Revisional bariatric surgery for unsuccessful weight loss and complications

Laparoscopic One Anastomosis Gastric Bypass as a Revisional Procedure After Failed Vertical Banded Gastroplasty: Our Center Experience

Background: Vertical banded gastroplasty (VBG) was historically a popular restrictive bariatric procedure, but long-term failure rates due to weight regain, stenosis, and gastroesophageal reflux have necessitated revisional interventions. One anastomosis gastric bypass (OAGB), also known as mini-gastric bypass, has emerged as a viable revisional option due to its technical simplicity, lower complication rates, and promising metabolic outcomes. This study evaluates the safety, efficacy, and outcomes of OAGB as a revisional procedure following failed VBG, based on our center's experience and a review of the current literature. Methods: Seventy-one patients who underwent revisional OAGB after failed open VBG between February 2014 and February 2020 were included in this retrospective study. Three years outcomes regarding weight loss (the percentage of excess body weight loss (EBWL %) and change in body mass index (BMI)), co-morbidities resolution, morbidity, and mortality were assessed. Results: The EBWL % after revisional OAGB was 68.2 ± 9.4%, 65.9 ± 2.5%, and 59.6 ± 7.4% after 1, 2, and 3 years, respectively. The mean BMI before revisional surgery was 41.8 ± 3.7 kg/m2,which decreased to 31.9 ± 4.2 kg/m2 3 years after the revisional surgery. After 1 year, there was a remarkable resolution of obesity-related co-morbidities, the remission of type 2 diabetes mellitus was 85.7%, and of hypertension was 80%. Remission of other comorbidities was also observed. Bile reflux was encountered in 6 cases (8.5%), two of them required surgical intervention. Conclusions: OAGB is a feasible and effective revisional procedure after failed open VBG. However, the risk of bile reflux should be considered to justify these findings; further prospective randomized controlled trials are required.

Black-vs-white racial disparities in 30-day outcomes following primary and revisional metabolic and bariatric surgery: a MBSAQIP database analysis

BACKGROUND

Previous studies have demonstrated Black-vs-White disparities in postoperative outcomes following primary metabolic and bariatric surgery (MBS). With the rising prevalence of MBS, it is important to examine racial disparities using quality indicators in primary and revisional procedures. This study explores Black-vs-White disparities in postoperative outcomes following primary and revisional MBS.

METHODS

We performed an observational cohort study using the 2015-2020 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database of adults who underwent primary or revisional Roux-en-Y gastric bypass, sleeve gastrectomy, duodenal switch, or one-anastomosis gastric bypass. Black and White patients were 1:1 matched using propensity scores across 19 covariates for primary and revisional MBS groups. McNemar's tests were used to compare 11 postoperative outcomes from the MBSAQIP semi-annual report and death, between matched cohorts.

RESULTS

We identified 112,495 Black and 434,266 White primary MBS and 10,838 Black and 37,075 White revisional MBS patients. A total of 219,114 primary and 21,314 revisional patients were matched. Following primary MBS, Black patients had higher rates of death (0.1% vs. 0.06%, p < 0.001), all occurrences morbidity (5.6% vs. 4.7%, p < 0.001), serious events (2.2% vs. 1.9%, p < 0.001), and all cause and related reoperations (1.2% vs. 1.1%, p = 0.006; 0.2% vs. 0.1%, p = 0.01), readmissions (4.6% vs. 3.4%, p < 0.001; 2.8% vs. 1.9%, p < 0.001), and interventions (1.4% vs. 1.1%, p < 0.001; 0.8% vs. 0.6%, p < 0.001) compared to White patients. In contrast, there were no significant Black-vs-White disparities in death, morbidity, serious events, reoperations, interventions, and bleeding following revisional MBS. Interestingly, Black patients had higher rates of all cause and related readmissions (7.4% vs. 6.2%, p = 0.005; 4.4% vs. 3.6%, p = 0.01), but lower surgical site infection rates (1.6% vs. 2.1%, p = 0.04).

CONCLUSIONS

Our findings demonstrate a measurable contrast between racial disparities in postoperative outcomes following primary and revisional MBS. Equity-focused measures in national MBS assessments are needed to elucidate and address these disparities.

Scientific Evidence for the Updated Guidelines on Indications for Metabolic and Bariatric Surgery (IFSO/ASMBS)

The 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) updated the indications for Metabolic and Bariatric Surgery (MBS), replacing the previous guidelines established by the NIH over 30 years ago. The evidence supporting these updated guidelines has been strengthened to assist metabolic and bariatric surgeons, nutritionists, and other members of multidisciplinary teams, as well as patients. This study aims to assess the level of evidence and the strength of recommendations compared to the previously published criteria.

Robotic bariatric surgery reduces morbidity for revisional gastric bypass when compared to laparoscopic: outcome of 8-year MBSAQIP analysis of over 40,000 cases

INTRODUCTION

Robotic-assisted metabolic and bariatric surgery (MBS) is gaining popularity. Revisional MBS is associated with higher perioperative morbidity compared to primary MBS. The optimal surgical approach to minimize complications in these complex cases is unclear. The goal of this study was to assess robot utilization in revisional MBS and compare laparoscopic and robotic revisional MBS outcomes in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

METHODS

A retrospective review of the MBSAQIP database was performed identifying revisional sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) cases from 2015 to 2022. Primary MBS, open/emergent cases, cases converted to another approach, and combined cases other than esophagogastroduodenoscopy were excluded. 30-Day outcomes for laparoscopic and robotic cases were compared using multivariate logistic regression adjusting for patient demographics, comorbidities, and operative variables.

RESULTS

41,404 Cases (14,474 SG; 26,930 RYGB) were identified. From 2015 to 2022, the percentage of revisional SG and RYGB cases performed robotically increased from 6.1% and 7.3% to 24.2% and 32.0% respectively. Laparoscopic SG had similar rates of overall morbidity, leak, bleeding, readmission, reoperation, and length of stay compared to robotic. Laparoscopic RYGB had significantly higher rates of overall morbidity (6.2% vs. 4.8%, p < 0.001, AOR 0.80 [0.70-0.93]), blood transfusion (1.5% vs. 1.0%, p < 0.05, AOR 0.74 [0.55-0.99]), superficial incisional SSI (1.2% vs. 0.4%, p < 0.001, AOR 0.30 [0.19-0.47]), and longer length of stay (1.87 vs. 1.76 days, p < 0.001) compared to robotic. Laparoscopic operative times were significantly shorter than robotic (SG: 86.4 ± 45.8 vs. 113.5 ± 51.7 min; RYGB: 130.7 ± 64.7 vs. 165.5 ± 66.8 min, p < 0.001).

CONCLUSION

Robot utilization in revisional bariatric surgery is increasing. Robotic surgery has lower postoperative morbidity and shorter length of stay in revisional RYGB when compared to laparoscopic. Robotic platforms may have the capacity to improve the delivery of care for patients undergoing revisional bariatric surgery.

Scientific evidence for the updated guidelines on indications for metabolic and bariatric surgery (IFSO/ASMBS)

The 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) updated the indications for metabolic and bariatric surgery (MBS), replacing the previous guidelines established by the National Institutes of Health (NIH) over 30 years ago. The evidence supporting these updated guidelines has been strengthened to assist metabolic and bariatric surgeons, nutritionists, and other members of multidisciplinary teams (MDTs), as well as patients. This study aims to assess the level of evidence and the strength of recommendations compared to the previously published criteria.

The SAGES MASTERS program bariatric surgery pathway selects 10 seminal publications on revisional bariatrics

BACKGROUND

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program designated bariatric surgery as a clinical pathway. Among the tiers of the Masters Program, revisional bariatric surgery is the highest tier of "mastery" within the pathway. This article presents the top 10 seminal studies representing the current landscape of revisional bariatrics.

METHODS

The literature was systematically searched and seminal articles designated by consensus agreement of the SAGES Metabolic and Bariatric Surgery committee using multiple criteria, including impact on the field, citation frequency, and expert opinion. Articles were reviewed by committee members and presented in summarized fashion.

RESULTS

The top 10 papers are presented in grouped thematic categories covering the early evolution of revisional bariatrics, changing criteria for reoperative bariatric surgery, divergence of revision versus conversion bariatric surgery, and recent technologic innovations in revisional bariatric surgery. Each summary is presented with expert appraisal and commentary.

CONCLUSION

These seminal papers represent a snapshot of the dynamic field of revisional bariatric surgery and emphasize the need to not only remain current with contemporary trends but also keep a patient-oriented perspective on patient and intervention selection for optimal success.

The Trajectory of Revisional Bariatric Surgery: Open to Laparoscopic to Robotic

Metabolic and bariatric surgery (MBS) is the most effective therapeutic intervention for patients with obesity, with sleeve gastrectomy (SG) being the most commonly performed primary MBS procedure. Long-term studies have demonstrated that 15-20% of patients require revisional bariatric surgery (RBS) due to weight-related issues or surgical complications. Despite the gold standard being laparoscopic revision, there are other available approaches such as open or robotic-assisted. An extensive literature review was performed for articles from their inception to February 2024. A descriptive review of MBS procedures (SG, Roux-en-Y gastric bypass (RYGB), single anastomosis duodeno-ileostomy (SADI) and biliopancreatic diversion-duodenal switch (BPD-DS)) was carried out to report and compare outcomes between primary and revisional bariatric surgery. A similar review was conducted to compare outcomes of revisional approaches (open, laparoscopic, robotic). RYGB remains the dominant RBS with a similar safety profile compared to revisional SADI and BPD-DS. In terms of the RBS surgical approach, all three options showed comparable short and long-term outcomes, with robotic RBS being associated with longer operative time and variable length of stay. Additional long-term studies are required to further validate our conclusions.

Roux-en-Y Gastric Bypass after Laparoscopic Sleeve Gastrectomy Failure: Could the Number of Previous Operations Influence the Outcome?

After a failed laparoscopic adjustable gastric band (LAGB), laparoscopic sleeve gastrectomy (LSG) has been proposed as revisional surgery. Those patients that receive a second restrictive procedure fall into a small subgroup of patients with more than one restrictive procedure (MRP). If also the second restrictive procedure fails, the correct surgical strategy is a challenge for the surgeon. Roux-en-Y gastric bypass (RYGB) may be an option but there is no evidence in the literature on whether the procedure is effective in treating failures after MRP. This study aims to evaluate the influence of the previous number of restrictive interventions (MRP vs single LSG) in the results of RYGB as revisional surgery. We have retrospectively analyzed patients who underwent conversion from laparoscopic sleeve gastrectomy (LSG), or from multiple restrictive procedures (MRP), to RYGB for weight regain (WR) or insufficient weight loss (IWL) between 2009 and 2019. The number of patients analyzed was 69 with conversion to RYGB after LSG and 44 after MRP. The reduction of excess weight (%TWL) at 3, 6, 12, 24 RYGB postoperative months was respectively of 11.03%, 16.39%, 21.43%, and 24.22% in the MRP group, and of 10.97%, 16.4%, 21.22%, and 22.71% in the LSG group. No significant difference was found in %TWL terms after RYGB for the MRP group and the LSG group with an overall %TWL, which was 11.00 ± 6.03, 16.40 ± 8.08, 21.30 ± 9.43, and 23.30 ± 9.91 respectively at 3, 6, 12, and 24 months. The linear regression model highlighted a positive relationship between the %EWL post-bypass at 24 months and the time elapsed only between the LSG and RYGB in the MRP group patients (p < 0.001). RYGB has proved to be a reliable technique with good results in terms of weight loss after failed bariatric surgery both in patients who previously underwent MRP and in those who underwent exclusively LSG. RYGB showed better results in patients who experienced WR than in those who had IWL from previous techniques.

Concurrent paraesophageal hernia repair in revisional/conversional laparoscopic Roux-en-Y gastric bypass: propensity score-matched analysis of the MBSAQIP database

BACKGROUND

Patients requiring concurrent paraesophageal hernia repair (CPHR) have been shown to have favorable outcomes in primary bariatric surgery. However, patients requiring revisional or conversional surgery represent a group of patients with higher perioperative risk. Currently, few reports on concurrent paraesophageal hernia repair utilizing the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database are available. The primary aim of this study was to determine perioperative complications associated with CPHR and the Roux-en-Y gastric bypass (RYGB) as a revisional/conversional operation.

METHODS

In this study, patients undergoing revisional/conversional RYGB between 2015 and 2020 were accessed via the MBSAQIP database. Patients were categorized based on the presence of a paraesophageal hernia as a concurrent procedure. Patients who underwent revisional/conversional surgery without additional procedures were utilized for controls. A propensity score-matched cohort was generated and E-analysis utilized to assess unmeasured confounding.

RESULTS

After exclusions, 35,698 patients were available. Patients receiving CPHR were more likely to be female (90.79% vs 87.37%; p < 0.001) and have increased frequency of gastroesophageal reflux disease (69.20% vs 51.69%; p < 0.001). However, these patients had lower frequencies of sleep apnea (24.12% vs 30.13%; p < 0.001), hypertension requiring medication (38.51% vs 42.59%; p < 0.001), and decreased frequency of hyperlipidemia (19.44% vs 21.60%;p < 0.001). After matching, 6,231 patient pairs were developed and showed that patients undergoing CPHR were at increased risk of readmission (9.44% vs 7.58%; p < 0.001), intervention (3.56% vs 2.79%; p = 0.018), increased requirement for outpatient dehydration treatment (5.87% vs 4.67%;p = 0.004), and overall increased operation time (169.3 min ± 76.0 vs 153.5 ± 73.3; p < 0.001). However, there were no significant increases in the rates of reoperation, death, postoperative leak complications, or bleeding complications after CPHR.

CONCLUSION

Patients undergoing revisional/conversional RYGB with CPHR may be at higher risk for a small number of rare postoperative complications. CPHR is a safe procedure in patients undergoing revisional/conversional RYGB in the short-term postoperative period.

Comparison of early post-operative complications in primary and revisional laparoscopic sleeve gastrectomy, gastric bypass, and duodenal switch MBSAQIP-reported cases from 2015 to 2019

BACKGROUND

Sleeve gastrectomy (SG) is now the most performed bariatric surgery, though gastric bypass (GB) and duodenal switch (DS) remain common, especially as conversion/revision (C/R) procedures. This analysis compared early postoperative outcomes of primary and C/R laparoscopic SG to DS and GB; and primary procedures of each vs C/R counterparts.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) dataset was queried for SG, GB, and DS cases from 2015 to 2019. Multivariable logistic regression calculated crude and adjusted odds ratios for surgical site infection (SSI), reoperation, and readmission at 30 days in two initial comparisons: (1) primary SG vs DS or GB and (2) C/R SG vs DS or GB. A secondary analysis compared primary GS, GB, or DS with C/R counterparts. Models were adjusted for confounding demographics and comorbidities.

RESULTS

Of 755,968 primary cases, most were SG (72.8%), followed by GB (26.3%), then DS (0.9%). Compared to SG, GB and DS demonstrated higher odds of SSI (aOR 3.02 [2.84, 3.2]), readmission (aOR 1.97 [1.92, 2.03]), and reoperation (aOR 2.74 [2.62, 2.86]), respectively. Of 68,716 C/R cases, SG was most common (43.2%), followed by GB (37.5%), then DS (19.2%). C/R GB and DS demonstrated greater risk of SSI (aOR 2.28 [1.98, 2.62]), readmission (aOR 2.10 [1.94, 2.27]), and reoperation (aOR 2.3 [2.04, 2.59]) vs SG, respectively. C/R SG and DS demonstrated greater risk of SSI (OR 2.09 [1.66, 2.63]; 1.63 [1.24, 2.14), readmission (OR 1.13 [1.02, 1.26]), and reoperation (OR 1.27 [1.06, 1.52]; 1.58 [1.24, 2.0]), vs primary procedures. C/R DS demonstrated greater risk of SSI (OR 1.23 [1.66, 2.63]).

CONCLUSIONS

Early complications are comparable between GB and DS, and greater than SG. In C/R procedures, GB and DS demonstrate greater risk than SG. Overall, C/R procedures demonstrate greater risk of most, but not all, early postoperative complications.

Endoscopic revision of one-anastomosis gastric bypass (ER-OAGB) for weight recurrence: a case series of 17 adults

Weight recurrence after one-anastomosis gastric bypass (OAGB), the third most common metabolic and bariatric surgery performed worldwide, is observed in a subset of patients due to the chronic, progressive nature of obesity. Endoscopic revision of the OAGB (ER-OAGB) through full-thickness suturing to reduce the gastrojejunal anastomosis and gastric pouch is a potential alternative to surgical revision. Here, we present a case series of ER-OAGB and long-term nutritional support at two international centers with expertise in bariatric endoscopy. Data were retrospectively evaluated from a prospectively maintained database. The primary outcome was total body weight loss (TBWL) at 12 months. Secondary outcomes included TBWL at 3, 6, and 15 months; excess weight loss (EWL) at 3, 6, 12, and 15 months; frequency of new/worsening symptoms of gastroesophageal reflux disease (GERD); and the frequency of serious adverse events. In this series, 17 adults (70.6% female, mean age 46.8 years, mean BMI 39.1 kg/m2) successfully underwent ER-OAGB an average of 8 years (range 2-21 years) after OAGB for a mean weight recurrence of 43.2% (range 10.9-86.9%). TBWL from ER-OAGB was 9.7 ± 1.8% at 3 months, 13.4 ± 3.5% at 6 months, 18.5 ± 2.1% at 12 months, and 18.1 ± 2.2% at 15 months. EWL from ER-OAGB was 30.5 ± 14.7% at 3 months, 42.6 ± 16.2% at 6 months, 54.2 ± 11.3% at 12 months, and 54.2 ± 11.7% at 15 months. There were no instances of new/worsening GERD symptoms or serious adverse events. In this small series of adults who experienced weight recurrence after OAGB, ER-OAGB facilitated safe and clinically meaningful weight loss, without new or worsening GERD symptoms, when performed by experienced bariatric endoscopists in concert with longitudinal nutritional support.

Predictors of morbidity in revisional bariatric surgery and bariatric emergencies at an MBSAQIP-accredited community hospital

INTRODUCTION

Bariatric surgery revisions and emergencies are associated with higher morbidity and mortality compared to primary bariatric surgery. No formal outcome benchmarks exist that distinguish MBSAQIP-accredited centers in the community from unaccredited institutions.

METHODS

A retrospective chart review was conducted on 53 bariatric surgery revisions and 61 bariatric surgical emergencies by a single surgeon at a high-volume community hospital accredited program from 2018 to 2020. Primary outcomes were complications or deaths occurring within 30-days of the index procedure. Secondary outcomes included operative time, leaks, surgical site occurrences (SSOs), and deep surgical site infections.

RESULTS

There were no significant differences in the demographic characteristics of the study groups. Mean operative time was significantly longer for revisions as compared to emergency operations (149.5 vs. 89.4 min). Emergencies had higher surgical site infection (5.7% vs. 21.3%, p < 0.05) and surgical site occurrence (SSO) (1.9% vs. 29.5%, p < 0.05) rates compared to revisions. Logistic regression analysis identified several factors to be predictive of increased risk of morbidity: pre-operative albumin < 3.5 g/dL (p < 0.05), recent bariatric procedure within the last 30 days (p < 0.05), prior revisional bariatric surgery (p < 0.05), prior duodenal switch (p < 0.05), and pre-operative COPD (p < 0.05).

CONCLUSION

Bariatric surgery revisions and emergencies have similar morbidity and mortality, far exceeding those of the primary operation. Outcomes comparable to those reported by urban academic centers can be achieved in community hospital MBSAQIP-accredited centers.

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.

Comparing weight loss outcomes after conversion to Roux-en-Y gastric bypass versus duodenal switch from sleeve gastrectomy in a community hospital

Background

Recidivism after initial sleeve gastrectomy (SG) remains common. Revisional surgery to convert SG to Roux-en-Y gastric bypass (RYGB) or duodenal switch (DS) for additional weight loss is increasing. This study aims to compare the outcomes after conversion of SG to RYGB or DS.

Methods

A retrospective single-institution review was conducted from 2015 to 2021, identifying 75 patients who underwent conversion from prior SG to either RYGB (40) or DS (35). Mean excess body weight loss (EBWL) at 3, 6, 12, and 24 months was assessed and compared. Secondary measures of length of stay (LOS), procedure length, and 30-day readmission rate were also reviewed.

Results

Percentage EBWL for RYGB vs DS was 24.0% vs 18.8% at 3 months (N = 36 vs 26; P < 0.0491), 34.8% vs 29.0% at 6 months (N = 29 vs 17; P < 0.2192), 43.0% vs 40.1% at 12 months (N = 28 vs 12; P < 0.6828), and 36.2% vs 41.7% at 24 months (N = 27 vs 7; P < 0.5553). Average LOS was 2.6 days ± 1.4 for RYGB and 2.8 days ± 1.3 for DS (P < 0.6032). Average procedure length was 134.4 min for RYGB and 189.8 min for DS (P < 0.0001). 30-day readmission rate was 27.5% (N = 11) for RYGB and 14.3% (N = 5) for DS (P < 0.1645). Significant weight loss was observed in both subgroups up to 12 months, with no significant weight loss between 12 and 24 months (RYGB N = 21, P < 0.2961; DS N = 5, P < 0.7233).

Conclusion

Both revisional RYGB and revisional DS procedures had significant and sustained weight loss in the first 12 months. There was no significant excess body weight loss difference between revisional RYGB and revisional DS patients at 6, 12, and 24 months, with only significant greater weight loss for RYGB patients at 3 months. Additionally, procedure length was significantly longer for DS compared to RYGB, with no significant differences in LOS and 30-day readmission rates.

Graphical abstract

Single Anastomosis Jejuno-ileal (SAJI): a New Model of Malabsorptive Revisional Procedure for Insufficient Weight Loss or Weight Regain After Roux-en-Y Gastric Bypass

BACKGROUND

In case of insufficient weight loss or weight regain or relapse of weight-related comorbidities after Roux-en-Y gastric bypass (RYGB), other procedures such as reduction of a large gastric pouch and stoma, lengthening of the Roux limb, conversion to sleeve gastrectomy and/or bilio-pancreatic diversion with duodenal switch have been advocated. Single anastomosis jejuno-ileal (SAJI) is a new revisional simple operation performed after RYGB failure which adds malabsorption to the previous gastric bypass.

METHODS

SAJI includes a single jejuno-ileal anastomosis specifically joining the ileum 250-300 cm proximal to the ileo-caecal valve and the jejunum 30 cm below the gastro-jejunal anastomosis on the Roux limb of the previous RYGB. Thirty-one patients underwent SAJI for insufficient weight loss and/or weight regain after RYGB. The percent total weight loss (%TWL) after RYGB and before SAJI was 21.8 ± 7.8. All SAJI operations were performed laparoscopically. The SAJI mean operating time was 145 min.

RESULTS

Regarding weight loss after SAJI, %TWL is 27.2 ± 7.4, 31.2 ± 6.4, 33.7 ± 5.9 and 32.9 ± 5.2 at 12, 24, 36 and 48 months, respectively. Our series recorded a low rate of peri-operative and medium-term complications with a low grade of severity (Clavien-Dindo classification grade). One patient required reoperation 36 days after SAJI for epigastrium incarcerated incisional hernia at the previous RYGB laparotomy site. Mortality was 0. Comorbidity reduction/resolution after SAJI is 83.2% for type 2 diabetes mellitus, 42.8% for arterial hypertension, 72.8% for dyslipidemia and 45.3% for OSA.

CONCLUSIONS

Treatment of failed RYGB is challenging. SAJI is a less complicated, purely low invasive malabsorptive operation that should reach satisfactory %TWL and comorbidity reduction/resolution.

Operative management of recalcitrant marginal ulcers following laparoscopic Roux-en-Y gastric bypass for morbid obesity: a systematic review

One of the short- and long-term complications following Roux-en-Y gastric bypass (RYGB) for morbid obesity is the development of marginal ulcers (MUs). Although chronic and recalcitrant/recurrent marginal ulcers (rMUs) are common, there is no consensus on their optimal management. The objective of this study was to perform a systematic review of the elective operative management of rMUs. A systematic search of the literature was conducted. Relevant databases were searched up to May 16, 2020. Articles were included if they met the following inclusion criteria: (1) bariatric patients were included as the study population, (2) laparoscopic RYGB was performed as the index operation, (3) study patients developed rMUs, and (4) MUs required elective operative (surgical, endoscopic) interventions. Quality of articles was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The search identified 3470 citations; of these, 16 observational studies were included. Elective management of rMUs consisted of endoscopic (oversewing ± stents) and surgical interventions (gastrojejunostomy revision, vagotomy, conversion to sleeve gastrectomy, subtotal/total gastrectomy, reversal to normal anatomy). Quality of the studies as assessed by the GRADE system was low to very low. Recalcitrant/recurrent MUs are challenging complications both for bariatric patients and for their treating surgeons. There are no established algorithms for the management of rMUs, and the currently available evidence in the literature is limited both in quantity and in quality. Future multicentre, multisurgeon, randomized, controlled trials are needed to address this issue.

Robotic-Assisted Versus Laparoscopic Revisional Bariatric Surgery: a Systematic Review and Meta-analysis on Perioperative Outcomes

This systematic review and meta-analysis investigated the role of robotic-assisted surgery in patients undergoing revisional bariatric surgery (RBS). According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search of PubMed, Cochrane Library, Web of Science, and Google Scholar was performed: (("sleeve"AND "gastr*")OR "bariatric"OR "gastric bypass")AND("robot*"OR "DaVinci"OR "Da Vinci")AND("revision*"OR "conversion*"). In this review, six studies with 29,890 patients were included (2459 in the robotic group). No difference in postoperative complications (RR 1.070, 95%CI 0.930-1.231, p = 0.950), conversions to open surgery (RR 1.339, 95%CI 0.736-2.438, p = 0.339), length of stay (SMD - 0.041, 95%CI - 0.420-0.337, p = 0.831) or operative time (RR 0.219, 95%CI - 0.539-0.977, p = 0.571) was found. This systematic review and meta-analysis showed no significant advantage of robotic-assisted RBS; on the other hand, it showed a non-inferior efficacy compared to standard laparoscopy.

Laparoscopic Adjustable Gastric Banding with the Adhesix® Bioring® for Weight Regain or Insufficient Weight Loss After a Roux-en-Y Gastric Bypass: Midterm Data from the Pronto Registry

PURPOSE

Although Roux-en-Y gastric bypass (RYGB) is one of the most common bariatric procedures, insufficient weight loss is described to be as high as 20-35%. To treat weight regain/inadequate weight loss, laparoscopic adjustable gastric banding (LAGB) could be a feasible revisional strategy.

MATERIALS AND METHODS

We report on a prospective study which included 35 patients who presented inadequate weight loss or significant weight regain after primary RYGB (percentage excess weight loss [%EWL] at revision < 50%). All patients underwent revisional LAGB with the placement of an Adhesix® Bioring® adjustable gastric band (Cousin Biotech, Wervicq-Sud, France). Patients' weight loss, complications, frequency of revisions and quality of life were evaluated.

RESULTS

Follow-up data at 24 months are available for 80% of the included patients. The mean BMI before RYGB was 43.6 ± 5.4 kg/m² and before revisional LAGB was 38.8 ± 4.3kg/m². The %EWL before revisional surgery was 23.3 ± 24.8%. The average time between both procedures was 6.7 (mean) ± 3.6 (SD) years. Twenty-four months after revisional LAGB, the average BMI calculated from the weight at RYGB dropped to 32.0 ± 4.5 kg/m², with an additional %EWL of 49.9 ± 30.3% resulting in a total %EWL of 60.7 ± 28%. The reoperation rate for complications related to LAGB was 21.2%. No band erosions occurred, but two bands needed to be removed during the study.

CONCLUSION

Revisional LAGB may be considered a valid salvage procedure in patients with weight regain or inadequate weight loss after RYGB, though band- and port-related complications remain a notable concern.

Conversion of One-Anastomosis Gastric Bypass (OAGB) to Roux-en-Y Gastric Bypass (RYGB) is Effective in Dealing with Late Complications of OAGB: Experience from a Tertiary Bariatric Center and Literature Review

Purpose

Both primary and revisional bariatric surgery are on the rise due to global obesity pandemic. This study aimed to assess the indications for revision after one-anastomosis gastric bypass (OAGB) and the outcomes after laparoscopic conversion of OAGB to roux-en-y gastric bypass (RYGB).

Materials and Methods

Retrospective review on patients that had undergone conversion of OAGB to RYGB between June 2007-June 2019 in a tertiary bariatric center, followed by literature review.

Results

Out of 386 revisional bariatric surgery, a total of 14 patients underwent laparoscopic conversion of OAGB to RYGB. The mean age was 44.7 with 71% female. The mean pre-revision BMI was 29.2 kg/m². The primary indications for revision were bile reflux (n=7), marginal ulcer (n=3), inadequate weight loss or weight regain (IWL/WR) (n=3) and protein-calorie malnutrition (n=1). Conversion of OAGB to RYGB was completed laparoscopically in all cases. The mean length of stay was 4.1 days. There was no intraoperative or early post-operative complication. The mean total weight loss (rTWL%) after revision at year one, year three and year five post-revision were 11.5%, 18.1% and 29.1%, respectively. All patients achieved resolution of bile reflux and marginal ulcer. There was no mortality in this cohort.

Conclusion

Bile reflux, marginal ulcer, IWL/WR and malnutrition were the main indications for revision after OAGB in this study. In concordance with the available evidence, laparoscopic conversion of OAGB to RYGB was safe and effective in dealing with late complications of OAGB.

Laparoscopic Conversion of Sleeve Gastrectomy to One Anastomosis Gastric Bypass in a Hostile Abdomen

PURPOSE

Failure of weight loss is the most common indication for revisional surgery following sleeve gastrectomy (SG) as reported by Guan et al. (Obes Surg. 2019; 29:1965-1975). Recent evidence suggests that the revision rates for SG can be up to 10% when patients are followed up for more than 3 years and as high as 22% after 10 years as reported by Guan et al. (Obes Surg. 2019; 29:1965-1975). Options for revisional surgery following a SG include Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB), and re-sleeve as the commonest procedures. There is good evidence supporting revisional surgery following failure of weight loss post-primary surgery as reported by Guan et al. (Obes Surg. 2019; 29:1965-1975); Cheung et al. (Obes Surg. 2014; 24:1757-1763); Shimizu et al. (Obes Surg. 2013; 23:1766-1773); and Mora Oliver et al. (Cirugia Espanola. 2019; 97:568-574). However, at the same time, retrospective studies suggest higher complication rates following revisional surgery with a major complication rate up to 10% as reported by Yilmaz et al. (Obes Surg. 2017; 27:2855-2860); Fulton et al. (Can J Surg J Can Chir. 2017; 60:205-211); and Abdelgawad et al. (Obes Surg. 2016; 26:2144-2149). Additionally, the durability of weight loss and morbidity reduction in re-operated patients is still debated and overall high-quality evidence in the field is lacking as discussed by Abdelgawad et al. (Obes Surg. 2016; 26:2144-2149). Aim of this educational video is to demonstrate a revisional bariatric procedure which was technically difficult due to extensive intra-abdominal adhesions and explain the available surgical options and the decision-making process adopted by the surgeons.

MATERIALS AND METHODS

The video describes a laparoscopic conversion of a SG to OAGB in a 37-year-old female patient due to weight regain. Her primary bariatric procedure was planned to be a RYGB but due to extensive intra-abdominal adhesions discovered at the time of primary surgery, a SG was performed. Pre-primary procedure weight was 134kg with a BMI of 52.3kg/m². After SG, the patient lost a maximum of 50kg (71.4% excess BMI loss) within the first 18 months before she started regaining weight. Her BMI was 45.4kg/m² when she was referred for revisional surgery. During the procedure, dense small bowel adhesions were encountered and required meticulous dissection in order to free adequate small bowel to allow a safe, effective, and tension-free anastomosis. One hundred fifty centimeters of small bowel was the maximum length that could be safely dissected starting from the ligament of Treitz. An OAGB was preferred to RYGB as it is routine practice in our unit to bypass 200cm of small bowel for revisional RYGB procedures (50-cm biliopancreatic limb and 150-cm alimentary limb), whilst all OAGB's (primary and revisional) have an afferent limb of 150cm. A re-sleeve was also considered as a viable alternative.

RESULTS

Extensive adhesiolysis followed by OAGB were performed successfully with an uneventful post-operative course. The patient was discharged on the second post-operative day. Excess BMI loss was 58% at 1-year follow-up.

CONCLUSION

Revisional surgery can be a challenging especially in the context of extensive surgical history. OAGB can be used as an alternative to RYGB.

Efficacy and safety of bariatric revisions in patients older than 65 years old

BACKGROUND

Bariatric surgery in advanced age patients (>65-years-old) has been proven safe and effective. Revisional bariatric surgery is infrequently required for cases of refractory obesity. However, there is a paucity of data regarding revisional surgery for the elderly. We hypothesize that revisional bariatric surgery is viable and safe in elderly patients.

METHODS

Retrospective chart review of all bariatric revisions performed at two high-volume bariatric centers of excellence between 2011 and 2018. Perioperative and long-term outcomes were compared between patients >65 and those <65-years-old.

RESULTS

145 bariatric revisions were performed for weight loss. 10% (N = 15) were >65 years old. There were no differences in mortality between the two groups There was a longer median length of stay in the younger cohort (2 vs 1 day, p = 0.001). Percent excess weight loss was similar at 12-months, as was resolution of comorbidities.

CONCLUSIONS

Bariatric revisions in elderly patients appears to be safe and effective. Revisional surgery in this population was not shown to have increased morbidity or mortality with similar excess body weight loss when compared to a younger cohort.

Role of Robotic Surgery in Complex Revisional Bariatric Procedures

PURPOSE

Revisional bariatric surgery (RBS) is becoming more common, with an estimated increase of more than 300% from 2017 to 2018. For these complex procedures, the role of robotics is still debated. The purpose of our study is to report the safety and effectiveness of robotic-assisted RBSs.

MATERIALS AND METHODS

A retrospective review of electronic medical records was conducted for robotic-assisted RBSs performed at the Mayo Clinic in Florida, between January 1, 2016, and January 1, 2020. Peri- and postoperative data were analyzed, reviewing patient characteristics, indications for surgery, and outcomes.

RESULTS

From 160 RBSs performed during the study period, 67 were robotic-assisted and met inclusion criteria. Primary procedures included sleeve gastrectomy (26 [38.8%]), adjustable gastric band (24 [35.8%]), Roux-en-Y gastric bypass (14 [20.9%]), vertical-banded gastroplasty (2 [3.0%]), and duodenal switch (1 [1.5%]). RBSs performed were Roux-en-Y gastric bypass (49 [73.1%]), redo gastrojejunostomy (14 [20.9%]), and duodenal switch (4 [6.0%]). Rate of conversion to open procedure and rate of readmission 1 month after surgery were 6.0% and 7.5%, respectively. Rate of 30-day Clavien-Dindo grade III or higher adverse events was 4.5%. No anastomotic leaks were documented. Fifty-two patients presented with preoperative symptoms, and 69.2% reported improvement after RBS. Mean (SD) excess weight loss was 57.62% (23.80) 12 months after RBS.

CONCLUSION

Robotic-assisted RBSs are safe with low major adverse event rates. Symptom resolution and weight loss outcomes are acceptable.

How Far Can Our Expectations Go on Revisional Bariatric Surgery After Failed Adjustable Gastric Banding?

PURPOSE

Bariatric surgery has proven its effectiveness in the treatment of obesity and related comorbidities. However, several procedures may be required to treat this chronic disease and/or complications after bariatric surgery. The most frequent revisional surgeries performed after failed laparoscopic adjustable gastric banding (AGB) have been Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). The aim of this study is to compare medium-term outcomes of primary and revisional bariatric procedures.

MATERIAL AND METHODS

Single institution, matched case-control study of obese patients submitted to bariatric surgery, divided into four groups of 50 patients: (A) primary RYGB; (B) primary SG; (C) revisional Roux-en-Y gastric bypass (rRYGB) after failed laparoscopic AGB; (D) revisional sleeve gastrectomy (rSG) after failed laparoscopic AGB. Demographic variables, surgical procedures characteristics and complications, weight loss outcomes and resolution of comorbidities were compared.

RESULTS

Mortality and morbidity were comparable between primary and revisional procedures. Weight loss outcomes were inferior in patients submitted to rRYGB when compared to those submitted to RYGB, with no significant differences found when comparing the other groups. Regarding comorbidities' outcomes, only patients submitted to rSG had lower odds of comorbidities' improvement. Patients submitted to rRYGB had an odd 7 times higher of comorbidities' improvement than those submitted to rSG, independent of weight loss outcomes.

CONCLUSION

Revisional surgeries are safe procedures with adequate weight loss outcomes in this difficult set of patients. The choice of revisional procedure may not influence weight loss outcomes, but rRYGB seems to be a better option regarding comorbidities' resolution.

Revisional Surgeries of Laparoscopic Sleeve Gastrectomy

Bariatric surgery has become increasingly common due to the worldwide obesity epidemic. A shift from open to laparoscopic surgery, specifically, laparoscopic sleeve gastrectomy (LSG), has occurred in the last two decades because of the low morbidity and mortality rates of LSG. Although LSG is a promising treatment option for patients with morbid obesity due to restrictive and endocrine mechanisms, it requires modifications for a subset of patients because of weight regain and tough complications, such as gastroesophageal reflux, strictures, gastric leak, and persistent metabolic syndrome., Revision surgeries have become more and more indispensable in bariatric surgery, accounting for 7.4% in 2016. Mainstream revisional bariatric surgeries after LSG include Roux-en-Y gastric bypass, repeated sleeve gastrectomy, biliopancreatic diversion, duodenal switch, duodenal-jejunal bypass, one-anastomosis gastric bypass, single anastomosis duodeno-ileal bypass (SAID) and transit bipartition. This review mainly describes the revisional surgeries of LSG, including the indication, choice of surgical method, and subsequent effect.

Guidelines for gastrostomy tube placement and enteral nutrition in patients with severe, refractory hypoglycemia after gastric bypass

BACKGROUND

Postbariatric hypoglycemia (PBH) affects up to 38% of Roux-en-Y gastric bypass (RYGB) patients. Severe cases are refractory to diet and medications. Surgical treatments including bypass reversal and pancreatectomy are highly morbid and hypoglycemia often recurs. We have developed a highly effective method of treatment by which enteral nutrition administered through a gastrostomy (G) tube placed in the remnant stomach replaces oral diet: if done correctly this reverses hyperinsulinemia and hypoglycemia, yielding substantial health and quality of life benefits for severely affected patients.

OBJECTIVES

To provide clinical guidelines for placement of a G-tube to treat postRYGB hypoglycemia, including candidate selection, preoperative evaluation, surgical considerations, and post-RYGB management.

SETTING

Stanford University Hospital and Clinics.

METHODS

Based on our relatively large experience with placing and managing G-tubes for PBH treatment, an interdisciplinary task force developed guidelines for practitioners.

RESULTS

A team approach (endocrinologist, dietitian, surgeon, psychologist) is recommended. Appropriate candidates have a history of RYGB, severe hypoglycemia refractory to medical-nutrition therapy, and significantly affected quality of life. Preoperative requirements include education and expectation setting, determination of initial enteral feeding program, and establishing service with a home enteral provider. Close postoperative follow-up is needed to ensure success and may require adjustments in formula and mode/rate of delivery to optimize tolerance and meet nutritional goals. G-tube nutrition must fully replace oral nutrition to prevent hypoglycemia.

CONCLUSIONS

G-tube placement in the remnant stomach represents a relatively well-tolerated and effective treatment for severe, refractory hypoglycemia after RYGB.

The effectiveness and safety of pharmaceuticals to manage excess weight post-bariatric surgery: a systematic literature review

Objective: To systematically review the literature on weight management pharmaceutical use in patients who have had bariatric surgery.

Methods: Google Scholar, Pubmed, Cochrane, Embase, Web of Science, and Clinical Trials were searched from inception to December 31st, 2018 inclusive.

Results: Thirteen studies met inclusion and reported decreases in weight with the use of weight management medications in post-bariatric surgical patients. Five studies examined weight loss outcomes by the type of bariatric surgery procedure, and four of these studies observed less weight loss in patients who had undergone gastric sleeve compared to those who had roux-en-y bypass (n = 3 papers) and adjustable gastric banding (n = 1 paper) with medication use. Four studies compared the effectiveness of medications for weight management and observed slightly greater weight loss with the use of topiramate and phentermine as a monotherapy compared to other weight loss medications. Using a sub-sample of participants, authors observed less weight loss on metformin but not phentermine or topiramate for younger adults. Another post-hoc analysis in the same sample observed greater weight loss for older adults with liraglutide 1.8 mg. Side effects were reported in seven studies and were overall consistent with those previously reported in non-surgical populations.

Conclusion: Results of this systematic review suggest pharmacotherapy may be an effective tool as an adjunct to diet and physical activity to support weight loss in post-bariatric surgery patients. However, due to most studies lacking a control or placebo group, more rigorous research is required to determine the efficacy of this intervention.

Robotic-Assisted Surgery Results in a Shorter Hospital Stay Following Revisional Bariatric Surgery

BACKGROUND

Revisional surgery is rapidly growing within the field of bariatric surgery. The use of robotic assisted surgery, considered controversial by many, may offer advantages in revisional bariatric surgery (RBS). There are few studies comparing laparoscopic and robotic-assisted RBS. The aim of this study is to compare the safety and outcome of laparoscopic and robotic RBS in a single accredited center.

METHODS

A retrospective analysis of data collected prospectively on patients undergoing either laparoscopic (L-RBS) or robotic (R-RBS) RBS between January 1, 2017 and December 31, 2019 was performed. The primary outcomes included length of stay (LOS), 30-day major and minor complication rates, readmission rates, and mortality rates.

RESULTS

A total of 167 patients were included in our analysis. Fifty-two patients underwent R-RBS (31%), and 115 underwent L-RBS (69%). Thirty-day major and minor complication rates for R-RBS and L-RBS were 1.9% and 5.8% vs 5.2% and 5.2%, respectively (p > .05). There was no difference in readmission rates (3.8% vs 8.7%, p > 0.05) or intraoperative blood loss (35.5 mL vs 37.4 mL, p > .05) between R-RBS and L-RBS. R-RBS resulted in a shorter length of stay when compared with L-RBS (40.2 h vs 62.6 h, p < .05).

CONCLUSIONS

R-RBS has a decreased, albeit non-significant, rate of 30-day major complications with no difference in minor complications, readmission rates, or intraoperative blood loss when compared with L-RBS. R-RBS resulted in a decreased length of stay when compared with L-RBS. Randomized clinical trials are needed to better elucidate our findings.

Efficacy of transoral outlet reduction in Roux-en-Y gastric bypass patients to promote weight loss: a systematic review and meta-analysis

Background and study aims  Transoral outlet reduction (TORe) is an endoscopic procedure used in patients with weight gain post Roux-en-Y gastric bypass (RYGB). We performed a systematic review and meta-analysis to evaluate the efficacy and safety of TORe with a full-thickness suturing device for treating patients with weight regain after RYGB. Patients and methods  We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, Google-Scholar, MEDLINE, SCOPUS, and Web of Science databases (earliest inception to March 2020). The primary outcomes assessed were technical success, absolute weight loss (AWL) and percent of total weight loss (% TWL) at 3, 6, and 12 months after the procedure. The secondary outcomes assessed were pooled rate of adverse events (AEs), adverse event subtypes and association of size of gastrojejunal anastomosis (GJA) and percent TWL. Results  Thirteen studies on 850 patients were included. The pooled rate of technical success was 99.89 %. The absolute weight loss (kg) at 3, 6, and 12 months was 6.14, 10.15, and 7.14, respectively. The percent TWL at 3, 6, and 12 months was 6.69, 11.34, and 8.55, respectively. The pooled rate of AE was 11.4 % with abdominal pain being the most common adverse event. The correlation coefficient (r) was -0.11 between post TORe GJA size and weight loss at 12 months. Conclusion  TORe is an endoscopic procedure that is safe and technically feasible for post RYGB with weight gain.

Treatment Options for Poor Responders to Bariatric Surgery

PURPOSE OF REVIEW

This review aims to evaluate the latest evidence on the treatment options for perceived poor responders to bariatric surgery and provide practitioners with a guide on when to consider revisional surgery and when to consider alternatives.

RECENT FINDINGS

The use of adjuvant pharmacotherapy has been increasingly described in the literature as an adjunct to primary bariatric surgery, in order to attain more weight loss or better control of obesity-related complications. The newer anti-obesity and anti-diabetes drugs also have cardiorenal benefits, which are shown in recent cardiovascular outcome trials. Revisional bariatric surgery has emerged as a distinctive entity and can be broadly organized into three categories: corrective, conversion, and reversal surgeries. Careful patient selection and preoperative optimization are needed to ensure long-term favorable outcomes. Newer treatment modalities involving the use of anti-obesity medications and endoscopic bariatric interventions provide patients and healthcare providers with more options, when faced with the challenge of poor response after bariatric surgery.

Midterm results of revisional bariatric surgery postsleeve gastrectomy: resleeve versus bypass

BACKGROUND

Bariatric surgery has been shown to produce the most predictable weight loss results, with laparoscopic sleeve gastrectomy (SG) being the most performed procedure as of 2014. However, inadequate weight loss may present the need for a revisional procedure.

OBJECTIVES

The aim of this study is to compare the efficacy of laparoscopic resleeve gastrectomy (LRSG) and laparoscopic Roux-en-Y gastric bypass in attaining successful weight loss.

SETTING

Public hospital following SG.

METHODS

A retrospective analysis was performed on all patients who underwent SG from 2008-2019. A list was obtained of those who underwent revisional bariatric surgery after initial SG, and their demographic characteristics were analyzed.

RESULTS

A total of 2858 patients underwent SG, of whom 84 patients (3%) underwent either a revisional laparoscopic Roux-en-Y gastric bypass (rLRYGB) or LRSG. A total of 82% of the patients were female. The mean weight and body mass index (BMI) before SG for the LRSG and rLRYGB patients were 136.7 kg and 49.9 kg/m² and 133.9 kg and 50.5 kg/m², respectively. The mean BMI showed a drop from 42.0 to 31.7 (P < .001) 1 year post revisional surgery for the LRSG group and 42.7 to 34.5 (P < .001) for the rLRYGB group, correlating to an excess weight loss (EWL) of 61.7% and 48.1%, respectively. At 5 years post revisional surgery, LRSG patients showed an increase in BMI to 33.8 (EWL = 45.3%), while those who underwent rLRYGB showed a decrease to 34.3 (EWL = 49.2%). Completeness of follow-up at 1, 3, and 5 years for rLRYGB and LRSG were 67%, 35%, and 24% and 45%, 21%, and 18%, respectively.

CONCLUSIONS

Revisional bariatric surgery is a safe and effective method for the management of failed primary SG. LRSG patients tended to do better earlier on; however, it leveled off with those who underwent rLRYGB by 5 years.

Patient Risk Factors Associated with Increased Morbidity and Mortality Following Revisional Laparoscopic Bariatric Surgery for Inadequate Weight Loss or Weight Recidivism: an Analysis of the ACS-MBSAQIP Database

PURPOSE

Revisional bariatric operations are associated with increased morbidity and mortality compared with primary bariatric operations. The purpose of this study was to determine if preoperative patient variables are associated with an increased risk of 30-day morbidity and mortality following revisional laparoscopic bariatric surgery for inadequate weight loss or weight recidivism and to generate expected model probabilities in order to risk stratify individual patients undergoing these operations.

MATERIALS AND METHODS

All patients undergoing revisional laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) from 2015 to 2016 were identified with the American College of Surgeons Metabolic and Bariatric Surgery Quality Improvement Program (ACS-MBSAQIP) database. The association of preoperative patient variables with 30-day morbidity and mortality was investigated using multivariable logistic regression analysis. Predictive outcome models were developed for each outcome of interest.

RESULTS

A total of 13,551 patients met inclusion criteria; 5310 (39.2%) underwent revisional RYGB. Each of the available preoperative variables was associated with one or more of the 30-day morbidity and mortality outcomes of interest. The strength of the predictive models, as reflected by the area under the curve, ranged from 0.63 for 30-day unplanned hospital readmission to 0.92 for cardiac events.

CONCLUSION

Preoperative patient and surgical variables are associated with an increased risk of 30-day morbidity and mortality following laparoscopic revisional bariatric surgery. With these results, we have built a risk calculator that can be used as a resource for prehabilitation and patient counseling prior to revisional bariatric surgery.

GLP-1 Analogues as a Complementary Therapy in Patients after Metabolic Surgery: a Systematic Review and Qualitative Synthesis

The evidence is strong that bariatric surgery is superior to medical treatment in terms of weight loss and comorbidities in patients with severe obesity. However, a considerable part of patients presents with unsatisfactory response in the long term. It remains unclear whether postoperative administration of glucagon-like peptide-1 analogues can promote additional benefits. Therefore, a systematic review of the current literature on the management of postoperative GLP-1 analogue usage after metabolic surgery was performed. From 4663 identified articles, 6 met the inclusion criteria, but only one was a randomized controlled trial. The papers reviewed revealed that GLP-1 analogues may have beneficial effects on additional weight loss and T2D remission postoperatively. Thus, the use of GLP-1 analogues in addition to surgery promises good results concerning weight loss and improvements of comorbidities and can be used in patients with unsatisfactory results after bariatric surgery.

Outcome of revisional bariatric surgery for insufficient weight loss after laparoscopic Roux-en-Y gastric bypass: an observational study

BACKGROUND

Insufficient weight loss or secondary weight regain with or without recurrence of comorbidity can occur years after laparoscopic Roux en Y gastric bypass (LRYGB). In selected patients, increasing restriction or adding malabsorption may be a surgical option after conservative measures failed.

OBJECTIVES

Evaluation of short and long term results of revisional surgery for insufficient weight loss or weight regain after LRYGB.

SETTING

Tertiary hospital.

METHODS

Retrospective analysis of prospectively collected data from a cohort of 1150 LRYGB patients. Included were patients, who underwent revisional bariatric surgery after LRYGB for insufficient weight loss with a follow-up of minimal 1 year.

RESULTS

Fifty-four patients were included in the analysis. After an interdisciplinary evaluation, patients with insufficient weight loss, signs of dumping syndrome, and lacking restriction were offered a nonadjustable band around the pouch (banded group, n = 34) and patients with sufficient restriction, excellent compliance, and adherence were offered a revision to laparoscopic biliopancreatic diversion (BPD group, n = 20). The revisional procedure was performed 3.3 ± 2.3 years after LRYGB in the banded-group and after 6.4 ± 4.3 years in the BPD group (P = .001). Mean body mass index at the time of the primary bariatric procedure was 41.7 ± 6.2 kg/m² in the banded group and 45.2 ± 8.2 kg/m² in the BPD group (P = .08); minimal body mass index between both operations was 29.1 ± 4.7 kg/m² in the banded group and 36.5 ± 9.4 kg/m² in the BPD group, and, at the time of revisional surgery, 31.4 ± 5.5 kg/m² in the banded group and 40.8 ± 6.7 kg/m² in the BPD group (P = .0001). The mean body mass index difference 1 year after revisional surgery was 1.3 ± 3.0 kg/m² in the banded group and 6.7 ± 4.5 kg/m² in the BPD group (P = .01). In the banded group, 11 patients (32.4%) needed removal of the band, 4 patients (11.8%) needed an adjustment, and 4 patients (11.8%) were later converted to BPD. In the BPD group, 2 (10.0%) patients needed revision for severe protein malabsorption.

CONCLUSIONS

Insufficient weight loss or secondary weight regain after LRYGB is a rare indication for revisional surgery. Banded bypass has modest results for additional weight loss but can help patients suffering from dumping. In very carefully selected cases, BPD can achieve additional weight loss with acceptable complication rate but higher risk for reoperation. Future "adjuvant medical treatments," such as glucagon-like peptide 1 analogues and other pharmacologic treatment options could be an alternative for achieving additional weight loss and better metabolic response.

Feasibility and safety of robot-assisted bariatric conversions and revisions

BACKGROUND

Conversions and revisions after bariatric procedures are inevitable and associated with longer operative time and higher complication rates. Because robot-assisted procedures allow better dissection, robotic conversions and revisions may be more beneficial to the patients than laparoscopic ones.

OBJECTIVES

This study aimed to compare the feasibility and safety of robot-assisted conversions and revisions to laparoscopic procedures.

SETTING

Academic Hospital, United States.

METHODS

A retrospective chart review was performed on 94 consecutive patients who underwent a bariatric conversion or revision (revision of gastrojejunostomy, conversions of vertical sleeve gastrectomy to Roux-en-Y gastric bypass, adjustable gastric banding to sleeve gastrectomy, Roux-en-Y gastric bypass to sleeve gastrectomy, adjustable gastric banding to Roux-en-Y gastric bypass, Roux-en-Y gastric bypass to duodenal switch, and adjustable gastric banding to duodenal switch) between January 1, 2017, and February 28, 2019. Of these, 30 underwent a robot-assisted conversion or revision.

RESULTS

Patients who underwent a robot-assisted approach were more likely to be older (45.4-versus 38.8-yr old) and lighter (44.6 versus 50.3 kg/m²) than patients who underwent a laparoscopic approach. The mean operative time was longer in the robot-assisted group (155.5 min) than in the laparoscopic group (113.3 min). No difference was observed between the 2 groups in the mean length of hospital stay, 30-day readmission rate, or 30-day reoperation rate. Results were similar when the baseline difference in age and body mass index were accounted for.

CONCLUSIONS

Robot-assisted conversions and revisions were as feasible and safe as laparoscopic procedures. However, operative time was longer in robot-assisted conversions.

The Use of the Overstitch for Bariatric Weight Loss

Obesity is a public health pandemic and leading contributor to morbidity and mortality. Endoscopic bariatric therapies have emerged as a viable minimally invasive treatment option to fill the therapeutic gap between conservative and surgical approaches. The ability to reliably place full-thickness sutures throughout the gastrointestinal tract has opened the door to novel endoscopic gastric restrictive procedures. A growing body of literature supports endoscopic sleeve gastroplasty as a safe, effective, and reproducible endoscopic treatment of obesity and metabolic syndrome. In addition, endoscopic sutured revision procedures following gastric bypass and sleeve gastrectomy are now first-line with demonstrable safety and long-term efficacy.

Gastric Bypass as a Third Bariatric Procedure-Our Experience with 42 Cases

BACKGROUND

It is not uncommon to encounter patients seeking a third, fourth, or even fifth bariatric procedure. With higher expected complication rates and questionable patient benefit, the indication for multiple revisions is still in doubt. To evaluate the perioperative and post-operative outcomes of patients undergoing gastric bypass after two previous bariatric surgeries or more.

METHODS

We identified all patients that underwent gastric bypass following at least 2 previous bariatric surgeries. We looked at patient demographics, previous bariatric surgeries, pre-operative body mass index (BMI) and obesity-related co-morbidities, perioperative complications, length of stay (LOS), re-admissions and re-operations, percentage of excess weight loss, and resolution or improvement in comorbidities.

RESULTS

Forty-two patients met the inclusion criteria, the majority being females (31, 73.8%). Average age was 45.6 years (range 27-62), average weight and BMI was 116 kg (range 75-175 kg) and 41.1 kg/m² (range 25.6-58.7 kg/m²), respectively. Thirty-two patients had two previous bariatric surgeries (73.8%), and 10 patients had 3 former bariatric surgeries (23.8%), and for one patient, this was the fifth bariatric procedure (2.4%). Mean LOS was 10 days (range 2-56 days). Eight patients (19%) needed re-admission and 5 (11.9%) needed re-operation. At a median follow up of 48 months (range 7-99 months), the average BMI was 34.5 kg/m² (range 23.7-55.1 kg/m²) reflecting an excess BMI loss of 43.3%.

CONCLUSIONS

Gastric bypass as a third or more bariatric procedure is effective yet associated with high complication rates, re-admissions, and re-operations.

Comparative analysis of robotic versus laparoscopic revisional bariatric surgery: perioperative outcomes from the MBSAQIP database

BACKGROUND

There are limited data evaluating the role of robotics in revisional bariatric surgery (RBS) compared with laparoscopy.

OBJECTIVE

The purpose of this study was to compare perioperative outcomes of laparoscopic and robotic RBS.

SETTING

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

METHODS

The 2015 to 2017 MBSAQIP database was queried for patients undergoing revisional robotic and laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Multivariate logistic regression was used to compare outcomes between robotic and laparoscopic approaches, adjusting for demographic characteristics, co-morbidities, and operative time.

RESULTS

A total of 17,012 patients underwent revisional SG with 15,935 (93.7%) laparoscopic and 1077 (6.3%) robotic, and 12,442 patients underwent revisional RYGB with 11,212 (90.1%) laparoscopic and 1230 (9.9%) robotic. Overall morbidity was higher in robotic SG compared with laparoscopic SG (6.7% versus 4.5%; adjusted odds ratio 1.51; P < .01) which was not the case after adjustment for operative time. Robotic RYGB was associated with comparable overall morbidity to laparoscopic (9.3% versus 11.6%; adjusted odds ratio .83; P = .07) although respiratory complications, pneumonia, superficial surgical site infections, and postoperative bleeding were lower with robotic RYGB. The robotic approach with both procedures was associated with longer operative time (P < .01). Length of stay was longer in the robotic group for SG (P < .01) but was not different for RYGB (P = .91).

CONCLUSIONS

Robotic RBS has an increased complication profile compared with the laparoscopic approach for SG and decreased for RYGB. Further analysis is needed regarding variability in surgeon technique and operative experience to determine what factors contribute to these differences.

Risk of Operative and Nonoperative Interventions Up to 4 Years After Roux-en-Y Gastric Bypass vs Vertical Sleeve Gastrectomy in a Nationwide US Commercial Insurance Claims Database

IMPORTANCE

There are few nationwide studies comparing the risk of reintervention after contemporary bariatric procedures.

OBJECTIVE

To compare the risk of intervention after Roux-en-Y gastric bypass (RYGB) vs vertical sleeve gastrectomy (VSG).

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used a nationwide US commercial insurance claims database. Adults aged 18 to 64 years who underwent a first RYGB or VSG procedure between January 1, 2010, and June 30, 2017, were matched on US region, year of surgery, most recent presurgery body mass index (BMI) category (based on diagnosis codes), and baseline type 2 diabetes. The prematch pool included 4496 patients undergoing RYGB and 8627 patients undergoing VSG, and the final weighted matched sample included 4476 patients undergoing RYGB and 8551 patients undergoing VSG.

EXPOSURES

Bariatric surgery procedure type (RYGB vs VSG).

MAIN OUTCOMES AND MEASURES

The primary outcome was any abdominal operative intervention after the index procedure. Secondary outcomes included the following subtypes of operative intervention: biliary procedures, abdominal wall hernia repair, bariatric conversion or revision, and other abdominal operations. Nonoperative outcomes included endoscopy and enteral access. Time to first event was compared using multivariable Cox proportional hazards regression modeling.

RESULTS

Among 13 027 patients, the mean (SD) age was 44.4 (10.3) years, and 74.1% were female; 13.7% had a preoperative BMI between 30 and 39.9, 45.8% had a preoperative BMI between 40 and 49.9, and 24.2% had a preoperative BMI of at least 50. Patients were followed up for up to 4 years after surgery (median, 1.6 years; interquartile range, 0.7-3.2 years), with 41.9% having at least 2 years of follow-up and 16.3% having at least 4 years of follow-up. Patients undergoing VSG were less likely to have any subsequent operative intervention than matched patients undergoing RYGB (adjusted hazard ratio [aHR], 0.80; 95% CI, 0.72-0.89) and similarly were less likely to undergo biliary procedures (aHR, 0.77; 95% CI, 0.67-0.90), abdominal wall hernia repair (aHR, 0.60; 95% CI, 0.47-0.75), other abdominal operations (aHR, 0.71; 95% CI, 0.61-0.82), and endoscopy (aHR, 0.54; 95% CI, 0.49-0.59) or have enteral access placed (aHR, 0.58; 95% CI, 0.39-0.86). Patients undergoing VSG were more likely to undergo bariatric conversion or revision (aHR, 1.83; 95% CI, 1.19-2.80).

CONCLUSIONS AND RELEVANCE

In this nationwide study, patients undergoing VSG appeared to be less likely than matched patients undergoing RYGB to experience subsequent abdominal operative interventions, except for bariatric conversion or revision procedures. Patients considering bariatric surgery should be aware of the increased risk of subsequent procedures associated with RYGB vs VSG as part of shared decision-making around procedure choice.

30-Day Outcomes of Revisional Bariatric Stapling Procedures: First Report Based on MBSAQIP Data Registry

INTRODUCTION

The number of bariatric revisional cases has nearly doubled since 2011, and now comprises 13.6% of the total number of cases. The objective of this study is to evaluate the outcomes and safety of the two most common stapling revisional procedures, namely, sleeve and gastric bypass in comparison to primary stapling procedures using the MBSAQIP data registry.

METHODS

We reviewed all the sleeve and gastric bypass cases entered between January 1, 2015, and December 31, 2015, in the MBSAQIP data registry. We, then, identified sleeve and bypass patients who have had a previous bariatric procedure. Demographics and 30 day outcomes of all sleeve and gastric bypass patients were analyzed. We conducted within group comparisons comparing primary sleeve gastrectomy (PS) and primary gastric bypass (PB) patients to revisional sleeve (RS) and revisional gastric bypass (RB) patients, respectively. We, then, conducted group comparisons comparing RS to RB patients.

RESULTS

The total number of patients analyzed was 141,577 (98,292 or 69% sleeve patients and 43,285 or 31% gastric bypass patients). Among the sleeve patients, 92,666 (94%) had a PS and 5626 (6%) had RS. Among the bypass patients, 39,567 (91%) had a PB and 3718 patients (9%) had RB. 30-day readmission rate of RS was significantly higher as compared to PS (4.1 vs 0.4%, p < 0.05). The incidence of at least one complication requiring reoperation or reintervention within 30 days following RS was twice as high as compared to PS (1.9 and 2% for RS vs 0.9 and 1.1% for PS respectively, p < 0.05). Length of stay and 30 day mortality rates for PS and RS were the same. 30-day readmission rate of RB as compared to PB was 8.3 vs 6.3% (p < 0.05). Also, the incidence of at least one complication requiring reoperation or reintervention following RB was 3.9 and 4%, respectively vs 2.4 and 2.7% for PB (p < 0.05). In addition, readmission rates and unplanned admission rates to the ICU were significantly higher for RB compared to RS (8.3 and 2% for RB vs 4.1 and 0.9% for RS respectively, p < 0.05). The incidence of at least one reoperation or one intervention following RB were also significantly higher compared to RS (3.9 vs 1.9% and 4 vs 2% respectively, p < 0.05).

CONCLUSION

Revisional stapling procedures are safe but the rates of complications following RS and RB are twice as high compared to PS and PB. Also, RB are more likely to develop complications compared to RS.

Association of revisions or conversions after sleeve gastrectomy with annual bariatric center procedural volume in the state of New York

INTRODUCTION

Although bariatric center procedural volume has been associated with early perioperative safety, data on the effect of such volume and long-term outcomes after sleeve gastrectomy (SG) are limited. This study aims to examine the relationship between annual bariatric center SG volume and the incidence of revisions or conversions (RC) after SG.

METHODS

The New York Statewide Planning and Research Cooperative System database was used to identify all patients who underwent SG between 2006 and 2012. Subsequent RC events were captured up to 2016. Bariatric centers having annual SG volume less than 45, between 45 and 65, and greater than 65 were defined as low (LV), medium (MV), and high volume (HV), respectively. Multivariable Cox proportional hazard regression analysis was performed to compare the risk of having RC among centers with different yearly sleeve volumes.

RESULTS

We identified 8389 patients who underwent SG. The overall estimated cumulative incidence of RC was 0.5% (95% CI 0.3-0.6%) at 1 year, 6.2% (95% CI 5.4-7.0%) at 5 years, and 15.3% (95% CI 12.6-18.0%) at 8 years after SG. The estimated cumulative incidence of RC for LV, MV, and HV at 8 years after SG was 16.7% (95% CI 11.1-22.3%), 15.5% (95% CI 11.2-19.8%), and 13.7% (95% CI 9.4-17.9%), respectively. HV centers have lower risk of RC compared to LV (hazard ratio 0.65; 95% CI 0.48-0.88) and MV (hazard ratio 0.75; 95% CI 0.57-0.98). LV and MV centers have comparable risk of RC (hazard ratio 1.15; 95% CI 0.87-1.51). Patients having the initial SG performed in LV were the least likely to have RC in the same institution (46.1% of LV, 13.2% of MV and 22.3% of HV; p < 0.0001).

CONCLUSION

Patients undergoing SG at LV centers experience the highest risk of subsequent RC. This effect persists after adjusting for patient-level factors. These data underline the relationship between volume threshold and long-term effect.