Endoscopic findings and outcomes of revisional procedures for patients with weight recidivism after gastric bypass

Weight Recidivism After Bariatric Surgery: A Narrative Review

Bariatric surgery, while effective for severe obesity, is often challenged by postoperative weight regain (WR), affecting 20-30% of patients. This review analyzes the mechanisms, risk factors, and management strategies for WR, emphasizing surgical considerations. WR is influenced by hormonal adaptations, including ghrelin rebound and leptin resistance, as well as metabolic adaptation, leading to reduced resting energy expenditure. Surgical factors, such as suboptimal technique, gastro-gastric fistulas, and stomach/anastomosis dilation, significantly contribute to WR. Specifically, inaccurate sleeve or pouch sizing, poorly calibrated anastomoses, and complications with gastric banding necessitate careful surgical planning and potential revision. Management strategies encompass lifestyle interventions (diet, exercise, behavioral therapy), pharmacotherapy (GLP-1 receptor agonists like liraglutide, semaglutide, and tirzepatide), and revisional surgery. Revisional procedures, including sleeve-to-bypass, bypass revision, sleeve-to-duodenal switch/SADI, and band removal with conversion to sleeve or bypass, address anatomical failures and enhance weight loss. Distinguishing surgical failure from patient nonadherence is crucial for appropriate intervention. Ultimately, a collaborative, multidisciplinary approach integrating these strategies optimizes long-term weight management and improves patient outcomes after bariatric surgery.

The Efficacy and Safety of Liraglutide in Patients Remaining Obese 6 Months after Metabolic Surgery

INTRODUCTION

The safety and efficacy of liraglutide as a weight loss intervention in individuals who remain obese within 1 year post-metabolic surgery remain unclear. This study aimed to evaluate the effects and safety of liraglutide (1.8 mg) in patients with persistent obesity at 6 months postoperatively.

METHODS

This retrospective cohort study included 61 patients who remained obese (body mass index [BMI] ≥ 28.0 kg/m2) at 6 months postoperatively. Among these patients, 27 were treated with 1.8 mg of liraglutide for 12 weeks, whereas 34 served as controls. The primary endpoint was the change in total weight loss (%TWL) after 24 weeks. Changes in weight, BMI, complications, and adverse events were also assessed.

RESULTS

The liraglutide group showed a greater reduction in %TWL than the control group (11.6% ± 1.1% vs. 4.9% ± 1.0%), with an estimated treatment difference of 6.6% (95% confidence interval [CI], 3.7-9.6%, P < 0.01). The adjusted mean differences in the reduction of weight and BMI between the liraglutide and control groups were - 6.2 kg (95% CI - 8.9 to - 3.4, P < 0.01) and - 3.0 kg/m2 (95% CI - 4.2 to - 1.7, P < 0.01), respectively. The liraglutide group exhibited increased rates of remission in non-alcoholic fatty liver disease and hypertension. No serious adverse reactions were observed.

CONCLUSIONS

For patients who remained obese at 6 months postoperatively, 12-week liraglutide treatment resulted in increased weight loss, improved metabolic control, and high rate of remission for obesity-related metabolic diseases after 24 weeks. Earlier and more timely adjuvant weight loss medication intervention based on BMI within 1 year postoperatively may enhance weight loss after metabolic surgery. Graphical abstract available for this article.

Gastric Pouch Resizing for Recurrent Weight Gain After Roux-en-Y Gastric Bypass-Does It Have Its Rational?

INTRODUCTION

The most effective treatment for obesity and associated comorbidities is metabolic-bariatric surgery (MBS). Nevertheless, recurrent weight gain is reported in up to 40% of patients after Roux-en-Y gastric bypass (RYGB), eventually with a recurrence of obesity-associated comorbidities. Gastric pouch resizing (GPR) is performed as a low-risk secondary surgery to cease weight regain. We herewith analyzed the effect of GPR after primary RYGB on long-term weight loss, course of comorbidities, safety, and patient satisfaction.

METHODS

Forty-eight patients undergoing GPR between 2016 and 2020 at the University Hospital of Zurich were included. Data were collected from a prospective database. GPR was performed laparoscopically and included a resection of the enlarged gastric pouch and a redo of the gastrojejunostomy. Additionally, 37 patients participated in a survey to evaluate PROMs (patient-reported outcome measures).

RESULTS

GPR followed RYGB after a mean time of 106.2 ± 45.5 months at a mean BMI of 39 ± 5.4 kg/m2. Mean follow-up was 55.9 ± 18.5 months with a mean BMI 1- and 5-years postoperative of 37 ± 5.5 kg/m2 and 35 ± 7.5 kg/m2, respectively. Obesity-associated comorbidities were resolved in 53% of patients at follow-up (p < 0.05). Minor postoperative complications occurred in 12.5% while major complications occurred in 10.4% of patients. The PROMs showed high levels of satisfaction after GPR.

CONCLUSION

GPR for recurrent weight gain after primary RYGB is a safe procedure resulting in weight stabilization and resolution of obesity-associated comorbidities. It is thus a valuable surgical option in well-selected patients.

Therapeutic Options for Recurrence of Weight and Obesity Related Complications After Metabolic and Bariatric Surgery: An IFSO Position Statement

Obesity is a chronic disease that may require multiple interventions and escalation of therapy throughout the years. Until recently, no universal definition existed for recurrent weight gain and insufficient weight loss. Standardization of reporting is key so outcomes can be compared and data can be pooled. The recent IFSO consensus provided standard terminology and definitions that will likely resolve this in the future, and publishers will need to enforce for authors to use these definitions. This current IFSO position statement provides guidance for the management of recurrent weight gain after bariatric surgery.

Is conversion to duodenal switch after Roux-en-Y gastric bypass safe? Short-term outcomes review

BACKGROUND

Weight regain after Roux-en-Y gastric bypass (RYGB) can be seen in approximately 20% of patients. Surgical management options include revision of RYGB and conversion to duodenal switch (DS). Using recently included revisional surgery variables in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, we compared the safety and efficacy of RYGB revision versus conversion to DS.

METHODS

An analysis of the 2020 MBSAQIP Participant Use Data File (PUF) revealed 1421 patients who underwent revision of RYGB (n = 1255) or conversion from RYGB to DS (n = 166) for inadequate weight loss or weight regain. Patient characteristics, preoperative body mass index (BMI), operating room (OR) time, and 30-day complications were compared between groups.

RESULTS

When compared with the revision RYGB group, the DS group had higher mean BMI (47.5 vs 42.7, p < 0.001) and longer operative time (209.1 vs 133.4 min, p < 0.001). DS had higher rates of any complication compared to revision RYGB (22.3 vs 5.58%, p < 0.001). DS had higher 30-day readmission rates (16.3 vs 5.50%, p < 0.001), reoperation within 30 days (9.04 vs 2.87%, p < 0.001), venous thromboembolism (VTE) (3.01 vs 0.08%, p < 0.001), intensive care unit (ICU) admission (8.43 vs 0.72%, p < 0.001), anastomotic leak (7.83 vs 0.40%, p < 0.001), surgical site occurrence (SSO) (11.5 vs 2.71%, p < 0.001), and death (0.60 vs 0%, p < 0.001).

CONCLUSION

This short-term data suggests that conversion of RYGB to DS is associated with higher rates of postoperative complications when compared with revision of RYGB. Given the complexity of the procedure, it is best performed by experienced surgeons with careful consideration given to appropriate patient selection and only after extensive patient counseling on associated risks and complications.

Impact of Gastrojejunostomy Anastomosis Diameter on Weight Loss Following Laparoscopic Gastric Bypass: A Systematic Review

Laparoscopic Roux-en-Y gastric bypass (RYGB) is crucial for significant weight reduction and treating obesity-related issues. However, the impact of gastrojejunostomy (GJ) anastomosis diameter on weight loss remains unclear. We investigate this influence on post-RYGB weight loss outcomes. A systematic search was conducted. Six studies met the inclusion criteria, showing varied GJ diameters and follow-up durations (1-5 years). Smaller GJ diameters generally correlated with greater short-to-medium-term weight loss, with a threshold beyond which complications like stenosis increased. Studies had moderate-to-low bias risk, emphasizing the need for precise GJ area quantification post-operation. This review highlights a negative association between smaller GJ diameters and post-RYGB weight loss, advocating for standardized measurement techniques. Future research should explore intra-operative and AI-driven methods for optimizing GJ diameter determination.

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.

Weight loss maintenance after bariatric surgery

Metabolic and bariatric surgery (MBS) is an effective treatment for patients with morbid obesity and its comorbidities. However, many patients experience weight regain (WR) after achieving their nadir weight. Establishing the definition of WR is challenging as postoperative WR has various definitions. Risk factors for WR after MBS include anatomical, racial, hormonal, metabolic, behavioral, and psychological factors, and evaluating such factors preoperatively is necessary. Long-term regular follow-up and timely treatment by a multidisciplinary team are important because WR after surgery is multi-factorial. Although lifestyle interventions that focus on appropriate dietary education, physical activity education or interventions, and behavioral psychological interventions are suggested, more well-designed studies are needed because studies evaluating intervention methods and the effectiveness of WR prevention are lacking. Anti-obesity drugs can be used to prevent and manage patients with WR after MBS; however, more research is needed to determine the timing, duration, and type of anti-obesity drugs used to prevent WR.

Weight Regain after Bariatric Surgery

Bariatric surgery (BS) is currently the most effective treatment for obesity, with long-lasting weight loss and improvement of related co-morbidities [...].

Weight Regain After Bariatric Surgery: Scope of the Problem, Causes, Prevention, and Treatment

PURPOSE OF REVIEW

Although bariatric surgery is the most effective treatment of severe obesity, a proportion of patients experience clinically significant weight regain (WR) with further out from surgery. The purpose of this review is to summarize the prevalence, predictors, and causes of weight regain.

RECENT FINDINGS

Estimating the prevalence of WR is limited by a lack of consensus on its definition. While anatomic failures such as dilated gastric fundus after sleeve gastrectomy and gastro-gastric fistula after Roux-en-Y gastric bypass can lead to WR, the most common causes appear to be dysregulated/maladaptive eating behaviors, lifestyle factors, and physiological compensatory mechanisms. To date, dietary, supportive, behavioral, and exercise interventions have not demonstrated a clinically meaningful impact on WR, and there is limited evidence for pharmacotherapy. Future studies should be aimed at better defining WR to begin to understand the etiologies. Additionally, there is a need for non-surgical interventions with demonstrated efficacy in rigorous randomized controlled trials for the prevention and reversal of WR after bariatric surgery.

Resizing of the Gastric Pouch for Weight Regain after Laparoscopic Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass: Is It a Valid Option?

Introduction: The laparoscopic resizing of the gastric pouch (LPR) has recently been proposed as a revisional technique in the case of weight regain (WR) after gastric bypass procedures. The aim of this study was to report our experience with LPR for WR. Materials and Methods: All patients with WR ≥ 25% after gastric bypass and with a dilated gastric pouch and/or gastrojejunal anastomosis who underwent LPR between January 2017 and January 2022 were retrospectively reviewed. From a radiological point of view, a gastric pouch was considered dilated when its volume was calculated at >80 cm3 for LRYGB and >200 cm3 for OAGB upon a 3D-CT scan. The endoscopic criterion considered both the diameter of the gastrojejunal anastomosis and the gastric pouch volume. All anastomoses > 20 mm for LRYGB and >40 mm for OAGB were considered dilated, while a gastric pouch was considered endoscopically dilated when the retrovision maneuver with the gastroscope was easily performed. These selection criteria were arbitrarily established on the basis of both our personal experience and literature data. Results: Twenty-three patients had LPR after a Roux-en-Y gastric bypass or one-anastomosis gastric bypass. The mean BMI at LPR was 36.3 ± 4.7 kg/m2. All patients underwent LPR, while the resizing of the GJA was also performed in 3/23 (13%) cases, and hiatoplasty was associated with the resizing of the pouch in 6/23 cases (26.1%). The mean BMI at the last follow-up was 29.3 ± 5.8 kg/m2. The difference between the BMI before resizing and the BMI at the last follow-up visit was statistically significant (p = 0.00005). The mean %TWL at 24.2 ± 16.1 months was 19.6 ± 9%. Comorbidities had an overall resolution and/or improvement rate of 47%. The mean operative time was 71.7 ± 21.9 min. The conversion rate was nil. Postoperative complications occurred in two cases (8.7%). Conclusions: In our series, LPR for WR showed good results in weight loss and in improvement/resolution of comorbidities, with an acceptable complication rate and operative time. Only further studies with a greater cohort of patients and a longer postoperative follow-up will be able to highlight the long-term benefits of this technique.

Effect of Banded Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy on Diabetes Remission at 5 Years Among Patients With Obesity and Type 2 Diabetes: A Blinded Randomized Clinical Trial

OBJECTIVE

To determine whether silastic ring laparoscopic Roux-en-Y gastric bypass (SR-LRYGB) or laparoscopic sleeve gastrectomy (LSG) produces superior diabetes remission at 5 years.

RESEARCH DESIGN AND METHODS

In a single-center, double-blind trial, 114 adults with type 2 diabetes and BMI 35-65 kg/m2 were randomly assigned to SR-LRYGB or LSG (1:1; stratified by age-group, BMI group, ethnicity, diabetes duration, and insulin therapy) using a web-based service. Diabetes and other metabolic medications were adjusted according to a prespecified protocol. The primary outcome was diabetes remission assessed at 5 years, defined by HbA1c <6% (42 mmol/mol) without glucose-lowering medications. Secondary outcomes included changes in weight, cardiometabolic risk factors, quality of life, and adverse events.

RESULTS

Diabetes remission after SR-LRYGB versus LSG occurred in 25 (47%) of 53 vs. 18 (33%) of 55 patients (adjusted odds ratios 4.5 [95% CI 1.6, 15.5; P = 0.009] and 4.2 [1.3, 13.4; P = 0.015] in the intention-to-treat analysis). Percent body weight loss was greater after SR-LRYGB than after LSG (absolute difference 10.7%; 95% CI 7.3, 14.0; P < 0.001). Improvements in cardiometabolic risk factors were similar, but HDL cholesterol increased more after SR-LRYGB. Early and late complications were similar in both groups. General health and physical functioning improved after both types of surgery, with greater improvement in physical functioning after SR-LRYGB. People of Māori or Pacific ethnicity (26%) had lower incidence of diabetes remission than those of New Zealand European or other ethnicities (2 of 25 vs. 41 of 83; P < 0.001).

CONCLUSIONS

SR-LRYGB provided superior diabetes remission and weight loss compared with LSG at 5 years, with similar low risks of complications.

Clinical Endoscopic and Histologic Findings of a Long-Term Follow-Up (10.7 Years) After Roux-en-Y Laparoscopic Gastric Bypass: a Prospective Study

INTRODUCTION

Bariatric surgery, with laparoscopic Roux-en-Y gastric bypass (LYGB), is one of the most effective treatments for long-term weight loss. However, there are few publications concerning endoscopic evaluations at late control. The purpose was to evaluate the macroscopic and histological findings at the distal esophagus, gastric pouch, jejunal limb and the evolution of Barrett's esophagus (BE) in the long term.

METHODS

Cohort of 110 patients with obesity underwent LYGB in a university hospital. Several clinical, endoscopic and histological evaluations were performed after surgery. Exclusion criteria were previous bariatric procedure, hiatal hernia > 4 cm, BE with histological dysplasia and body mass index (BMI) > 50 kg/m².

RESULTS

Average age was 38.7 ± 9 years with 70% females. BMI averaged 39.6 ± 6 kg/m². Follow-up was 10.7 ± 2 years, and 18 patients (16.4%) were lost. The total weight loss was 23.4 ± 7 kg. Erosive esophagitis, present in 33% of patients, decreased to 5%. After surgery, intestinal metaplasia regressed to cardial mucosa in 5 of 8 patients. One patient developed a short-segment BE. The level of control to gastroesophageal reflux disease (GERD) symptom control was 87% to responders (Visick I-II) and 13% to non-responders (Visick III-IV). An increase in dilated cardia type III was observed (p < 0.001). The length of the gastric pouch increased significantly after surgery (p < 0.001). Anastomotic ulcers healed at 6 months with proton pump inhibitor (PPI) use, without recurrence.

CONCLUSION

LYGB is a very effective surgical procedure to control symptoms of GERD and/or endoscopic erosive esophagitis. Besides, regression of Barrett's mucosa to carditis occurred in 62%.

Revisional Adjustable Gastric Band in Roux-en-Y Gastric Bypass-Is It Worth It?

PURPOSE

A subset of patients undergoing Roux-en-Y gastric bypass (RYGB) presents with either insufficient weight loss or weight regain. Data on the revisional restrictive options including laparoscopic adjustable gastric band (LAGB) is scarce. This study analyzes the mid-term efficacy and safety of LAGB as a revisional procedure after RYGB.

METHODS

Data of all patients with revisional LAGB after primary RYGB between January 2011 and May 2019 were retrospectively reviewed. Outcomes included assessment of weight changes, resolution of comorbidities, and early and late complications during the study period.

RESULTS

Twenty patients were included. The median Body Mass Index (BMI) before revisional LAGB was 34.8 (interquartile range [IQR] 31.9-38.1) kg/m2. After a median follow-up of 33.5 (IQR 19.5-76.5) months, the median BMI was 28.7 (IQR 26.1-32.2) kg/m2. The median additional Excess Weight Loss (EWL) was 37.6% (IQR 23-44.4), leading to a median total EWL of 79.5% (IQR 54.4-94.6). BMI and EWL post-LAGB improved significantly compared to BMI and EWL pre-LAGB (p<0.001 and p<0.001, respectively). Obstructive sleep apnea syndrome resolved 6 months after LAGB in one patient. Three band deflations occurred during the follow-up. Six patients underwent band removal after a median time of 19 (IQR 15.8-26) months. Overall, thirteen patients underwent a reoperation. There was no loss of follow-up until 5 years. After that, two patients were lost to follow-up.

CONCLUSION

LAGB may be a salvage option after failed RYGB. However, the high rate of revisions after secondary LAGB needs to be taken into consideration.

Gastrojejunostomy in Roux-En-Y Gastric Bypass for Morbid Obesity: Linear Stapler Length Does Not Affect Mid-term Outcomes

BACKGROUND

The purpose of this study was to compare whether different linear stapler lengths used to form the gastrojejunostomy during laparoscopic Roux-En-Y gastric bypass affects mid-term weight loss outcomes.

MATERIALS AND METHODS

A retrospective single center analysis was performed. Surgical technique was identical other than either a 35 or 45 mm linear stapler being used to form the gastrojejunostomy. Multivariate regression was used to assess the relationship between the different stapler lengths and weight loss outcomes 2 years following surgery.

RESULTS

Of the 97 patients identified, 67 (69.1%) were included in the study. There were 30 patients in the 35 mm group and 37 in the 45 mm group. The groups were comparable in terms of basic demographic data and preoperative weight characteristics. There was no significant difference in weight loss outcomes 2 years following surgery when comparing between the different linear stapler lengths.

CONCLUSION

Thirty-five versus 45 mm linear stapler lengths does not affect mid-term weight loss outcomes.

Weight Regain and Insufficient Weight Loss After Bariatric Surgery: Definitions, Prevalence, Mechanisms, Predictors, Prevention and Management Strategies, and Knowledge Gaps-a Scoping Review

Some patients experience weight regain (WR) or insufficient weight loss (IWL) after bariatric surgery (BS). We undertook a scoping review of WR and IWL after BS. We searched electronic databases for studies addressing the definitions, prevalence, mechanisms, clinical significance, preoperative predictors, and preventive and treatment approaches including behavioral, pharmacological, and surgical management strategies of WR and IWL. Many definitions exist for WR, less so for IWL, resulting in inconsistencies in the reported prevalence of these two conditions. Mechanisms and preoperative predictors contributing to WR are complex and multifactorial. A range of the current knowledge gaps are identified and questions that need to be addressed are outlined. Therefore, there is an urgent need to address these knowledge gaps for a better evidence base that would guide patient counseling, selection, and lead to improved outcomes.

Multidisciplinary Approach for Weight Regain-how to Manage this Challenging Condition: an Expert Review

Weight regain is a multifactorial condition that affects many patients following bariatric surgery. The purpose of the paper is to review the multidisciplinary approach for the management of weight regain. We performed a search in current clinical evidence regarding the causes, consequences, and treatments of weight regain. The multidisciplinary approach with periodic monitoring is of fundamental importance to prevent or treat weight regain. Several therapeutic options are ranging from nutritional to surgical options, which should be tailored according to patients' anatomy, lifestyle behavior, and compliance. Specialized multidisciplinary care is the key to achieve optimal long-term weight loss and maintenance goals following bariatric surgery.

Approach to the Patient: Management of the Post-Bariatric Surgery Patient With Weight Regain

CONTEXT

Weight regain (WR) after bariatric surgery is emerging as a common clinical problem due to the increase in the number of procedures performed. Early interventions are necessary to curtail the potential recurrence of comorbid conditions. However, it is often difficult to recognize WR early enough to introduce mitigating measures because there are no current guidelines for timely diagnosis and assessment of the severity of this condition.

OBJECTIVE

We present a practical approach for the early recognition of WR, based on 11-year follow-up data from our multiethnic bariatric surgery patient population.

METHODS

We classify WR according to the rate of increase in weight relative to nadir weight, normalized per 30-day interval. We also review pertinent literature about the etiologic factors contributing to WR after bariatric surgery.

RESULTS

According to our algorithm, mild, moderate, and rapid WR are defined as weight increases of 0.2% to <0.5%, 0.5% to 1.0%, and more than 1.0% of nadir weight per 30 days, respectively. Treatment options, including dietary counseling, use of antiobesity medication, and consideration of surgical revision, are described. A case is presented to illustrate the utility of timely identification of WR and the importance of collaboration between bariatric surgeons, obesity medicine specialists, and dietitians.

CONCLUSION

Our approach emphasizes the importance of regular long-term follow-up for all bariatric surgery patients.

Reliability and usefulness of upper gastro intestinal contrast studies to assess pouch size in patients with weight loss failure after Roux-en-Y gastric bypass

Background: Weight loss failure or weight regain occurs in up to 25% of patients with a Roux-en-Y gastric bypass (RYGB). Post-operative anatomical changes, like pouch or stoma dilatation, might contribute. Aim of this study is to assess reliability and usefulness of upper gastro intestinal (UGI) contrast studies to detect pouch dilatation.Methods: Retrospective case-control study of patients with weight loss failure between 2010 and 2015 (failure group, n = 101) and a control group (n = 101) with adequate weight loss. Pouch dilatation was systematically reassessed. Clinical parameters were extracted from the electronic patient records.Results: Systematic reassessment showed 23/101 (23%) pouch dilatation in the failure group, compared to 11/101 (11%) in the control group (p = .024). Revision surgery was performed in 43/101 patients in the failure group. After this surgery, only 8% of patients with pouch dilatation achieved adequate weight loss, whereas 39% of patients without pouch dilatation achieved adequate weight loss (p = .07). There was no difference in return to adequate weight loss between patients treated surgically and conservatively (30% vs 28%).Conclusion: Systematic reassessment of UGI contrast studies showed 23% pouch dilatation in patients with weight loss failure after RYGB. However, low interobserver agreement and discrepancy in success rate of revision surgery greatly questions the reliability and usefulness of this diagnostic modality.

Swallow Magnetic Resonance Imaging Compared to 3D-Computed Tomography for Pouch Assessment and Hiatal Hernias After Roux-en-Y Gastric Bypass

Introduction/Purpose

Weight regain and weight loss failure after bariatric surgery are important issues that may require a weight regain procedure. Three-dimensional-computed tomography (3D-CT) is a well-established method allowing exact measurements of pouch volume. The aims of this study were to prove the applicability of swallow MRI as a non-ionizing procedure and compare it to 3D-CT in patients after weight regain procedures following RYGB.

Materials and Methods

Twelve post-RYGB patients who had a follow-up operation for weight regain before 12/2017 were included in this prospective study. Swallow MRI and 3D-CT were performed in each patient to evaluate the size of the anastomosis, pouch volume, and intrathoracic pouch migration (ITM).

Results

Mean pouch volume in swallow MRI and 3D-CT were 40.4 ± 21.0 ml and 43.5 ± 30.2 ml, respectively (p = 0.83), and pouch diameter at the maximal distention was 35.3 ± 5.9 ml (MRI) and 31.0 ± 10.0 ml (CT) (p = 0.16). The rate of ITM was 75% in both examinations (p = 1.0).

Conclusion

Swallow MRI is a valid method for the assessment of pouch volume in different phases of the swallowing process and is comparable to 3D-CT. The diagnosis of ITM using swallow MRI was equal to 3D-CT.

Weight regain after bariatric surgery: a systematic literature review and comparison across studies using a large reference sample

Published estimates of weight regain (WR) after bariatric surgery vary greatly. Understanding the sources of variability in the literature and clarifying the magnitude of WR after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are critical for informing expectations and planning interventions. A literature search through January 2019 yielded 15 English-language studies that reported WR in at least 30 participants, not selected based on weight loss or WR, at least 3 years after primary RYGB (n = 11) or SG (n = 5). Median follow-up was 5.0 (range, 3.2-10.0) years. Median sample size was 62 (range, 33-464). Samples represented a median of 54.3% (range, 10.7%-100%) of eligible participants. Nadir weight was determined by serial research assessments (n = 1), medical records (n = 7), participant recall (n = 4), or an undisclosed method (n = 4). Three continuous and 8 binary WR measures (the latter, based on various thresholds for clinically meaningful WR) were reported. To enable comparison across studies, the percentage difference in WR in each study versus a reference sample (n = 1433 RYGB), matched on time since surgery and WR measure, was calculated. Median WR in the reference sample increased from 8.2 (25th-75th percentile: 0-19.5) to 23.8 (25th-75th percentile: 9.0-33.9) percent of maximum weight lost, 3 to 6 years post RYGB surgery. Studies of RYGB versus SG, with larger versus smaller samples, with higher versus lower participation rates, that determined nadir weight via participant recall versus medical records, and reported continuous versus binary WR measures tended to have WR values closer to the reference sample and each other. Variation in WR estimates was explained by heterogeneity in WR measures, timing of assessment, surgical procedure, and study design characteristics. The best estimate of WR after RYGB likely comes from the large reference sample. WR after SG versus RYGB appears higher. However, additional high-quality studies with uniform reporting of WR by surgical procedure are needed.

Bariatric reduction system - BARS: device, technique and first clinical experience

BACKGROUND

Roux-en-Y gastric by-pass (RYGB) is one of the most effective bariatric procedures, but the rate of weight regain (WR) can reach 63% after the second year. Enlargement of the gastrojejunal anastomosis is one of the reported causes. A newly CE-marked flexible endoscopic system, Bariatric Anastomotic Reduction System (BARS) (Ovesco Endoscopy, Tuebingen, Germany), derivative of the well-established endoscopic over-the-scope-clip (OTSC) clipping system, has been recently developed. It was tested in pre-clinical and preliminary clinical use for feasibility and effectiveness in bariatric anastomotic reduction.

MATERIAL AND METHODS

Using a single-channel endoscope with external supplemental working channel, the BARS device captures the two limbs of the anastomosis, reducing its size, thus slowing food passage. After preclinical assessment, six patients with at least a 15% WR and the presence of an enlarged gastrojejunostomy > 20 mm were enrolled. The mean patient age was 49 years (range 24-67). Average interval between gastric bypass and BARS procedure: 8 years (4-13).

RESULTS

All procedures were safely performed without complications. Mean procedure time: 52 min (37 - 75). Preliminary results: mean weight loss 6 kg (4-9) at a 3-month FU.

CONCLUSIONS

BARS could be a promising endoscopic system in case of WR after gastric bypass due to enlargement of the anastomosis.

Impact of Laparoscopic Banded Gastric Bypass on Weight Loss Surgery Outcomes: 5 Years' Experience

OBJECTIVE

Evaluate 5-year outcomes of banded gastric bypass (BRYGB) as a primary and conversion bariatric procedure.

METHODS

Retrospective review of BRYGB between January 2011and March 2013. Outcomes included percentage of total weight loss (%TWL), weight loss maintenance, and band-related complications.

RESULTS

One hundred forty-two patients underwent BRYGB, 106 primary and 36 conversions. Indications for conversion to BRYGB were complications of the primary procedure (n = 19), insufficient weight loss (n = 5), and weight regain (n = 12). In the primary group, mean preoperative BMI was 44.8 kg/m² (± 6.9 kg/m²). Compared with preoperative weight, mean %TWL was 33.9% (n = 95), 34.1% (n = 82), 34.0% (n = 70), 33.9% (n = 62), and 31.8% (n = 75) after 1, 2, 3, 4, and 5 years, respectively. In conversions secondary to failed primary procedure (insufficient WL and weight regain), mean preoperative BMI was 40.8 kg/m² (± 6.01 kg/m²). Despite one patient gaining weight, mean %TWL was 25.7% (n = 13), 28% (n = 11), 23.9% (n = 8), 18.3% (n = 8), and 15.1% (n = 12) after 1, 2, 3, 4, and 5 years, respectively. In conversions secondary to primary procedure complications (n = 19), mean preoperative BMI was 28.4 kg/m² (± 3.5 kg/m²). After 1, 2, 3, 4, and 5 years, mean BMI was 28.1 (n = 15), 29 (n = 10), 29.8 (n = 9), 30.6 (n = 10), and 30.9 (n = 12) kg/m², respectively. Band-related complications after 5 years: three erosion and five patients complained of persistent dysphagia. One band needed reposition. Perioperative surgical complications: two bleeding, one leakage, one port-site hernia, and one food impaction.

CONCLUSION

Banded gastric bypass has good results in terms of weight loss and weight loss maintenance in both primary and conversional bariatric procedures with acceptable incidence of band-related complications.

Efficacy of Utilizing Argon Plasma Coagulation for Weight Regain in Roux-en-Y Gastric Bypass Patients: a Multi-center Study

BACKGROUND

Endoscopic approaches exist for targeting weight regain after Roux-en-Y gastric bypass (RYGB), including endoscopic suturing, clipping, and sclerotherapy. Argon plasma coagulation (APC) is a noncontact electrocoagulation method, and when used in RYGB patients, it has shown reduction in the diameter of the gastrojejunal anastomosis.

OBJECTIVES

To study the effectiveness of APC for weight regain in terms of weight loss for RYGB patients, from eight bariatric centers.

METHODS

A retrospective chart review was performed for 558 patients at eight bariatric centers in the USA (1) and Brazil (7) who underwent APC procedure between 31st July 2009 and 29th March 2017. APC was performed on patients who regained weight after RYGB procedure.

RESULTS

Upon exploratory analysis of the individual BMI data, the mean BMI decreased slightly during the first 24 months and increased slightly afterwards following the APC intervention. The mean weight was 94.5 ± 18.6 kg and the mean BMI was 34.0 kg/m² at APC. Where data were available, the mean of lowest weight was 67.0 ± 23.0 kg and the mean of lowest BMI was 24.1 kg/m² following gastric bypass. The mean weight loss was 6.5, 7.7, and 8.3 kg at 6, 12, and 24 months, respectively, and the changes in weight over time was statistically significant (p < 0.0001). Multi-level for change model showed the low body mass index (BMI) group (BMI < 30 kg/m²) to have greater TWL than the high BMI (BMI ≥ 30 kg/m²) group at 6, 12, and 24 months. In the low BMI group, the mean TWL was 4.7, 6.1, 6.9, and 2.4%, at 6, 12, and 24 months, respectively. In the high BMI group, the mean TWL was 7.5, 10.4, 13.4, and 3.7%, at 6, 12, 24, and 36 months, respectively. Of the 333 patients in four centers who provided complication information, complications after APC included stenosis (n = 9), GJ ulcer (n = 3), vomiting (n = 3), GJ leakage (n = 2), and melena (n = 1).

CONCLUSION

APC can be useful in reducing the regained weight after RYGB, and patients showed 6-10% total weight loss at 12 months. Randomized trials would be needed to validate the findings.

Surgical therapy of weight regain after Roux-en-Y gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is a well-established surgical method for morbid obesity; however, weight regain (WR) after initially good results may be considered an issue, the treatment of which has found no consensus yet.

OBJECTIVES

The aim of this study was to compare the different surgical methods treating WR after RYGB that are used at the Vienna Medical University in a larger number of patients, concerning further weight loss, complications, and reoperations.

SETTING

University hospital, Austria.

METHODS

This study includes all patients with RYGB who were reoperated due to WR at the Vienna Medical University by December 2016 (n = 84). The follow-up rate was 93%. The following 4 approaches to treating WR after RYGB were taken: (1) pouch resizing, (2) pouch banding, (3) pouch resizing plus pouch banding, and (4) common limb shortening (i.e., distalization).

RESULTS

The mean maximum excess weight loss referring to the WR procedure in the 4 groups was as follows: group 1: 69.0% ± 35.2%, group 2: 62.8% ± 39.5%, group 3: 83.1% ± 30.9%, and group 4: 81.5% ± 41.6%. Reoperations occurred in the following different groups: group 1 had 2 balloon dilations (20%), groups 2 (n = 13) and 3 (n = 29) had 5 (38% and 17%) band removals each, and group 4 had 9 reversal procedures due to malnutrition (30%).

CONCLUSIONS

There are nonsignificant differences in terms of additional weight loss between the different methods. However, differences lay in the areas of adverse symptoms and further reoperations. While there was no risk of malnutrition with pouch resizing, there was with distalization. Pouch banding (with or without resizing) poses a higher risk of dysphagia.

Predictors of weight regain after sleeve gastrectomy: an integrative review

BACKGROUND

Sleeve gastrectomy (SG) is one of the most effective treatments for severe obesity, but weight regain after surgery is a challenging issue. The mechanism of postoperative weight relapse is barely understood because of the lack of long-term data.

OBJECTIVES

To review and synthesize current evidence related to factors that contribute to weight regain after SG.

METHODS

Whittemore and Knafl's integrative method guided the research. The databases PubMed, EMBASE, and CINAHL, as well as 2 selected journals, were searched through October 2018 to gather English-language journal articles on the potential predictors of post-SG weight regain among adult populations. Only articles with sample size ≥10 were included. A narrative synthesis was used to analyze the 17 studies included in the review.

RESULTS

In recent years there has been an upward trend in the published reports of SG on longer-term outcomes. After a review of 6863 records, 17 eligible studies were identified, reporting various definitions of weight regain and 3 main categories of predictors: surgical/anatomic factors, hormonal/metabolic imbalance, and behavioral/mood factors. The 17 studies used quantitative (n = 16) and qualitative methods (n = 1).

CONCLUSION

There is a dearth of available literature addressing predictors of weight regain after SG, and the inconsistency in the definition of regain limited the comparability between studies. Besides the surgical/anatomic factors that have been reported as significant predictors, other modifiable factors such as behavioral and psychosocial determinants need to be further investigated.

Endoscopic management of weight regain following Roux-en-Y gastric bypass

INTRODUCTION

With the cumulative increase in the number of patients undergoing bariatric surgery, postoperative weight regain has become a considerable challenge. Mechanisms for weight regain are not fully understood and the process is likely multifactorial in many cases. Endoluminal revisions that reduce gastric pouch size and diameter of the gastrojejunal anastomosis may offer an effective and less invasive management strategy for this population.

AREAS COVERED

We critically review data from case series, retrospective and prospective studies, and meta-analyses pertaining to weight regain after gastric bypass. A variety of endoscopic revision approaches are reviewed, including technique details, procedural safety and efficacy, and post-procedure care.

EXPERT COMMENTARY

Given the proliferation of endoluminal therapies with evidence showing safety and efficacy in the treatment of weight regain, it is likely that endoscopic revision will be the gold standard to treat weight regain in patients with gastric bypass.

Endoscopic Treatment of Weight Regain Following Roux-en-Y Gastric Bypass: a Systematic Review and Meta-analysis

Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric procedure. Despite its high efficacy, some patients regain part of their lost weight. Several endoscopic therapies have been introduced as alternatives to treat weight regain, but most of the articles are relatively small with unclear long-term data. To systematically assess the efficacy of endoscopic therapies for weight regain after RYGB. We searched MEDLINE, EMBASE, Scopus, Web of Science, Cochrane, OVID, CINAHL/EBSCo, LILACS/Bireme, and gray literature. Primary outcomes were absolute weight loss (AWL), excess weight loss (EWL), and total body weight loss (TBWL). Thirty-two studies were included in qualitative analysis. Twenty-six described full-thickness (FT) endoscopic suturing and pooled AWL, EWL, and TBWL at 3 months were 8.5 ± 2.9 kg, 21.6 ± 9.3%, and 7.3 ± 2.6%, respectively. At 6 months, they were 8.6 ± 3.5 kg, 23.7 ± 12.3%, and 8.0 ± 3.9%, respectively. At 12 months, they were 7.63 ± 4.3 kg, 16.9 ± 11.1%, and 6.6 ± 5.0%, respectively. Subgroup analysis showed that all outcomes were significantly higher in the group with FT suturing combined with argon plasma coagulation (APC) (p < 0.0001). Meta-analysis included 15 FT studies and showed greater results. Three studies described superficial-thickness suturing with pooled AWL of 3.0 ± 3.8, 4.4 ± 0.07, and 3.7 ± 7.4 kg at 3, 6, and 12 months, respectively. Two articles described APC alone with mean AWL of 15.4 ± 2.0 and 15.4 ± 9.1 kg at 3 and 6 months, respectively. Full-thickness suturing is effective at treating weight regain after RYGB. Performing APC prior to suturing seems to result in greater weight loss. Head-to-head studies are needed to confirm our results. Few studies adequately assess effectiveness of other endoscopic techniques.

Endoscopic Evaluation and Treatment of Postoperative Bariatric Surgery Complications

The number of patients undergoing bariatric surgery continues to increase. The American Society for Metabolic and Bariatric Surgery (ASMBS) estimates the number of bariatric surgical procedures performed increased from 158 000 in 2011 to 190 000 in 2015. Concurrently, the incidence of postoperative complications specific to bariatric patients will inevitably increase as well. Endoscopic evaluation of postoperative bariatric patients and endoscopic interventions are rapidly evolving. We present a review of the postoperative anatomy of bariatric patients, what complications to expect, and treatment options.

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.

Gastric pouch emptying of solid food in patients with successful and unsuccessful weight loss after Roux-en-Y gastric bypass surgery

BACKGROUND

After Roux-en-Y gastric bypass (RYGB), approximately 10% of patients have insufficient weight loss (excess body mass index loss<50%). Gastric pouch emptying may have a role in weight loss.

OBJECTIVES

To compare pouch emptying of patients with poor weight loss and patients with successful weight loss after RYGB.

SETTING

A research-intensive nonacademic hospital and center of expertise in bariatric surgery in the Netherlands METHODS: Female patients were included from among patients with the least (poor weight loss group [P-WL]) and the most weight loss (successful weight loss group [S-WL]) in our center 2 years after RYGB. Pouch emptying scintigraphy was performed after ingestion of a radiolabeled solid meal. Emptying curves, intestinal content (IC) at meal completion and after 15, 30, 45, and 60 minutes, half emptying time, and maximal pouch emptying rate were compared.

RESULTS

Five individuals were included in P-WL and 5 in S-WL, on average 2.5 ± .3 years after RYGB. Total weight loss was 18 ± 4.1% in P-WL and 44 ± 5.7% in S-WL (P<.001). In P-WL, a fast initial pouch emptying and exponential emptying curve was observed, compared with a slower initial emptying and more linear curve in S-WL. Faster emptying in P-WL was also shown by a larger IC_meal (42 ± 18% versus 4.0 ± 3.3%,), IC₁₅ (76 ± 15% versus 35 ± 22%), and IC₃₀ (85 ± 12% versus 54 ± 25%), and a greater maximal pouch emptying rate (17 ± 4.7 versus 5.6 ± 3.4%/min) compared with S-WL (P<.05). A linear correlation was found between total weight loss and maximal pouch emptying rate (Pearson R = .82, P = .004).

CONCLUSIONS

Pouch emptying for solid food was faster in patients with the least weight loss compared with patients with the most weight loss after RYGB. If pouch emptying is an important mechanism in weight loss, altering the pouch outlet may improve poor weight loss management.

Sociodemographic and lifestyle factors as determinants of energy intake and macronutrient composition: a 10-year follow-up after bariatric surgery

BACKGROUND

Early identification of the potential to adopt a long-term unhealthy diet, could improve weight outcomes for patients having undergone bariatric surgery.

OBJECTIVES

We explored whether presurgical sociodemographic and lifestyle characteristics, together with the type of surgery, could predict 10-year changes in dietary intake after bariatric surgery.

SETTING

Surgical departments and primary healthcare centers, nationwide.

METHODS

Participants were from the Swedish Obese Subjects study, a matched (nonrandomized) prospective trial comparing bariatric surgery with standard care for obese patients. This study included the 1695 surgery patients with complete information on presurgery diet. Questionnaires were completed before and 6 months, 1-4, 6, 8, and 10 years after surgery. Analyses were conducted with linear mixed-model.

RESULTS

Dietary changes were observed in 1561, 1298, and 1243 participants, at the 2-, 6-, and 10-year follow-ups, respectively. Sex and treatment type predicted changes in energy, carbohydrate, protein, and fiber intake over the follow-up (P<.05). Furthermore, male sex, younger age, a sedentary behavior, and gastric bypass predicted increased alcohol consumption (P<.001). Two important phases for intervening bariatric patients' diet were identified. The first was 6 months after surgery, when the maximal changes in diet were achieved. The second, stretched from 6 months until 4 years after surgery, during which earlier commitments to dietary changes were largely abandoned.

CONCLUSIONS

Male sex and banding surgery in particular predicted unfavorable post-surgery changes in energy and macronutrient intake. Furthermore, gastric bypass, a younger age, and an unhealthy lifestyle presurgery, may predispose individuals to increased alcohol intake after surgery.

Banded Gastric Bypass: Better Long-Term Results? A Cohort Study with Minimum 5-Year Follow-Up

BACKGROUND

While gastric bypass has been the treatment of choice for morbid obesity, insufficient weight loss and even weight regain has been observed in a sub-group of patients. Dilatation of the pouch, pouch outlet, and proximal alimentary limb have been suggested to cause weight regain on the long term. The banded gastric bypass surgery has been introduced to overcome this problem.

METHODS

Four hundred thirty-two patients (n = 254, non-banded/n = 178, banded-GaBP Ring™) were followed-up for 5 years. Patients were evaluated for weight loss, % excess weight loss (%EWL), weight regain and BMI.

RESULTS

No significant differences between groups in the first year following surgery were observed in terms of weight loss and %EWL. %EWL at 5 years was as follows: non-banded 65.2 ± 20.0 %; banded 74.0 ± 15.1 %. At 5 years, the banded group showed more weight loss (non-banded 35.4 ± 12.5; banded 43.9 ± 11.9 kg, P < 0.0001); weight regain was significantly higher in the non-banded group (P < 0.0001). Only minor complications were reported; no signs of ring migration or slippage were reported.

CONCLUSION

Although, following the first year after surgery, no differences in treatment groups were observed in terms of weight loss, 5 years following surgery, patients who received banded surgery maintained better weight loss and had less weight regain compared to the non-banded group. These results suggest that laparoscopic banded gastric bypass using a silastic ring was effective in maintaining weight loss on the long term, while the complication rate was low. The banded gastric bypass is regarded by us as the new gold standard.

Review article including treatment algorithm: endoscopic treatment of luminal complications after bariatric surgery

The worldwide number of performed bariatric surgeries is increasing continuously, whereas laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy are conducted most frequently. Alongside with the usual post-operative and metabolic complications, luminal complications such as anastomotic bleeding, ulceration, leakage, fistula formation, enlargement and stenosis of the anastomosis may occur. Evolution of interventional endoscopy frequently allows endoscopic management of complications, avoiding surgical interventions in most cases. Here, we review the various luminal complications after bariatric surgery with a focus on their endoscopic management.

Validation of a new method for the endoscopic measurement of post-bariatric gastric outlet using a standard guidewire: an observer agreement study

Background and aims

Between 10 and 20% of all patients undergoing bariatric surgery procedures regain weight secondary to a gastrojejunostomy enlargement. The aim of this study was to validate the interobserver agreement while measuring gastric outlet diameters using a new standard guidewire.

Methods

We selected thirty-five videos of consecutive endoscopic procedures on patients undergoing esophagogastroduodenoscopy after a Roux-en-Y gastric bypass procedure. All videos were evaluated by four raters: two expert endoscopists and two trainees. We excluded videos having a slipped Fobi ring or a strictured gastric outlet. Anastomosis diameter was measured using a novel device with standardized markings on a guidewire (Hydra jagwire, Boston Scientific, Natick. MA) as well as the current gold standard defined as a calibrated endoscopic measuring instrument (Olympus America, Center Valley, PA).

Results

We obtained 272 measurements of the gastric outlet. Overall agreement measured through intra-class correlation coefficients for the gold standard was 0.84 (p < 0.01) and 0.83 (p < 0.01) for the new guidewire. Agreement among experts was 0.699 (p < 0.01), while among trainees it was 0.822 (p < 0.01).

Conclusion

The new guidewire demonstrated a high degree of observer reliability, also presenting similar results between expert endoscopists and trainees.

Outcomes following 50 consecutive endoscopic gastrojejunal revisions for weight gain following Roux-en-Y gastric bypass: a comparison of endoscopic suturing techniques for stoma reduction

BACKGROUND

Approximately 20-30 % of morbidly obese patients undergoing Roux-en-Y gastric bypass (RYGB) will experience significant weight regain in the years following surgery. Endoscopic gastrojejunal revision (EGJR) has been shown to be a safe, effective and less invasive alternative to revisional surgery, with promising weight loss outcomes. However, minimal data exist regarding how to perform the procedure most effectively and what factors may predict good outcomes. We compared weight loss outcomes between patients undergoing endoscopic stoma revision by one of two full-thickness suturing techniques.

METHODS

A retrospective review of patients undergoing EGJR between 06/2012 and 09/2015 was performed. Included patients were adults 18-74 years of age who had experienced weight regain ≥2 years after initial RYGB with stoma dilation ≥15 mm in diameter. Revision was done with either an interrupted (IRT) or purse-string (PST) suture technique. A linear mixed effects model was constructed to predict postoperative weight loss.

RESULTS

Fifty revisions (IRT = 36, PST = 14) were performed in 47 patients (92 % female, mean age of 50.9 ± 10.9 years and body mass index of 41.4 ± 7.1 kg/m²). Technical success (stoma diameter ≤10 mm) was achieved in all cases. Final diameter was significantly smaller in the PST group, 6.6 ± 2.2 mm versus 4.8 ± 1.8 mm (p < 0.01), resulting in a significantly greater % stoma reduction (76.8 ± 8.5 % vs. 84.2 ± 5.1 %, p < 0.01) versus the IRT group. PST resulted in greater % excess weight loss over time compared to IRT. Sixteen comorbid conditions resolved among 12 patients. No major complications occurred.

CONCLUSION

Endoscopic revision of the gastric outlet results in meaningful weight loss and comorbidity resolution in select patients experiencing weight regain following RYGB. A PST revision likely results in higher and more sustainable weight loss when compared to IRT.

Mechanisms of long-term weight regain in patients undergoing sleeve gastrectomy

OBJECTIVES

Weight regain after bariatric surgery may be associated with behavioral, metabolic, or mechanical factors alone or in combination. The aim of this study was to investigate which factors are related to weight regain in the long-term after sleeve gastrectomy (SG).

METHODS

A retrospective case-control study with 40 patients undergoing SG (32 women, 8 men; age 42.9 ± 10.7 y; preoperative body mass index 35 ± 2.8 kg/m(2)), was performed. Patients were grouped according percentile->50% (cases) or <50% (controls)-of weight regain (%WR cutoff: 25% of weight loss). Weight history, anthropometry, glucose, insulin, homeostasis model assessment-estimated insulin resistance (HOMA-IR), thyroid-stimulating hormone, resting energy expenditure, body composition, dietary survey, psychological test, and physical activity were recorded. Residual gastric capacity was estimated using a radiologic method. RESULTS (MEDIAN [P25-P75]): The evaluation was conducted 38.5 mo (34-41 mo) after SG. Percent weight regain ranged from 2.7% to 129.2% (25.4% [13-37.1]). Patients in the higher %WR group had a greater residual gastric volume (252.7 ± 108.4 versus 148.5 ± 25.3; P < 0.05) and the estimated volume was significantly correlated with %WR (r = 0.673; P = 0.023). Significantly higher body mass index (P = 0.001), resting energy expenditure (P = 0.04), fasting insulin (P = 0.01), and HOMA-IR (P = 0.02) were observed in the higher %WR group. A higher fat intake and a trend toward higher total energy intake were observed in the group with greater %WR. Clinical or borderline levels of anxiety were more frequently observed in the higher %WR group (70% versus 30%; P = 0.01).

CONCLUSIONS

Results from the present study demonstrated that the most important factor associated with long-term weight regain after SG was residual gastric volume. Additional prospective studies with larger numbers of patients are necessary to confirm our results.

Outcomes of a third bariatric procedure for inadequate weight loss

Background and Objectives:

The robust volume of bariatric surgical procedures has led to significant numbers of patients requiring reoperative surgery because of undesirable results from primary operations. The aim of this study was to assess the feasibility, safety, and outcomes of the third bariatric procedure after previous attempts resulted in inadequate results.

Methods:

We retrospectively identified patients who underwent a third bariatric procedure for inadequate weight loss or significant weight regain after the second operation. Data were analyzed to establish patient demographic characteristics, perioperative parameters, and postoperative outcomes.

Results:

A total of 12 patients were identified. Before the first, second, and third procedures, patients had a mean body mass index of 67.1 ± 29.3 kg/m², 60.9 ± 28.3 kg/m², and 49.4 ± 19.8 kg/m², respectively. The third operations (laparoscopic in 10 and open in 2) included Roux-en-Y gastric bypass (n = 5), revision of pouch and/or stoma of Roux-en-Y gastric bypass (n = 3), limb lengthening after Roux-en-Y gastric bypass (n = 3), and sleeve gastrectomy (n = 1). We encountered 5 early complications in 4 patients, and early reoperative intervention was needed in 2 patients. At 1-year follow-up, the excess weight loss of the cohort was 49.4% ± 33.8%. After a mean follow-up time of 43.0 ± 28.6 months, the body mass index of the cohort reached 39.9 ± 20.8 kg/m², which corresponded to a mean excess weight loss of 54.4% ± 44.0% from the third operation. At the latest follow-up, 64% of patients had excess weight loss >50% and 45% had excess weight loss >80%.

Conclusion:

Reoperative bariatric surgery can be carried out successfully (often laparoscopically), even after 2 previous weight loss procedures.

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.