate antiobesity drugs, only a few of them have been proven able to inhibit appetite for palatable foods without the concurrent reduction in regular food consumption. In this review, we discuss the interrelationships between homeostatic and hedonic food intake control mechanisms in promoting overeating with palatable foods and assess the potential usefulness of systemically administered pharmaceuticals that impinge on the endogenous cannabinoid, opioid, aminergic, cholinergic, and peptidergic systems in the modification of food preference behavior. Also, certain dietary supplements with the potency to reduce specifically palatable food intake are presented. Based on human and animal studies, we indicate the most promising therapies and agents that influence the effectiveness of appetite-modifying drugs. It should be stressed, however, that most of the data included in our review come from preclinical studies; therefore, further investigations aimed at confirming the effectiveness and safety of the aforementioned medications in the treatment of obese humans are necessary.

[Management of failures and complications in weight loss surgery]

The specific management of the surgical risks linked to obesity, as well as technological advances combined with the standardisation of techniques, have significantly reduced the morbidity and mortality associated with bariatric surgery over recent decades. However, as with all surgery, patients are exposed to medical and surgical failures and complications.

Food cravings and food consumption after Roux-en-Y gastric bypass versus cholecystectomy

BACKGROUND

Food cravings and consumption of craved foods after Roux-en-Y gastric bypass (RYGB) are poorly understood. Food cravings after bariatric surgery may explain why some patients fail to change eating behaviors after RYGB, and understanding these cravings may provide better information for nutritional counseling to either enhance weight loss or prevent weight regain.

OBJECTIVES

To study cravings in RYGB patients and compare them with cholecystectomy (CC) control patients.

SETTING

This study took place in a university hospital.

METHODS

RYGB patients (n = 50) and CC control patients (n = 38) completed a validated food craving inventory before surgery and at 2 and 6 weeks postoperatively. In addition, RYGB patients completed the food craving inventory at 12, 24, 36, and 52 weeks postoperatively. A linear mixed-effect model with a first-order autoregressive structure for correlations was used to evaluate changes in food consumption and food cravings between visits. Correlations between food cravings and body mass index (BMI) or weight changes before and after RYGB were assessed with Spearman correlation coefficients. P<.05 was considered statistically significant.

RESULTS

After RYGB, food consumption decreased significantly compared with CC control patients and was lowest at 2 weeks. Consumption progressively increased over time in the first year but remained significantly less than that from presurgery. In addition, a higher preoperative BMI was found to correlate moderately with higher preoperative cravings of the total of all 4 food groups studied (r = .3, P = .04); high-fat foods (r = .3, P = .04); and sweets (r = .3, P = .03). However, with the exception of preoperative cravings for high-fat foods, these scores were not predictive of changes in BMI after surgery. Overall, RYGB did not significantly affect food cravings after surgery compared with CC control patients.

CONCLUSION

These findings indicate that RYGB may limit food consumption but does not affect the drive to consume certain types of food. Because food cravings are high in patients with obesity before surgery and remain high after surgery, these findings suggest a possible reason for noncompliance with dietary recommendations after RYGB.

[Conversional and endoscopic procedures following bariatric surgery]

The Roux-en-Y gastric bypass (RYGB) is the therapy of choice in bariatric surgery. Sleeve gastrectomy and gastric banding are showing higher rates of treatment failure, reducing obesity-associated morbidity and body weight insufficiently. Moreover, gastroesophageal reflux disease (GERD) can occur refractory to medication. Therefore, a laparoscopic conversion to RYGB can be reasonable as long as specific conditions are fulfilled.Endoscopic procedures are currently being applied to revise bariatric procedures. Therapy failure following RYGB occurs in up to 20 % of cases. Transoral outlet reduction is the minimally invasive method of choice to reduce gastrojejunal anastomosis of the alimentary limb. The diameter of a gastric sleeve can be unwantedly enlarged as well; that can be reduced by placement of a longitudinal full-thickness suture.Severe hypoglycemic episodes can be present in patients following RYGB. Hypoglycemic episodes have to be diagnosed first and can be treated conventionally. Alternatively, a laparoscopic approach according to Branco-Zorron can be used for non-responders. Hypoglycemic episodes can thus be prevented and body weight reduction can be assured.Conversional and endoscopic procedures can be used in patients with treatment failure following bariatric surgery. Note that non-invasive approaches should have been applied intensively before a revisional procedure is performed.

The future of the Roux-en-Y gastric bypass

Archaic surgical procedures such as the jejunoileal bypass, vertical banded gastroplasty and duodenal switch have contributed to the current best practice of Roux-en-Y gastric bypass (RYGB) procedure for the treatment of obesity and its consequences. Despite this, RYGB has been blighted with late occurring adverse events such as severe malnutrition, marginal ulcer and reactive hypoglycemia. Despite this, RYGB has given us an opportunity to examine the effect of surgery on gut hormones and the impact on metabolic syndrome which in turn has allowed us to carry out a lower impact but equally, if not more effective, procedure - the vertical sleeve gastrectomy (VSG). We examine the benefits of sleeve gastrectomy from the less challenging technical aspect to the effect on obesity and its metabolic syndrome long-term and have concluded that sleeve gastrectomy is possibly the next current best practice.

Evolution of pharmacological obesity treatments: focus on adverse side-effect profiles

Pharmacotherapy directed toward reducing body weight may provide benefits for both curbing obesity and lowering the risk of obesity-associated comorbidities; however, many weight loss medications have been withdrawn from the market because of serious adverse effects. Examples include pulmonary hypertension (aminorex), cardiovascular toxicity, e.g. flenfluramine-induced valvopathy, stroke [phenylpropanolamine (PPA)], excess non-fatal cardiovascular events (sibutramine), and neuro-psychiatric issues (rimonabant; approved in Europe, but not in the USA). This negative experience has helped mould the current drug development and approval process for new anti-obesity drugs. Differences between the US Food and Drug Administration (FDA) and the European Medicines Agency, however, in perceptions of risk-benefit considerations for individual drugs have resulted in discrepancies in approval and/or withdrawal of weight-reducing medications. Thus, two drugs recently approved by the FDA, i.e. lorcaserin and phentermine + topiramate extended release, are not available in Europe. In contrast, naltrexone sustained release (SR)/bupropion SR received FDA approval, and liraglutide 3.0 mg was recently approved in both the USA and Europe. Regulatory strategies adopted by the FDA to manage the potential for uncommon but potentially serious post-marketing toxicity include: (i) risk evaluation and mitigation strategy programmes; (ii) stipulating post-marketing safety trials; (iii) considering responder rates and limiting cumulative exposure by discontinuation if weight loss is not attained within a reasonable timeframe; and (iv) requiring large cardiovascular outcome trials before or after approval. We chronicle the adverse effects of anti-obesity pharmacotherapy and consider how the history of high-profile toxicity issues has shaped the current regulatory landscape for new and future weight-reducing drugs.

Outcomes of Robot-Assisted Roux-en-Y Gastric Bypass as a Reoperative Bariatric Procedure

BACKGROUND

We evaluate the outcomes of robot-assisted Roux-en-Y gastric bypass (RRYGB) as a reoperative bariatric procedure (RBP).

METHODS

A retrospective analysis was done from 2007 to 2014, and all the patients who underwent RRYGB as a RBP at a teaching university hospital were included.

RESULTS

A total of 32 patients underwent RRYGB as a reoperation from adjustable gastric band (AGB n = 16) or sleeve gastrectomy (SG n = 11) or previous gastric bypass (n = 5). Twenty patients underwent conversion to RRYGB due to weight loss failure, either after AGB (n = 13) or SG (n = 7). Twelve patients underwent reoperation because of complications of index procedure. Mean preoperative weight was 109.7 ± 29.5 kg, and BMI was 40 ± 10.6 kg/m(2). The mean operative time for RRYGB was 226 ± 45.3 min with a blood loss of 20 ± 15.9 ml. Average length of stay was 3 days. In two cases, pin point leaks were detected intraoperatively during check gastroscopy, and they were repaired with sutures. There were no postoperative anastomotic leaks or hemorrhage or gastrojejunostomy strictures. None of the patients required a blood transfusion or reoperation within perioperative period. In the patients who underwent RRYGB for weight loss failure (n = 20), the mean excess weight loss (EWL) was 39.2% at 6 months (n = 11), 53.8% at 1 year (n = 13), and 60.7% at 2 years (n = 6).

CONCLUSIONS

RRYGB is safe and effective to be used as a revisional bariatric procedure. The weight loss outcomes and complication rates compare favorably with the published results of laparoscopic technique, although the small sample size may not be enough to reach definite conclusions.

Management of obesity

A modern approach to obesity acknowledges the multifactorial determinants of weight gain and the health benefits to be derived from weight loss. Foundational to any weight loss effort is lifestyle change, diet, and increased physical activity. The approach should be a high quality diet to which patients will adhere accompanied by an exercise prescription describing frequency, intensity, type, and time with a minimum of 150 min moderate weekly activity. For patients who struggle with weight loss and who would receive health benefit from weight loss, management of medications that are contributing to weight gain and use of approved medications for chronic weight management along with lifestyle changes are appropriate. Medications approved in the USA or European Union are orlistat, naltrexone/bupropion, and liraglutide; in the USA, lorcaserin and phentermine/topiramate are also available. Surgical management (gastric banding, sleeve gastrectomy, and Roux-en Y gastric bypass) can produce remarkable health improvement and reduce mortality for patients with severe obesity.

Evaluation of the obesity surgery mortality risk score for the prediction of postoperative complications after primary and revisional laparoscopic Roux-en-Y gastric bypass

BACKGROUND

The Obesity Surgery Mortality Risk Score (OS-MRS) is a validated instrument for mortality risk prediction in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures classifying patients into low risk (class A), intermediate risk (class B), and high risk (class C).

OBJECTIVES

The primary aim of this study was to evaluate the accuracy of the OS-MRS in predicting postoperative complications after LRYGB. Secondarily, the postoperative complication rate between primary and revisional LRYGB was systematically analyzed.

SETTING

The Obesity Center Amsterdam, located in a large teaching hospital, in Amsterdam, The Netherlands.

METHODS

The OS-MRS was applied to a consecutive database of patients who underwent LRYGB from November 2007 onwards. Postoperative complications were scored according to the Clavien-Dindo classification. Revisional LRYGB was separately analyzed.

RESULTS

LRYGB was performed in 1667 patients either as a primary (81.5%) or revisional (18.5%) procedure. The majority (n = 1371, 82.2%) were female, mean age 44.6 (standard deviation 14.4) years and mean body mass index 44.2 (6.5) kg/m². Nine hundred and four (54.2%) were OS-MRS class A, 642 class B (38.5%), and 121 (7.3%) class C. Complications occurred in 143 (10.5%) and 44 (14.2%) patients after primary and revisional surgery, respectively. In both primary and revisional LRYGB, there was no association between complications and the OS-MRS classification. Subanalysis comparing primary with revisional LRYGB found a significant association between revisional surgery and the development of severe complications (Clavien-Dindo≥3) (P = .003) and mortality (P = .017).

CONCLUSION

The OS-MRS was not an accurate predictor for postoperative complications in patients who underwent primary or revisional LRYGB. As in other studies, revisional surgery is an independent risk factor for the development of severe complications.

Revisional Roux-en-Y Gastric Bypass and Sleeve Gastrectomy: a Systematic Review of Comparative Outcomes with Respective Primary Procedures

Though primary bariatric surgery is now firmly established as the first-line treatment for morbid obesity, this is not the case with revisional bariatric surgery. Despite proven benefits and patient demand, revisional bariatric surgery continues to attract controversy. Even though it is widely believed to be riskier and less effective than primary bariatric surgery, there is currently no systematic review in literature addressing this point. This review aims to establish outcomes after revisional bariatric surgery in comparison with those after primary bariatric surgery. Since Roux-en-Y gastric bypass or sleeve gastrectomy is currently the commonest anatomy achieved after revisional bariatric surgery, this review focuses on the outcome of revisional Roux-en-Y gastric bypass and revisional sleeve gastrectomy in comparison with respective primary procedures.

Revisional Laparoscopic Gastric Pouch Resizing for Inadequate Weight Loss After Roux-en-Y Gastric Bypass

Background

Weight regain due to gastric pouch dilatation after Roux-en-Y gastric bypass (RYGB) is seen more frequently after long-term follow-up. We studied the feasibility and safety of laparoscopic pouch resizing (LPR) for dilated gastric pouch after RYGB associated with inadequate weight loss.

Methods

From 1st June 2011 to 1st September 2013, patients who underwent LPR after failed RYGB were retrospectively compared and analyzed. Data included patient demographics, comorbidity, indication for revision, preoperative weight and BMI, operative time, hospital stay, conversion rate, mean follow-up, body mass index (BMI) loss, percentage excess weight loss (%EWL), reoperation rate, morbidity, and mortality.

Results

Out of 170 revisional bariatric procedures, 32 LPR (27/5, F/M) were performed for dilated gastric pouch after RYGB. The mean age, preoperative weight, and BMI were 38.3 ± 9.3 years, 101.7 ± 22.8 kg, 38.8 ± 6.4 kg/m², respectively. The median operative time and hospital stay were 100 min and 2 days, respectively. All pouch resizing procedures were carried out laparoscopically, with none requiring conversion to open surgery. The overall complication and reoperation rates were 15.6 and 3.1 %, respectively. There were no deaths. The mean follow-up was 14.1 ± 6.2 months. The mean postoperative BMI was 32.8 ± 7.3 kg/m², and the median %EWL was 29.1 %.

Conclusions

LPR is safe and can lead to adequate weight loss. However, long-term follow-up is needed to determine the efficiency and durability of this procedure.

SADI-S WITH RIGHT GASTRIC ARTERY LIGATION: TECHNICAL SYSTEMATIZATION AND EARLY RESULTS

Background

Bariatric surgery is performed all over the world with close to 500.000 procedures per year. The most performed techniques are Roux-en-Y gastric bypass and sleeve gastrectomy. Despite this data, the most effective procedure, biliopancreatic diversion with or without duodenal switch, represents only no more than 1.5% of the procedures. Technical complexity, morbidity, mortality, and severe nutritional adverse effects related to the procedure are the main fears that prevent most universal acceptance.

Aim

To explain the technical aspects and the benefits of the SADI-S with right gastric artery ligation as an effective simplification from the original duodenal switch.

Methods

Were included all patients undergoing this procedure from the November 2014 to May 2016, describing and analysing aspects of this technique, the systematization and early complications associated with the procedure.

Results

A series of 67 patients were operated; 46 were women (68.7%); mean age of the group was 44 years old (33-56); and an average BMI of 53.5 kg/m2 (50-63.5). Surgical time was 115 min (80-180). A total of five patients (7.5%) had any complication and two (2.9%) had to be reoperated. There were two patients with leak, one at the duodenal stump and other at the esophagogastric angle. There was no mortality. Patients stayed at the hospital a median of 2.5 days (1-25).

Conclusions

SADI-S with right gastric artery ligation is a safe procedure with few preliminary complications. The technical variations introduced to the classical duodenal switch are reproducible and may allow this procedure to be more popular. All the complications in this series were not related to the ligation of the right gastric artery.

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

Background

Roux-en-Y gastric bypass (RYGB) is a standard therapy in bariatric surgery. Sleeve gastrectomy and gastric banding, although with good results in the literature, are showing higher rates of treatment failure to reduce obesity-associated morbidity and body weight. Other problems after bariatric may occur, as band erosion, gastroesophageal reflux disease and might be refractory to medication. Therefore, a laparoscopic conversion to a RYGB can be an effective alternative, as long as specific indications for revision are fulfilled.

Objective

The objective of this study was to analyse own and literature data on revisional bariatric procedures to evaluate best alternatives to current practice.

Methods

Institutional experience and systematic review from the literature on revisional bariatric surgery.

Results

Endoscopic procedures are recently applied to ameliorate failure and complications of bariatric procedures. Therapy failure following RYGB occurs in up to 20%. Transoral outlet reduction is currently an alternative method to reduce the gastrojejunal anastomosis. The diameter and volume of sleeve gastrectomy can enlarge as well, which can be reduced by endoscopic full-thickness sutures longitudinally. Dumping syndrome and severe hypoglycemic episodes (neuroglycopenia) can be present in patients following RYGB. The hypoglycemic episodes have to be evaluated and usually can be treated conventionally. To avoid partial pancreatectomy or conversion to normal anatomy, a new laparoscopic approach with remnant gastric resection and jejunal interposition can be applied in non-responders alternatively. Hypoglycemic episodes are ameliorated while weight loss is sustained.

Conclusion

Revisional and endoscopic procedures following bariatric surgery in patients with collateral symptomatic or treatment failure can be applied. Conventional non-surgical approaches should have been applied intensively before a revisional surgery will be indicated. Former complex surgical revisional procedures are evolving to less complicated endoscopic solutions.

Endoscopic revision of gastric bypass: Holy Grail or Epic fail?

BACKGROUND

Approximately 20-30 % of patients who undergo Roux-en-Y gastric bypass (RYGB) will not meet the goals of weight loss surgery. Revisional surgery is associated with higher morbidity compared to initial operative management, and results in terms of weight loss have been inconsistent. Endoscopic plication has been seen as a less invasive option, with encouraging initial results. The objective was to analyze the outcomes after Restorative Obesity Surgery, Endolumenal (ROSE) procedure.

METHODS

We retrospectively analyzed patients who underwent ROSE between 5/2008 and 11/2013. All patients had failure of weight loss or regain weight after RYGB. Demographics, operative data, and follow-up were recorded.

RESULTS

Twenty-seven patients underwent ROSE. One patient was excluded due to lack of follow-up. Twenty-five (96 %) patients were female. Mean time since initial RYGB was 11.9 ± 4.3 years. Mean initial weight and BMI were 236 ± 47 lb and 40.6 ± 8.1 kg/m(2), respectively. Mean OR time was 77 ± 30 min. Preoperative average pouch length and stoma diameter were 6.8 ± 2.3 and 2.1 ± 0.7 cm, respectively. On average, 4 ± 1.6 stitches were placed. Final pouch length and stoma diameter were 3.4 ± 1.6 (50 % reduction) and 0.86 ± 0.4 cm (61 % reduction). A total of 12 (46 %) and seven (28 %) patients underwent EGD at 3 and 12 months postoperatively. The mean pouch length and stoma diameter were 5 ± 1.9 (26.5 % reduction) and 1.2 ± 0.7 cm (42.9 % reduction) at 3 months and 6.14 ± 1.6 (10 % reduction) and 2.2 ± 1.2 cm (4.7 % increase) at 12 months, respectively. The %EWL was 8.9, 9.3, 8, 6.7, -10.7, -13.5, -5.8, -4.5 at 3, 6, 12, 24, 36, 48, 60, and 72 months, respectively.

CONCLUSION

Although endoscopic plication achieved the intended reduction in the pouch and stoma diameter at 3 months, these tend toward the preoperative diameter at 12 months. This anatomical failure and the lack of follow-up may explain why most patients failed to achieve sustainable weight loss.

Revisional metabolic/bariatric surgery: a moral obligation

Revisional metabolic/bariatric surgery is a moral obligation; for not to perform revisional surgery is a denial of the precepts of our discipline and an abandonment of the underprivileged population who has placed its trust and future in our hands.

What are the support experiences and needs of patients who have received bariatric surgery?

Objective

To explore the support needs and experiences of patients who had received publicly or privately funded bariatric surgery and the importance of this support in mediating outcomes of surgery.

Methods

Seven semi‐structured focus groups were conducted. A broad interview schedule guided the discussions which were audio‐recorded and transcribed verbatim. Data were analysed thematically.

Results

Twenty‐six women and 15 men with a mean age of 54 years (range 24–72) participated in the study. Participants described support needs from health professionals, significant others (family and friends), peers (bariatric surgery recipients) and the general community. Peer, dietetic and psychological support were identified as important factors influencing the outcomes (e.g. weight reduction or health improvement) or experience of bariatric surgery but were identified as infrequently received or inadequately provided. Psychological support was proposed as one of the most significant but commonly overlooked components of care. Support needs appeared higher in the first year post‐surgery, when subsequent related or unrelated surgeries were required and following significant life change such as worsening health. For some participants, deficits in support appeared to negatively influence the experience or outcomes of surgery.

Conclusion

Providers of bariatric surgery should discuss support needs and accessibility regularly with patients especially in the first year post‐surgery and following significant change in a patient's life (e.g. declined health or childbirth). Nutrition, psychological and peer support (e.g. through support groups) may be especially important for some patients.

Psychosocial Interventions Pre and Post Bariatric Surgery

Despite positive results overall, a substantial number of patients experience poor long-term outcomes following bariatric surgery. One reason for variability in weight loss may be difficulty in making and sustaining changes in dietary intake and physical activity; post-surgery binge eating has also been associated with poorer weight outcomes. In this paper, we review available evidence on adjunctive psychosocial interventions for bariatric surgery patients. Although the literature is limited, evidence suggests that bariatric surgery patients may benefit from a comprehensive approach targeting diet, activity and psychological factors. We think the optimal time to initiate adjunctive intervention is after surgery, but before significant weight regain has occurred. Adaptive interventions incorporating advances in technology may prove to be effective for promoting behavioural self-management and psychosocial adjustment following bariatric surgery. For some patients, pharmacotherapy and reoperation may also play a role in a personalized approach to post-surgery care.

Laparoscopic conversion of failed vertical banded gastroplasty to Roux-en-Y gastric bypass or biliopancreatic diversion

BACKGROUND

The Silastic ring vertical gastroplasty (SRVG), a modification of Mason's vertical banded gastroplasty (VBG), was the restrictive procedure of choice for many bariatric surgeons. The reoperation rate for failure/complications reported in long-term studies is approximately 50%.

OBJECTIVE

We report our experience in laparoscopic conversion of failed SRVG to Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD).

SETTING

A single surgeon's experience at a university-affiliated hospital.

METHODS

Between March 2006 and April 2014, 39 patients underwent conversion of SRVG to laparoscopic RYGB (n = 25) or BPD (n = 14). The outcomes were retrieved from a prospectively collected database and analyzed.

RESULTS

Most (89%) of the conversions were completed laparoscopically. The mean operative time was 195 and 200 min for RYGB and BPD, respectively. There was no mortality. Complications occurred in 11 patients (28%), 5 in RYGB (19%) and 6 in BPD (42%). At the 3-year follow-up, the mean body mass index decreased from 47±8 kg/m(2) to 26±4 kg/m(2) for BPD, and from 43 kg/m(2) to 34 kg/m(2) (P = .05) for RYGB. Weight (kg) decreased from 110 to 84 and to 92, and from 123 to 81 and 68, at 1 and 3 years for RYGB and BPD, respectively.

CONCLUSIONS

The weight loss for RYGB and BPD was equal at 1 year but tended to be better for BPD at 3 years postoperatively. Laparoscopic conversion of failed VBG to RYGB or BPD was feasible, but it was followed by prohibitively high complication rates in BPD patients. The risk:benefit ratio of these procedures in this series is questionable.

The Challenges and Opportunities Associated with Reimbursement for Obesity Pharmacotherapy in the USA

Obesity has become a serious public health problem that has stimulated primordial and primary prevention efforts, and a triad of management options (lifestyle, pharmacotherapy, and surgical interventions). A growing body of evidence supports the need for a multi-pronged, clinic-based approach that leverages the synergy between pharmaceutical and lifestyle modification. Recent US policy changes-namely, the passage of the Patient Protection and Affordable Care Act coupled with recognition of obesity as a disease by the American Medical Association-suggest that financial incentives and attitudes towards obesity management are changing. This paradigm shift has implications for current and future obesity pharmacotherapy. However, barriers to pharmacotherapy utilization include patient and physician perceptions of modest efficacy, historical safety issues, regulatory obstacles, and lack of reimbursement. The shifting attitudes and challenges associated not only with a multi-payer system, but also the lack of clearly defined cross-payer reimbursement strategies, prompted a survey to determine coverage for obesity treatment. Participants indicated that federal/state mandates and growth of quality-driven healthcare initiatives will eventually drive wider pharmacotherapy reimbursement within 1-5 years. There are signs that federal/state programs are already moving towards reimbursement by improving quality measures to track obesity outcomes and reduce costs. Future research on clinical and economic outcomes of combination weight-management programs coupled with innovative approaches (e.g., eHealth) in the real-world setting that demonstrate value to patients, healthcare providers, payers, and employers will help reshape obesity management by reducing barriers and broadening reimbursement coverage for anti-obesity pharmacotherapy.

Presentation and surgical management of leaks after mini-gastric bypass for morbid obesity

BACKGROUND

Few data exist about the characteristics and management of enteric leaks after mini-gastric bypass (MGB).

OBJECTIVES

We aimed to describe the incidence, presentation, and surgical management of enteric leaks in patients who underwent laparoscopic MGB for morbid obesity.

SETTING

Private practice.

METHODS

An 8-year, 9-month retrospective chart review was performed on patients who had enteric leak requiring reoperation after MGB at a single institution.

RESULTS

Thirty-five of 2321 patients were included. Ninety-seven percent had symptoms. Arterial hypertension and heavy smoking were predicting factors of leaks occurrence post-MGB (P<.01). Enteric leak was diagnosed by systematic upper gastrointestinal series in 4 pts (11.4%) and by computed tomography with oral water soluble contrast in 4 of 31 pts (13%). In the other 27 patients, diagnosis of the leak was made intraoperatively. Eleven patients (32%) had leak arising from the gastric stapler line (type 1), 4 (11%) from the gastrojejunal anastomosis (type 2), and 20 (57%) from undetermined origin. The most common presentation was intra-abdominal abscess in type 1 and leaks of undetermined origin and generalized peritonitis in type 2. One third of the patients who underwent reoperation developed well-drained chronic fistula into the irrigation-drainage system, with complete healing in all patients without any further procedure. The mean hospital stay was 19 days with no mortality reported.

CONCLUSION

Enteric leak leading to intra-abdominal sepsis post-MGB is rare (1.5%) An operative aggressive management based on clinical symptoms is the treatment of choice allowing no postoperative leak-related mortality and complete healing.