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Cornejo J, Evans LA, Castillo-Larios R, Celik NB, Elli EF. One anastomosis gastric bypass as a primary bariatric surgery: MBSAQIP database analysis of short-term safety and outcomes. Surg Endosc 2024; 38:270-279. [PMID: 37989890 DOI: 10.1007/s00464-023-10535-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/12/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND One anastomosis gastric bypass (OAGB) is described as a simpler, potentially safe, and effective bariatric-metabolic procedure that has been recently endorsed by the American Society of Metabolic and Bariatric Surgery. OBJECTIVES First, we aim to compare the 30-day outcomes between OAGB and other bypass procedures: Roux-en-Y gastric bypass (RYGB) and single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S). Second, identify the odds between postoperative complications and each surgical procedure. METHODS Patients who underwent primary OAGB, RYGB, and SADI-S were identified using the MBSAQIP database of 2020 and 2021. An analysis of patient demographics and 30-day outcomes were compared between these three bypass procedures. In addition, a multilogistic regression for overall complications, blood transfusions, unplanned ICU admissions, readmission, reoperation, and anastomotic leak stratified by surgical procedure was performed. RESULTS 1607 primary OAGBs were reported between 2020 and 2021. In terms of patient demographics, patients who underwent RYGB and SADI-S showed a higher incidence of comorbidities. On the other hand, OAGB had shorter length of stay (1.39 ± 1.10 days vs 1.62 ± 1.42 days and 1.90 ± 2.04 days) and operative times (98.79 ± 52.76 min vs 125.91 ± 57.76 min and 139.85 ± 59.20 min) than RYGB and SADI-S. Similarly, OAGB showed lower rates of overall complications (1.9% vs 4.5% and 6.4%), blood transfusions (0.4% vs 1.1% and 1.8%), unplanned ICU admission (0.3% vs 0.8% and 1.4%), readmission (2.4% vs 4.9% and 5.0%), and reoperation (1.2% vs 1.9% and 3.1%). A multilogistic regression analysis was performed, RYGB and SADI-S demonstrated higher odds of 30-day complications. CONCLUSION The incidence of primary OAGB has increased since its approval by ASMBS, from 0.05% reported between 2015 and 2019 to 0.78% between 2020 and 2021. OAGB had better 30-day outcomes and shorter operative times than RYGB and SADI-S and therefore, could be considered a viable alternative.
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Affiliation(s)
- Jorge Cornejo
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Lorna A Evans
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Rocio Castillo-Larios
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Nafiye Busra Celik
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Enrique F Elli
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
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Davarpanah Jazi AH, Shahabi S, Sheikhbahaei E, Tolone S, Skalli ME, Kabir A, Valizadeh R, Kermansaravi M. A systematic review and meta-analysis on GERD after OAGB: rate, treatments, and success. Expert Rev Gastroenterol Hepatol 2023; 17:1321-1332. [PMID: 38148703 DOI: 10.1080/17474124.2023.2296992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 12/15/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION This review aims to investigate the gastroesophageal reflux disease (GERD) as one of the important concerns for both surgeons and patients after one anastomosis gastric bypass (OAGB). METHOD PubMed, Scopus, Embase, Web of Science, and Cochrane were reviewed by the end of the 2021 with keywords relating to GERD, OAGB, and their equivalents. Data regarding OAGB, number of patients with GERD, treatment for GERD, endoscopy findings, the interval between GERD and OAGB were retrieved by two independent investigators. The primary effect/effect size measure was prevalence. RESULTS 40 studies examining 17,299 patients were included revealing that 2% of patients experience GERD following OAGB. Reflux after revisional OAGB is six times higher than primary OAGB. Despite being unclear, medical and surgical treatments for GERD after OAGB were used in 60% and 41% of patients with estimated success rate of 85% and 100%, respectively. CONCLUSION Based on how GERD was identified after OAGB, its rate ranged from 0 to 55%; the pooled rate of 2% is near to Roux-en-Y gastric bypass. GERD symptoms can be mild to be tolerated without medical treatment, moderate that respond to acid-reducing agents, or severe enough that are categorized as interactable and would need a surgical intervention.
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Affiliation(s)
- Amir Hossein Davarpanah Jazi
- Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Iran University of Medical Sciences, Tehran, Iran
| | - Shahab Shahabi
- Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Iran University of Medical Sciences, Tehran, Iran
| | - Erfan Sheikhbahaei
- Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Iran University of Medical Sciences, Tehran, Iran
| | - Salvatore Tolone
- Division of General and Bariatric Surgery, Department of Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy
| | - Mehdi El Skalli
- Centre Hospitalier Universitaire Montpellier, Université de Montpellier 1, Montpellier, France
| | - Ali Kabir
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Mohammad Kermansaravi
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Rasool-E Akram University Hospital, Tehran, Iran
- Center of Excellence of European Branch of International Federation for Surgery of Obesity (IFSO), Hazrat-E Rasool University Hospital, Tehran, Iran
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Esparham A, Ahmadyar S, Zandbaf T, Dalili A, Rezapanah A, Rutledge R, Khorgami Z. Does One-Anastomosis Gastric Bypass Expose Patients to Gastroesophageal Reflux: a Systematic Review and Meta-analysis. Obes Surg 2023; 33:4080-4102. [PMID: 37880462 DOI: 10.1007/s11695-023-06866-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 10/27/2023]
Abstract
This systematic review and meta-analysis aimed to investigate the incidence of new-onset gastroesophageal reflux, reflux change, esophagitis, Barrett's esophagus, and revision due to reflux, gastritis, and marginal ulcer after one-anastomosis gastric bypass (OAGB). We performed subgroup analyses based on primary and revisional OAGB and time of follow-up. Meta-analysis of 87 studies with 27,775 patients showed a 6% rate of new-onset reflux after OAGB. Preoperative reflux status did not change significantly after OAGB. The rate of esophagitis and Barrett's esophagus was 15% and 1%, respectively. The new-onset reflux rate after OAGB was significantly higher than gastric bypass but not different with sleeve gastrectomy. The current study showed a relatively low rate of reflux and its complications after OAGB, but it was significantly higher than Roux-en-Y gastric bypass.
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Affiliation(s)
- Ali Esparham
- Student Research Committee, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Soheil Ahmadyar
- Student Research Committee, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Tooraj Zandbaf
- Department of General Surgery, Faculty of Medicine, Mashhad Medical Sciences, Islamic Azad University, Mashhad, Iran
| | - Amin Dalili
- Department of General Surgery, School of Medicine, Surgical Oncology Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alireza Rezapanah
- Department of General Surgery, School of Medicine, Surgical Oncology Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Robert Rutledge
- Center for Laparoscopic Obesity Surgery, 6240 N Durango Dr STE 120, Las Vegas, NV, 89149, USA
| | - Zhamak Khorgami
- Department of Surgery, University of Oklahoma School of Community Medicine, 1919 S. Wheeling Avenue, Suite 600, Tulsa, OK, 74104-5638, USA.
- Harold Hamm Diabetes Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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Si Y, Lin S, Li C, Shen J, Guan W, Liang H. Comparison of Single Versus Double Anastomosis Bariatric Metabolic Surgery in Obesity: a Systematic Review and Meta-analysis. Obes Surg 2023; 33:3545-3564. [PMID: 37700148 DOI: 10.1007/s11695-023-06805-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 08/11/2023] [Accepted: 08/18/2023] [Indexed: 09/14/2023]
Abstract
Major BMS are modified through loop rather than Roux-en-Y type reconstruction recently, and this study systematically reviews the BMS from the perspective of SA (single anastomosis) and DA (double anastomosis) procedures, aiming to research the differences among bariatric procedures. A total of 39 studies compared SA- and DA-BMS were finally eligible for analysis after searching in PubMed, Web of Science, and Cochrane Library. Compared with DA, SA shortens operative time and decreases complications especially obstruction, internal hernia, and reoperation. SA-GB (gastric bypass) has significantly higher %TWL and T2DM remission rate than DA-GB 1- and 5-year postoperatively. SA-DS (duodenal switch) has similar 1-year %TWL and lower 5-year %TWL, and comparable 1- and 5-year T2DM remission with DA-DS. SA provides significant advantages about simplicity and safety. This, together with the shorter learning curve, makes SA a promising choice.
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Affiliation(s)
- Yiming Si
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Shibo Lin
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Cong Li
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - JiaJia Shen
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Wei Guan
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Hui Liang
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China.
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Ferrer-Márquez M, García-Redondo M, Maturana-Ibáñez V, Estébanez-Ferrero B, Fernández-Alonso A, Rubio-Gil F, Zamora Soler JA, Ferrer-Ayza M. Bile reflux and marginal ulcers after one-anastomosis gastric bypass (OAGB). A narrative review. Cir Esp 2023; 101 Suppl 4:S69-S75. [PMID: 37085133 DOI: 10.1016/j.cireng.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/24/2022] [Accepted: 12/11/2022] [Indexed: 04/23/2023]
Abstract
One-anastomosis gastric bypass has now become the third most commonly performed bariatric technique worldwide. However, as a consequence of the configuration of this surgery, it can present some chronic complications (anastomotic mouth ulcers and biliary reflux) that physicians must come to better understand and assess. In this narrative review, we aimed to update our knowledge of both the diagnosis and treatment of these two complications in the context of bariatric surgeries. We concluded that a series of pre-, intra-, and postoperative preventive strategies should be considered by surgeons to help reduce the appearance of these complications.
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Affiliation(s)
- Manuel Ferrer-Márquez
- Departamento de Cirugía Bariátrica, Hospital Universitario Torrecárdenas, Almería, Spain; Departamento de Cirugía Bariátrica (Obesidad Almería), Hospital Mediterráneo, Almería, Spain.
| | - Manuel García-Redondo
- Departamento de Cirugía Bariátrica, Hospital Universitario Torrecárdenas, Almería, Spain.
| | | | | | - Ana Fernández-Alonso
- Departamento de Obstetricia y Ginecología, Hospital Universitario Torrecárdenas, Almería, Spain.
| | - Francisco Rubio-Gil
- Departamento de Cirugía Bariátrica (Obesidad Almería), Hospital Mediterráneo, Almería, Spain.
| | - José A Zamora Soler
- Clinical Nursing Research Group, Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Alicante, Alicante, Spain.
| | - Manuel Ferrer-Ayza
- Departamento de Cirugía Bariátrica (Obesidad Almería), Hospital Mediterráneo, Almería, Spain.
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Dolores Frutos Bernal M. Bile reflux after bariatric surgery. Cir Esp 2023; 101 Suppl 4:S63-S68. [PMID: 37979939 DOI: 10.1016/j.cireng.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/12/2023] [Indexed: 11/20/2023]
Abstract
The growing epidemic of obesity and the increase in weight loss surgery has led to a resurgence of interest in biliary reflux because anatomical alterations may be refluxogenic. HIDA scan is the least invasive scan with good patient tolerability, sensitivity and reproducibility for the diagnosis of biliary reflux. Patients with more advanced oesophageal lesions have a higher degree of duodenal reflux. It has been shown in animal models and in vitro that there is more Barrett's and dysplasia with duodenal reflux. There are two cases of post-OAGB malignancy reported in 20 years, both without correlation with a biliary aetiology, so the carcinogenic risk probably remains theoretical. Prospective trials on OAGB should include endoscopy preoperatively and at 5-year intervals, to have data on the real effects of bile exposure on the gastric reservoir and oesophagus.
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Affiliation(s)
- M Dolores Frutos Bernal
- Cirugía Bariátrica y Laparoscópica, Departamento de Cirugía General, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.
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7
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Othman AA, Dwedar AA, ElSadek HM, AbdElAziz HR, Abdelrahman AA. Post-cholecystectomy bile reflux gastritis: Prevalence, risk factors, and clinical characteristics. Chronic Illn 2023; 19:529-538. [PMID: 35469484 DOI: 10.1177/17423953221097440] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Bile reflux gastritis is caused by the backward flow of duodenal fluid into the stomach. A retrospective cohort study was performed to estimate the prevalence and risk factors of bile reflux gastritis postcholecystectomy, and to evaluate the endoscopic and histopathologic changes in gastric mucosa. METHODS Patients with refractory upper abdominal pain right below the ribs with symptoms of bloating, burping, nausea, vomiting, and bile regurgitation during the period from January 2018 to December 2020, submitted to Zagazig University Hospitals were enrolled in this study. The studied 64 patients were divided into two groups; the control group (CG): 30 subjects who had never undergone any biliary interventions, and the post-cholecystectomy group (PCG): 34 patients who had undergone cholecystectomy. RESULTS The prevalence of bile reflux gastritis was (16.7%) and (61.8%) in CG and PCG, respectively. Diabetes, obesity, elevated gastric bilirubin, and elevated stomach pH were all risk factors for bile reflux gastritis in both groups (r = .28,.48,.78,.57 respectively). Age, sex, epigastric pain, heartburn, vomiting, and the existence of bile reflux gastritis, on the other hand, had no correlation. DISCUSSION After a cholecystectomy, bile reflux gastritis is prevalent, especially among obese and diabetic patients.
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Affiliation(s)
- Amira Aa Othman
- Department of Internal Medicine, Faculty of Medicine, Suez University, Suez, Egypt
| | - Amal Az Dwedar
- Department of Internal Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hany M ElSadek
- Department of Internal Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hesham R AbdElAziz
- Department of Pathology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Abeer Af Abdelrahman
- Department of Clinical Pathology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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8
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Arnon-Sheleg E, Farraj M, Michael S, Mari A, Khoury T, Sbeit W. Modified Hepatobiliary Scintigraphy for the Diagnosis of Bile Reflux in One-Anastomosis Gastric Bypass Surgery: a Prospective Multicenter Study. Obes Surg 2023; 33:1997-2004. [PMID: 37184825 DOI: 10.1007/s11695-023-06632-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/27/2023] [Accepted: 05/04/2023] [Indexed: 05/16/2023]
Abstract
PURPOSE One-anastomosis gastric bypass (OAGB) is a relatively simple surgical procedure for those afflicted with severe obesity. Studies reported symptomatic biliary reflux gastritis and esophagitis as predominant complications. Hepatobiliary scintigraphy (HIDA) is the least invasive test for the diagnosis of bile reflux, with good sensitivity, patient tolerability, and reproducibility. The aim of this study was to define an optimized HIDA scintigraphy protocol for demonstrating bile reflux in post-OAGB patients. MATERIAL AND METHODS We conducted a prospective multicenter study. Patients after OAGB with dyspeptic complaints were included. All patients underwent HIDA scan with a dedicated protocol for demonstrating bile reflux; prevalence and severity were reported. RESULTS Nineteen patients were included, 18 females and one male, with mean age of 41.8 years and mean time of 22.4 months from operation to the scan. Bile reflux into the gastric pouch was documented in 11 patients (53%). Reflux to the stomach pouch was severe in three patients (27%), moderate in two patients (18%), and mild in six patients (55%). Bile reflux into the esophagus was documented in four patients (21%), severe reflux in one patient (25%), and mild in the other three (75%). A correlation was found between complaints of vomiting, heartburn and regurgitation, and findings of esophagitis on gastroscopy in patients with vs. without reflux. CONCLUSIONS The tailored HIDA scan protocol detected bile reflux in more than half of the post-OAGB patients included in the study, with a high diagnostic sensitivity.
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Affiliation(s)
- Elite Arnon-Sheleg
- Nuclear Medicine Department, Galilee Medical Center, 2210001, Nahariya, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Moaad Farraj
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Department of Surgery, The Baruch Padeh Medical Center, 1528001, Tiberias, Israel
| | - Samar Michael
- Radiology Department, Galilee Medical Center, 2210001, Nahariya, Israel
| | - Amir Mari
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Gastroenterology Department, Nazareth Hospital, 16100, Nazareth, Israel
| | - Tawfik Khoury
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel.
- Department of Gastroenterology, Galilee Medical Center, 2210001, Nahariya, Israel.
| | - Wisam Sbeit
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Department of Gastroenterology, Galilee Medical Center, 2210001, Nahariya, Israel
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Ospanov O, Yeleuov G, Buchwald JN, Zharov N, Yelembayev B, Sultanov K. A Randomized Controlled Trial of Acid and Bile Reflux Esophagitis Prevention by Modified Fundoplication of the Excluded Stomach in One-Anastomosis Gastric Bypass: 1-Year Results of the FundoRing Trial. Obes Surg 2023; 33:1974-1983. [PMID: 37099252 DOI: 10.1007/s11695-023-06618-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/14/2023] [Accepted: 04/19/2023] [Indexed: 04/27/2023]
Abstract
BACKGROUND The advantages and disadvantages of one-anastomosis gastric bypass (OAGB) with primary modified fundoplication using the excluded stomach ("FundoRing") is unclear. We aimed to assess the impact of this operation in a randomized controlled trial (RCT) and answer the next questions: (1) What the impact of wrapping the fundus of the excluded part of the stomach in OAGB on protection in the experimental group against developing de novo reflux esophagitis? (2) If preoperative RE could be improved in the experimental group? (3) Can preoperative acid reflux as measured by PH impedance, be treated by the addition of the "FundoRing"? METHODS The study design was a single-center prospective, interventional, open-label (no masking) RCT (FundoRing Trial) with 1-year follow-up. Endpoints were body mass index (BMI, kg/m2) and acid and bile RE assessed endoscopically by Los Angeles (LA) classification and 24-h pH impedance monitoring. Complications were graded by Clavien-Dindo classification (CDC). RESULTS One hundred patients (n = 50 FundoRingOAGB (f-OAGB) vs n = 50 standard OAGB (s-OAGB)) with complete follow-up data were included in the study. During OAGB procedures, patients with hiatal hernia underwent cruroplasty (29/50 f-OAGB; 24/50 s-OAGB). There were no leaks, bleeding, or deaths in either group. At 1 year, BMI in the f-OAGB group was 25.3 ± 2.77 (19-30) vs 26.48 ± 2.8 (21-34) s-OAGB group (p = 0.03). In f-OAGB vs s-OAGB groups, respectively, acid RE was seen in 1 vs 12 patients (p = 0.001) and bile RE in 0 vs 4 patients (p < 0.05). CONCLUSION Routine use of a modified fundoplication of the OAGB-excluded stomach to treat patients with obesity decreased acid and prevented bile reflux esophagitis significantly more effectively than standard OAGB at 1 year in a randomized controlled trial. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04834635.
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Affiliation(s)
- Oral Ospanov
- Department of Surgical Disease and Bariatric Surgery, Astana Medical University, Beybitshilik Street 49A, 010000, Astana, Kazakhstan.
- Surgery Center of Professor Oral Ospanov, Astana, Kazakhstan.
| | - Galymzhan Yeleuov
- Department of Surgical Disease and Bariatric Surgery, Astana Medical University, Beybitshilik Street 49A, 010000, Astana, Kazakhstan
| | - J N Buchwald
- Division of Scientific Research Writing, Medwrite Medical Communications, Maiden Rock, WI, USA
| | - Nurlan Zharov
- Department of Surgical Disease and Bariatric Surgery, Astana Medical University, Beybitshilik Street 49A, 010000, Astana, Kazakhstan
| | | | - Kassymkhan Sultanov
- Department of Surgical Disease, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
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Ghanem OM, Ghazi R, Abdul Razzak F, Bazerbachi F, Ravi K, Khaitan L, Kothari SN, Abu Dayyeh BK. Turnkey algorithmic approach for the evaluation of gastroesophageal reflux disease after bariatric surgery. Gastroenterol Rep (Oxf) 2023; 11:goad028. [PMID: 37304555 PMCID: PMC10256627 DOI: 10.1093/gastro/goad028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/12/2022] [Accepted: 02/01/2023] [Indexed: 06/13/2023] Open
Abstract
Bariatric surgeries are often complicated by de-novo gastroesophageal reflux disease (GERD) or worsening of pre-existing GERD. The growing rates of obesity and bariatric surgeries worldwide are paralleled by an increase in the number of patients requiring post-surgical GERD evaluation. However, there is currently no standardized approach for the assessment of GERD in these patients. In this review, we delineate the relationship between GERD and the most common bariatric surgeries: sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), with a focus on pathophysiology, objective assessment, and underlying anatomical and motility disturbances. We suggest a stepwise algorithm to help diagnose GERD after SG and RYGB, determine the underlying cause, and guide the management and treatment.
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Affiliation(s)
- Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rabih Ghazi
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, St Cloud Hospital, St Cloud, MN, USA
| | - Karthik Ravi
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Leena Khaitan
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
| | | | - Barham K Abu Dayyeh
- Corresponding author. Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Tel: +1-507-284-2511; Fax: +1-507-284-0538;
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11
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Reicher R, Cohen NA, Fishman S, Shnell M. Endoscopic Transoral Outlet Reduction for the Treatment of Biliary Reflux Symptoms in Patients After One-Anastomosis Gastric Bypass-a Case Series. Obes Surg 2023; 33:870-878. [PMID: 36689142 DOI: 10.1007/s11695-023-06463-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/24/2023]
Abstract
PURPOSE OAGB is the third most common bariatric surgery. Biliary reflux (BR) is an inherent complication of this unique anatomy, although there is still controversy regarding its significance and long-term risks including carcinogenesis. To date, there is no effective treatment for BR with conversion to RYGB reserved for refractory patients. TORe is an effective treatment for weight-regain and dumping syndrome after RYGB. We hypothesized that narrowing the anastomosis would decrease the amount of bile refluxate entering the stomach and esophagus in patients with BR symptoms after OAGB and alleviate symptoms. The purpose of this study is to evaluate the efficacy of TORe for the treatment of BR symptoms after OAGB. MATERIALS AND METHODS BR was diagnosed clinically in patients after OAGB using the gastroesophageal reflux disease health-related quality of life (GERD-HRQL) instrument after treatment with high-dose proton pump inhibitor (PPI) excluded possible acid reflux. TORe was carried out using a suture pattern that narrowed and elongated the anastomosis. All patients were prospectively followed. RESULTS Twelve patients, post-OAGB, underwent TORe for BR. Symptoms resolved in 9 (75%) patients. GERD-HRQL score at 6 months declined from an average of 33.7 (SD 1.9) before the procedure to 16.1 (SD 10, p < 0.001). In one case, a small perforation was identified during the procedure and was immediately sutured with no further sequela. DISCUSSION TORe appears a safe and effective treatment for BR symptoms after OAGB, at least in the short term. Accurate tools for BR diagnosis, a larger cohort, and longer follow-up periods are needed to better show the effectiveness and durability of this treatment option.
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Affiliation(s)
- Relly Reicher
- Tel Aviv Sourasky Medical Center, Bariatric Endoscopy Unit, Department of Gastroenterology and Liver Diseases, Affiliated to Tel Aviv University, Tel Aviv, Israel.
| | - Nathaniel A Cohen
- Tel Aviv Sourasky Medical Center, Bariatric Endoscopy Unit, Department of Gastroenterology and Liver Diseases, Affiliated to Tel Aviv University, Tel Aviv, Israel
| | - Sigal Fishman
- Tel Aviv Sourasky Medical Center, Bariatric Endoscopy Unit, Department of Gastroenterology and Liver Diseases, Affiliated to Tel Aviv University, Tel Aviv, Israel
| | - Mati Shnell
- Tel Aviv Sourasky Medical Center, Bariatric Endoscopy Unit, Department of Gastroenterology and Liver Diseases, Affiliated to Tel Aviv University, Tel Aviv, Israel
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12
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Thaher O, Croner RS, Hukauf M, Driouch J, Stroh C. The effect of Roux-en-Y gastric bypass compared with omega-loop gastric bypass on weight loss, perioperative surgical events, and comorbidities. Minerva Surg 2023; 78:11-22. [PMID: 35785938 DOI: 10.23736/s2724-5691.22.09580-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND In comparison to conservative therapy, bariatric surgery has shown many reasonable results. The current study investigates whether Omega-loop-gastric-bypass (OAGB) or Roux-en-Y gastric-bypass (RYGB) improves weight loss, comorbidities, and perioperative complications. METHODS The study included 28,683 patients after RYGB and OAGB. Outcome criteria were perioperative morbidity, perioperative complications, and remission of comorbidities after one year of follow-up. RESULTS Of them 14,253 patients had completed a one-year follow-up (13,483 patients by RYGB and 770 by OAGB). BMI reduction was a significant difference in favor of OAGB (17.5±5.6 kg/m2 for OAGB vs. 15.2±5.0 for RYGB; P<0.001). The %EWL was not significantly different between the two groups (P=0.073). There was also no significant difference in perioperative complications between the two groups (overall P>5%). Significant differences in favor of OAGB were observed in remission of insulin-dependent diabetes mellitus (IDDM) (P<0.001), and sleep apnea (P=0.002). Remission of reflux was more observed in RYGB than OAGB (P<0.001). Operating time was significantly higher in RYGB than OAGB (P<0.001). CONCLUSIONS Compared with RYGB, OAGB showed significant advantages in many respects. In particular, remission of comorbidities was significantly better after OAGB than in patients after RYGB during the one-year follow-up period. Nevertheless, many other factors such as medical history, long-term expected goals of bariatric surgery, and preexisting comorbidities should be taken into account when determining indications between the two procedures. Further studies with longer follow-up periods should be conducted to determine the efficacy of the two methods more accurately.
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Affiliation(s)
- Omar Thaher
- Department of Surgery, Marien Hospital Herne, Ruhr-Universität Bochum, Herne, Germany -
| | - Roland S Croner
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Martin Hukauf
- StatConsult Society for Clinical and Health Services Research GmbH, Magdeburg, Germany
| | - Jamal Driouch
- Department of Surgery, Marien Hospital Herne, Ruhr-Universität Bochum, Herne, Germany
| | - Christine Stroh
- Department of General, Abdominal and Pediatric Surgery, Municipal Hospital, Gera, Germany
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13
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Endoscopic and histopathological assessment of individuals undergoing one anastomosis gastric bypass: a 2-year follow-up. Surg Endosc 2023; 37:3720-3727. [PMID: 36650354 DOI: 10.1007/s00464-023-09884-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 01/08/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND There is much debate over the occurrence of biliary reflux to the gastric pouch after one anastomosis gastric bypass (OAGB) and its potential risks. OBJECTIVE To assess endoscopic and histopathological findings following a standardized protocol of biopsy collection two years after OAGB. METHODS A historical cohort study was conducted, based on a prospectively collected database, which involved 39 participants who underwent OAGB. Participants underwent clinical evaluation and esophagogastroduodenoscopy at the time of surgery and 24 months afterward. Post-operatively, biopsy specimens in esophagogastric junction, pouch, and anastomosis were systematically collected. RESULTS 92.3% of the participants were female and the mean age was 37 ± 8.5 years. The mean body mass index (BMI) significantly decreased from 37.6 ± 5.7 kg/m2 to 27 ± 4.1 kg/m2 after 2 years (p < 0.001). The mean %TWL was 27.2 ± 10.5%. The prevalence of non-erosive gastritis significantly increased from 25.6 to 51.3% (p = 0.02). Erosive gastritis significantly decreased from 28.2 to 10.3% (p = 0.04). Four cases of marginal ulcers were identified (10.3%). The commonest histopathological finding was mild inflammation in 74.3% (esophagogastric junction), 58.9% (pouch), and 71.8% (anastomosis). There was one case of focal intestinal metaplasia in each site of interest and no cases of dysplasia or severe inflammation. CONCLUSIONS Using a standardized protocol of post-operative biopsy collection, low rates of severe endoscopic and histopathological abnormalities were observed two years after OAGB. Nevertheless, as most patients have histologically proven inflammation, bile in the gastric pouch, and endoscopic gastritis, long-term surveillance is essential because of the uncertain risk of these abnormalities.
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14
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Lange UG, Moulla Y, Mehdorn M, Tuennemann J, Zabel-Langhennig A, Ouaid A, Dietrich A. Laparoscopic conversion of omega loop gastric bypass to Roux-en-Y gastric bypass for Barrett's esophagus: case report. BMC Surg 2022; 22:273. [PMID: 35836240 PMCID: PMC9284751 DOI: 10.1186/s12893-022-01695-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 06/21/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The number of mini gastric bypass / one anastomosis bypass (MGB-OAGB) procedures in bariatric patients that have been performed world-wide has drastically increased during the past decade. Nevertheless, due to the risk of subsequent biliary reflux and development of ulcer and neoplastic (pre)lesions caused by long-time bile exposure, the procedure is still controversially discussed. In here presented case report, we could endoscopically demonstrate a transformation from reflux oesophagitis to Barrett's metaplasia most likely caused by bile reflux after mini-gastric bypass. To our knowledge, this is a first case study that shows development of Barrett's metaplasia after MGB-OAGB. CASE PRESENTATION We present the case of a 50-year-old female which received a mini-gastric bypass due to morbid obesity (body mass index (BMI) 42.4 kg/m2). Because of history gastroesophageal reflux disease (GERD), a fundoplication had been performed earlier. Preoperative gastroscopy showed reflux esophagitis (Los Angeles classification grade B) with no signs of Barrett's metaplasia. Three months post mini-gastric bypass, the patient complained about severe bile reflux under 40 mg pantoprazole daily. Six months postoperative, Endoscopically Barrett's epithelium was detected and histopathologically confirmed (C1M0 after Prague classification). A conversion into Roux-en-Y gastric bypass was performed. The postoperative course was without complications. In a follow up after 6 months the patient denied reflux and showed no signs of malnutrition. CONCLUSIONS The rapid progress from inflammatory changes of the distal esophagus towards Barrett's metaplasia under bile reflux in our case is most likely a result of previous reflux disease. Nevertheless, bile reflux appears to be a potential decisive factor. Study results regarding presence of bile reflux or development of endoscopically de-novo findings after MGB-OAGB are widely non-conclusive. Long-term prospective studies with regular endoscopic surveillance independent of clinical symptoms are needed.
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Affiliation(s)
- U G Lange
- Clinic for Visceral, Transplant and Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - Y Moulla
- Clinic for Visceral, Transplant and Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - M Mehdorn
- Clinic for Visceral, Transplant and Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - J Tuennemann
- Division of Gastroenterology, Department of Internal Medicine, Neurology and Dermatology, University Hospital of Leipzig, Leipzig, Germany
| | - A Zabel-Langhennig
- Division of Gastroenterology, Department of Internal Medicine II, St. Elisabeth Hospital, Leipzig, Germany
| | - A Ouaid
- Division of Gastroenterology, Department of Internal Medicine II, St. Elisabeth Hospital, Leipzig, Germany
| | - A Dietrich
- Clinic for Visceral, Transplant and Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
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15
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Eldredge TA, Bills M, Ting YY, Dimitri M, Watson MM, Harris MC, Myers JC, Bartholomeusz DL, Kiroff GK, Shenfine J. Once in a Bile — the Incidence of Bile Reflux Post-Bariatric Surgery. Obes Surg 2022; 32:1428-1438. [PMID: 35226339 PMCID: PMC8883020 DOI: 10.1007/s11695-022-05977-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/08/2022] [Accepted: 02/17/2022] [Indexed: 12/11/2022]
Abstract
Purpose Excellent metabolic improvement following one anastomosis gastric bypass (OAGB) remains compromised by the risk of esophageal bile reflux and theoretical carcinogenic potential. No ‘gold standard’ investigation exists for esophageal bile reflux, with diverse methods employed in the few studies evaluating it post-obesity surgery. As such, data on the incidence and severity of esophageal bile reflux is limited, with comparative studies lacking. This study aims to use specifically tailored biliary scintigraphy and upper gastrointestinal endoscopy protocols to evaluate esophageal bile reflux after OAGB, sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Methods Fifty-eight participants underwent OAGB (20), SG (15) or RYGB (23) between November 2018 and July 2020. Pre-operative reflux symptom assessment and gastroscopy were performed and repeated post-operatively at 6 months along with biliary scintigraphy. Results Gastric reflux of bile was identified by biliary scintigraphy in 14 OAGB (70%), one RYGB (5%) and four SG participants (31%), with a mean of 2.9% (SD 1.5) reflux (% of total radioactivity). One participant (OAGB) demonstrated esophageal bile reflux. De novo macro- or microscopic gastroesophagitis occurred in 11 OAGB (58%), 8 SG (57%) and 7 RYGB (30%) participants. Thirteen participants had worsened reflux symptoms post-operatively (OAGB, 4; SG, 7; RYGB, 2). Scintigraphic esophageal bile reflux bore no statistical association with de novo gastroesophagitis or reflux symptoms. Conclusion Despite high incidence of gastric bile reflux post-OAGB, esophageal bile reflux is rare. With scarce literature of tumour development post-OAGB, frequent low-volume gastric bile reflux likely bears little clinical consequence; however, longer-term studies are needed. Clinical Trial Registry Australian New Zealand Clinical Trials Registry number ACTRN12618000806268. Graphical abstract ![]()
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Affiliation(s)
- Thomas A Eldredge
- Discipline of Surgery, University of Adelaide, Adelaide, South Australia, Australia.
- Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, Adelaide, South Australia, 5011, Australia.
| | - Madison Bills
- Department of Nuclear Medicine, PET and Bone Densitometry, Royal Adelaide Hospital and SA Medical Imaging, Adelaide, South Australia, Australia
| | - Ying Yang Ting
- Discipline of Surgery, University of Adelaide, Adelaide, South Australia, Australia
- Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, Adelaide, South Australia, 5011, Australia
| | - Mikayla Dimitri
- Department of Nuclear Medicine, PET and Bone Densitometry, Royal Adelaide Hospital and SA Medical Imaging, Adelaide, South Australia, Australia
| | - Matthew M Watson
- Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, Adelaide, South Australia, 5011, Australia
| | - Mark C Harris
- Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, Adelaide, South Australia, 5011, Australia
| | - Jennifer C Myers
- Discipline of Surgery, University of Adelaide, Adelaide, South Australia, Australia
- Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, Adelaide, South Australia, 5011, Australia
| | - Dylan L Bartholomeusz
- Department of Nuclear Medicine, PET and Bone Densitometry, Royal Adelaide Hospital and SA Medical Imaging, Adelaide, South Australia, Australia
- Department of Gastroenterology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - George K Kiroff
- Discipline of Surgery, University of Adelaide, Adelaide, South Australia, Australia
- Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, Adelaide, South Australia, 5011, Australia
| | - Jonathan Shenfine
- Discipline of Surgery, University of Adelaide, Adelaide, South Australia, Australia
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16
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Chemaly R, Diab S, Khazen G, Al-Hajj G. Gastroesophageal Cancer After Gastric Bypass Surgeries: a Systematic Review and Meta-analysis. Obes Surg 2022; 32:1300-1311. [PMID: 35084611 DOI: 10.1007/s11695-022-05921-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/13/2022] [Accepted: 01/14/2022] [Indexed: 12/11/2022]
Abstract
Data comparing the occurrence of gastroesophageal cancer after gastric bypass procedures are lacking and are only available in the form of case reports. We perform in this study a systematic review and a meta-analysis of all the reported cases of gastroesophageal cancer following Roux-en-Y gastric bypass (RYGB) and loop gastric bypass-one anastomosis gastric bypass/mini gastric bypass (LGB-OAGB/MGB). We conducted a systematic review of all the reported cases in articles referenced in PubMed/Medline, Cochrane, and Scholar Google. Only cases of gastro-esophageal adenocarcinoma following RYGB or LGB-OAGB/MGB are included. Statistical analysis was done accordingly. Fifty cases were identified, along with 2 reported in this paper. Sixty-one percent (27/44) of the cancers after RYGB were in the gastric tube compared to 37.5% (3/8) after LGB-OAGB/MGB. This resulted in an odds ratio of 0.38 (p-value = 0.26), which failed to prove an increase in cancer occurrence in the gastric tube after LGB-MGB/OAGB compared to RYGB. The most common symptoms were dysphagia for cancers occurring in the gastric tube (15/30) and abdominal pain for those occurring in the excluded stomach (10/22). Twenty-nine/thirty of the cancers in the gastric tube were diagnosed by gastroscopy and 13/22 of the cancers in the excluded stomach were diagnosed by CT scan. Gastroesophageal cancers after gastric bypass procedures occur commonly in the excluded stomach where many are not identified by conventional means. Physician awareness and patient education as well as lifelong follow-up are essential for maintaining bypass surgeries on the beneficial side.
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Affiliation(s)
- Rodrigue Chemaly
- Department of General Surgery, Lebanese American University Medical Center - Rizk Hospital, LAU Gilbert and Rose-Marie Chagoury School of Medicine, Beirut, Lebanon. .,Department of General Surgery, Middle East Institute of Health (MEIH), Bsalim, Lebanon.
| | - Samer Diab
- Department of General Surgery, Lebanese American University Medical Center - Rizk Hospital, LAU Gilbert and Rose-Marie Chagoury School of Medicine, Beirut, Lebanon
| | - Georges Khazen
- Department of Computer Science and Mathematical, Lebanese American University, Beirut, Lebanon
| | - Georges Al-Hajj
- Department of General Surgery, Lebanese American University Medical Center - Rizk Hospital, LAU Gilbert and Rose-Marie Chagoury School of Medicine, Beirut, Lebanon.,Department of General Surgery, Middle East Institute of Health (MEIH), Bsalim, Lebanon
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Othman AA, Dewedar AA, ElSadek HM, AbdelAziz HR, AdelRahman AA. Do obesity and diabetes increase the frequency and risk
of bile reflux gastritis post-cholecystectomy? POLISH JOURNAL OF SURGERY 2022; 94:1-8. [DOI: 10.5604/01.3001.0015.6980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
<br><b>Introduction:</b> Biliary gastropathy is a disease characterized by upper abdominal pain, frequent heartburn, nausea, and vomiting of bile. It is caused by the backward flow of duodenal fluid into the stomach and esophagus.</br>
<br><b>Aim:</b> A retrospective cohort study was performed to estimate the prevalence and risk factors of bile reflux gastritis secondary to cholecystectomy and to evaluate the endoscopic and histopathologic changes in gastric mucosa caused by bile reflux gastritis.</br>
<br><b>Materials and methods:</b> The study involved 64 patients with epigastric pain and/or dyspeptic symptoms during the period from January 2018 to December 2020 who presented to Zagazig University Hospitals. The subjects were divided into two groups: the control group (CG), with 30 subjects who had never undergone any biliary interventions, and the post-cholecystectomy group (PCG), consisting of 34 patients who had undergone cholecystectomy.</br>
<br><b>Results:</b> The prevalence of bile reflux gastritis was 16.7% in the CG and 61.8% in the PCG. In both groups, diabetes, obesity, increased gastric bilirubin, and increased gastric pH were risk factors for bile reflux gastritis (r = 0.28, 0.48, 0.78, and 0.57, respectively). However, there were no correlations between age, sex, epigastric pain, heartburn, vomiting, and the presence of bile reflux gastritis.</br>
<br><b>Discussion:</b> Bile reflux gastritis is a common complication following cholecystectomy and is more common among obese and diabetic patients.</br>
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Affiliation(s)
- Amira A.A. Othman
- Department of Internal Medicine, Faculty of Medicine, Suez University, Suez, Egypt
| | - Amal A.Z. Dewedar
- Department of Internal Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hany M. ElSadek
- Department of Internal Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hesham R. AbdelAziz
- Department of Pathology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Abeer A.F. AdelRahman
- Department of Clinical Pathology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Revisional Surgery After One Anastomosis/Minigastric Bypass: an Italian Multi-institutional Survey. Obes Surg 2022; 32:256-265. [PMID: 34973123 PMCID: PMC8795019 DOI: 10.1007/s11695-021-05779-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 11/04/2021] [Accepted: 11/04/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Efficacy and safety of OAGB/MGB (one anastomosis/mini gastric bypass) have been well documented both as primary and as revisional procedures. However, even after OAGB/MGB, revisional surgery is unavoidable in patients with surgical complications or insufficient weight loss. METHODS A questionnaire asking for the total number and demographics of primary and revisional OAGB/MGBs performed between January 2006 and July 2020 was e-mailed to all S.I.C. OB centres of excellence (annual caseload > 100; 5-year follow-up > 50%). Each bariatric centre was asked to provide gender, age, preoperative body mass index (BMI) and obesity-related comorbidities, previous history of abdominal or bariatric surgery, indication for surgical revision of OAGB/MGB, type of revisional procedure, pre- and post-revisional BMI, peri- and post-operative complications, last follow-up (FU). RESULTS Twenty-three bariatric centres (54.8%) responded to our survey reporting a total number of 8676 primary OAGB/MGBS and a follow-up of 62.42 ± 52.22 months. A total of 181 (2.08%) patients underwent revisional surgery: 82 (0.94%) were suffering from intractable DGER (duodeno-gastric-esophageal reflux), 42 (0.48%) were reoperated for weight regain, 16 (0.18%) had excessive weight loss and malnutrition, 12 (0.13%) had a marginal ulcer perforation, 10 (0.11%) had a gastro-gastric fistula, 20 (0.23%) had other causes of revision. Roux-en-Y gastric bypass (RYGB) was the most performed revisional procedure (109; 54%), followed by bilio-pancreatic limb elongation (19; 9.4%) and normal anatomy restoration (19; 9.4%). CONCLUSIONS Our findings demonstrate that there is acceptable revisional rate after OAGB/MGB and conversion to RYGB represents the most frequent choice.
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19
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Laparoscopic Fundoplication Using the Excluded Stomach as a Novel Management Option for Refractory Bile Reflux Following One Anastomosis Gastric Bypass (OAGB). Obes Surg 2021; 32:561-566. [PMID: 34817792 PMCID: PMC8795036 DOI: 10.1007/s11695-021-05804-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/05/2021] [Accepted: 11/10/2021] [Indexed: 11/27/2022]
Abstract
Background One anastomosis gastric bypass (OAGB) is now a mainstream bariatric procedure. Refractory gastroesophageal reflux is a significant complication following OAGB, and conversion to Roux-en-Y has long been the treatment of choice for this issue. Strengthening the lower esophageal sphincter by Nissen fundoplication (NF) has been reported as an effective anti-reflux surgery. Here we report the short-term outcomes of a modified NF procedure using the excluded stomach (excluded stomach fundoplication—ESF) to treat refractory bile reflux in post-OAGB patients. Methods Thirteen post-OAGB patients underwent ESF for refractory bile reflux during the study, as detailed in the surgical technique. This paper reports the 12 patients whose follow-up data are available. Results Following ESF, the GERD-HRQL heartburn score improved from 22.7 ± 3.9 to 1.8 ± 3.5 (p < 0.05). The mean aggregate GERD-HRQL score improved from 27.9 ± 5.3 to 5.7 ± 5.9 (p < 0.05). The GERD-HRQL global satisfaction score showed that 100% of patients were satisfied with the improvement of symptoms. The mean VISICK score improved from 3.8 ± 0.39 to 1.2 ± 0.39 (p < 0.05). One patient was returned to the operating theatre to have the wrap loosened due to dysphagia. Eleven patients did not require PPIs after surgery. Conclusions ESF significantly improved the VISICK score and GERD-HRQL of post-OAGB patients with refractory bile reflux in the short term. The current study is being continued to increase the sample size and the follow-up period.
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20
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Acid Reflux Is Common in Patients With Gastroesophageal Reflux Disease After One-Anastomosis Gastric Bypass. Obes Surg 2021; 31:4717-4723. [PMID: 34232446 DOI: 10.1007/s11695-021-05542-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/09/2021] [Accepted: 06/16/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Patients with one-anastomosis gastric bypass (OAGB) can develop gastroesophageal reflux disease (GERD). The nature of this GERD (acid or biliary) remains unclear. OBJECTIVE To assess the nature of GERD via impedance pH testing in patients presenting with reflux post OAGB. METHODS Retrospective analysis of a prospectively collected database of 43 patients with OAGB backgrounds who developed postoperative GERD and were investigated with impedance pH monitoring between 2006 and 2019. RESULTS Mean age was 52.48 ± 9 years. Mean body mass index (BMI) prior to OAGB was 46.82 kg/m2. None of these patients had clinical GERD before surgery. The median time interval between surgery and investigation with 24-h impedance pH monitoring was 64 (56) months. The mean BMI at the time of investigations was 32.67 ± 6.9 kg/m2. The type of reflux was acid in 13 (30.2%), non-acid (biliary) in 12 (27.9%), and mixed (acid and biliary) in 5 (11.6%) patients. However, it remained not confirmed in 13 (30.2%). Median DeMeester score was 48.95 (27.67) in patients with acid, 2.8 (7.4) in patients with biliary, and 28.7 (5.6) in patients with mixed reflux. Median percent of time spent with pH < 4 was 9.65 (8) in patients with acid, 0.6 (1.75) in patients with biliary, and 7.7 (3.9) in patients with mixed reflux. CONCLUSION Acid reflux seems to be as common as bile reflux in patients presenting with GERD after OAGB. In case of revisional surgery for severe GERD post OAGB, 24-h impedance pH monitoring could be essential to determine the surgical procedure of choice.
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21
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IFSO Update Position Statement on One Anastomosis Gastric Bypass (OAGB). Obes Surg 2021; 31:3251-3278. [PMID: 33939059 DOI: 10.1007/s11695-021-05413-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 04/03/2021] [Accepted: 04/07/2021] [Indexed: 12/11/2022]
Abstract
The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued a position statement on the role of one anastomosis gastric bypass (OAGB) in the field of bariatric/metabolic surgery in 2018 De Luca et al. (Obes Surg. 28(5):1188-206, 2018). This position statement was issued by the IFSO OAGB task force and approved by the IFSO Scientific Committee and IFSO Executive Board. In 2018, the OAGB task force recognized the necessity to update the position statement in the following 2 years since additional high-quality data could emerge. The updated IFSO position statement on OAGB was issued also in response to inquiries to the IFSO by society members, universities, hospitals, physicians, insurances, patients, policy makers, and media. The IFSO position statement on OAGB has been reviewed within 2 years according to the availability of additional scientific evidence. The recommendation of the statement is derived from peer-reviewed scientific literature and available knowledge. The IFSO update position statement on OAGB will again be reviewed in 2 years provided additional high-quality studies emerge.
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22
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Saarinen T, Pietiläinen KH, Loimaala A, Ihalainen T, Sammalkorpi H, Penttilä A, Juuti A. Bile Reflux is a Common Finding in the Gastric Pouch After One Anastomosis Gastric Bypass. Obes Surg 2021; 30:875-881. [PMID: 31853864 PMCID: PMC7347680 DOI: 10.1007/s11695-019-04353-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Data on postoperative bile reflux after one anastomosis gastric bypass (OAGB) is lacking. Bile reflux scintigraphy (BRS) has been shown to be a reliable non-invasive tool to assess bile reflux after OAGB. We set out to study bile reflux after OAGB with BRS and endoscopy in a prospective series (RYSA Trial). METHODS Forty patients (29 women) underwent OAGB between November 2016 and December 2018. Symptoms were reported and upper gastrointestinal endoscopy (UGE) was done preoperatively. Six months after OAGB, bile reflux was assessed in UGE findings and as tracer activity found in gastric tube and esophagus in BRS (follow-up rate 95%). RESULTS Twenty-six patients (68.4%) had no bile reflux in BRS. Twelve patients (31.6%) had bile reflux in the gastric pouch in BRS and one of them (2.6%) had bile reflux also in the esophagus 6 months postoperatively. Mean bile reflux activity in the gastric pouch was 5.2% (1-21%) of total activity. De novo findings suggestive of bile reflux (esophagitis, stomal ulcer, foveolar inflammation of gastric pouch) were found for 15 patients (39.5%) in postoperative UGE. BRS and UGE findings were significantly associated (P = 0.022). Eight patients experienced de novo reflux symptoms at 6 months, that were significantly associated with BRS and de novo UGE findings postoperatively (P = 0.033 and 0.0005, respectively). CONCLUSION Postoperative bile reflux in the gastric pouch after OAGB is a common finding in scintigraphy and endoscopy. The long-term effects of bile exposure will be analyzed in future reports after a longer follow-up. TRIAL REGISTRATION Clinical Trials Identifier NCT02882685.
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Affiliation(s)
- Tuure Saarinen
- Department of Gastrointestinal Surgery, Helsinki University Hospital, Abdominal Center, Helsinki, Finland. .,HUS Jorvi Hospital, Turuntie 150, 02740, Espoo, Finland. .,Department of Gastrointestinal Surgery, Helsinki University Hospital, Abdominal Center, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland.
| | - Kirsi H Pietiläinen
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland.,Department of Endocrinology, Helsinki University Hospital, Abdominal Center, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
| | - Antti Loimaala
- HUS Medical Imaging Center, Clinical Physiology and Nuclear Medicine, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
| | - Toni Ihalainen
- HUS Medical Imaging Center, Clinical Physiology and Nuclear Medicine, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
| | - Henna Sammalkorpi
- Department of Gastrointestinal Surgery, Helsinki University Hospital, Abdominal Center, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
| | - Anne Penttilä
- Department of Gastrointestinal Surgery, Helsinki University Hospital, Abdominal Center, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
| | - Anne Juuti
- Department of Gastrointestinal Surgery, Helsinki University Hospital, Abdominal Center, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
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Bile reflux after one anastomosis gastric bypass surgery: A review study. Ann Med Surg (Lond) 2021; 64:102248. [PMID: 33868682 PMCID: PMC8040101 DOI: 10.1016/j.amsu.2021.102248] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 12/11/2022] Open
Abstract
Background Recently the performance rate of one anastomosis gastric bypass (OAGB) bariatric surgery has increased. Bile reflux is on of common considered complication of OAGB challenging surgeon. Methods We searched English full text with keyword "bile reflux" AND "OAGB" OR "one anastomosis gastric bypass" OR "SAGB" OR "single anastomosis gastric bypass" that published from January 1st, 2000 to December 31st, 2020 in PubMed, EMBASE, Google scholar and Cochrane Library. We included prospective or retrospective systematic review, review, clinical, and meta-analysis human article that its full text was available and focused on bile reflux after OAGB/SAGB as the fundamental performed bariatric surgery. Results A total of 1259 articles were analyzed, of which 5 were included. Analysis of number articles by year revealed that 2019 and 2020 was the highest number of published articles (n = 232; 68%). Study type analysis revealed that review studies and clinical research (n = 62; 18.2%) were the most frequent study types. Reported data on bile reflux after OAGB had diversity. Implicitly, postoperative incidence of bile reflux differed from 7.8 to 55.5%. General consensus was not existed among authors to consider the OAGB as the first suspect leading to postoperative bile reflux among other bariatric surgery types. Conclusion Although surgeons prefer to conduct OAGB procedure because of its easier surgical approach needing just one anastomosis formation it is not virtually clear that is the procedure costly benefitted regarding bile reflux outcomes.
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Hussain A, El-Hasani S. Anastomotic Gastrojejunal Ulcer Perforation Following One Anastomosis Gastric Bypass. Obes Surg 2020; 31:1334-1335. [PMID: 32948999 DOI: 10.1007/s11695-020-04979-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 06/24/2020] [Accepted: 09/11/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Abdulzahra Hussain
- Bariatric Unit, Doncaster and Bassetlaw Teaching Hospitals, Doncaster, UK.
| | - Shamsi El-Hasani
- Bariatric Unit, Princess Royal University Hospital, King's College Hospitals NHS Foundation Trust, London, UK
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Ahuja A, Mahawar K. Bariatric surgery in patients with gastroesophageal reflux disease and/or hiatus hernia. MINERVA CHIR 2020; 75:345-354. [PMID: 32773756 DOI: 10.23736/s0026-4733.20.08486-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) and hiatus hernia (HH) are frequently encountered comorbidities in patients seeking bariatric and metabolic surgery (BMS) for obesity. sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and one anastomosis gastric bypass (OAGB) are the three commonest bariatric procedures performed worldwide. The purpose of this review was to analyze and compare the data on outcomes of these three procedures in patients with GERD and/or HH. EVIDENCE ACQUISITION We examined published English language scientific literature available on PubMed for data comparing SG, RYGB, and OAGB with specific focus on GERD outcomes and outcomes in those with GERD and/or HH. EVIDENCE SYNTHESIS Several authors have addressed the outcome of GERD after bariatric surgery. There have been randomized control trials and comparative studies in the literature comparing the results of these procedure. But very few studies have exclusively looked into the outcome of different procedures in patients with pre-existing GERD and/or HH. In this narrative review, we evaluate pros and cons of three commonest bariatric procedures worldwide in this subgroup of patients seeking BMS. We also suggest an algorithm on the basis of our experience and the available data in scientific literature. CONCLUSIONS Though RYGB is the best anti reflux procedure it is associated with significant higher morbidity/mortality as compared to SG and OAGB. These two procedures can be used in the majority of patients with GERD and/or HH seeking BMS with an acceptance that some patients will need conversion to RYGB in the long term.
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Affiliation(s)
- Anmol Ahuja
- Department of General and Laparoscopic Surgery, Sir Ganga Ram Hospital, New Delhi, India -
| | - Kamal Mahawar
- Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, Sunderland, UK.,Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
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Musella M, Vitiello A. The Eternal Dilemma of the Bile into the Gastric Pouch After OAGB: Do We Need to Worry? Obes Surg 2020; 31:426-427. [PMID: 32656728 DOI: 10.1007/s11695-020-04845-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/10/2020] [Accepted: 07/06/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Mario Musella
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II"-Via S. Pansini 5, 80131, Naples, Italy
| | - Antonio Vitiello
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II"-Via S. Pansini 5, 80131, Naples, Italy.
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Pizza F, D'Antonio D, Lucido FS, Tolone S, Dell'Isola C, Gambardella C. Postoperative Clinical-Endoscopic Follow-up for GERD and Gastritis After One Anastomosis Gastric Bypass for Morbid Obesity: How, When, and Why. Obes Surg 2020; 30:4391-4400. [PMID: 32621053 DOI: 10.1007/s11695-020-04805-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The one anastomosis gastric bypass (OAGB) is a widely diffused surgical procedure for morbid obesity. Several studies considered OAGB at risk for biliary reflux and anastomotic ulcers. The aim of the study was to evaluate gastro-esophageal reflux disease (GERD) and esophagitis/gastritis rate after OAGB diagnosed by upper endoscopy (UE), comparing the results with GERD-Health-Related Quality of Life (HRQL) score. METHODS From July 2014 to February 2019, patients underwent OAGB with at least 12-month follow-up were retrospectively evaluated. Clinical evaluation was associated with GERD-HRQL scoring. UE with a mucosal biopsy was also performed. A comparison among clinical scores and endoscopic findings was performed. RESULTS Two hundred forty-one patients were analyzed in the study. Anthropometric features (BMI, %Excess weight loss, %Total weight loss) were significantly improved. Only 30% of patients with GERD-HQRL>30 showed esophagitis at UE: 11/181 (6.1%) showed grade A erosive esophagitis, 2/181 (1.1%) grade B esophagitis, whereas no patient resulted in grade C/D. Fifty-two patients (28.7%) showed endoscopic remnant gastritis of at least grade 1, with histological gastritis of at least mild grade in 70/181 patients (38.7%). CONCLUSION OAGB is a feasible and effective procedure in terms of weight reduction and comorbidities control, but controversies remain about the long-term onset of GERD and bile reflux. The incidence of esophagitis was increased after OAGB. However, the severity and incidence were lower compared to sleeve gastrectomy. Conversely, the incidence of gastritis, ileo-gastric anastomotic inflammation, and HP positivity were not negligible, suggesting the potential benefits of endoscopic surveillance after OAGB.
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Affiliation(s)
- Francesco Pizza
- Division of General and Emergency Surgery, Asl Napoli 2 nord, Frattamaggiore, Naples, Italy.
| | - Dario D'Antonio
- Division of General and Emergency Surgery, Asl Napoli 2 nord, Frattamaggiore, Naples, Italy
| | - Francesco Saverio Lucido
- Division of General, Mininvasive and Bariatric Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Salvatore Tolone
- Division of General, Mininvasive and Bariatric Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Chiara Dell'Isola
- AORN "dei Colli" Monaldi-Cotugno_CTO Department of Infectious Diseases, Naples, Italy
| | - Claudio Gambardella
- Division of General, Mininvasive and Bariatric Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
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Kermansaravi M, Kabir A, Mousavimaleki A, Pazouki A. Association between hiatal hernia and gastroesophageal reflux symptoms after one-anastomosis/mini gastric bypass. Surg Obes Relat Dis 2020; 16:863-867. [PMID: 32331999 DOI: 10.1016/j.soard.2020.03.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 02/01/2020] [Accepted: 03/05/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND One-anastomosis gastric bypass (OAGB) is an accepted bariatric and metabolic surgery with certain important complications, such as postoperative gastroesophageal reflux disease (GERD) and bile reflux (BR), which are not well addressed in literature. OBJECTIVES The present study was conducted to determine the true incidence of postoperative de novo GERD and BR and their associations with a hiatal hernia (HH). SETTING The present research setting comprised the Center of Excellence of the European Branch of the International Federation for the Surgery of Obesity and Metabolic Disorders, Hazrat-e-Rasoul Hospital, Tehran, Iran. METHODS The present cohort study recruited 200 patients with morbid obesity undergoing OAGB/minigastric bypass from December 2016 to February 2018 without any preoperative GERD symptoms. These patients were followed up for 1 year after the surgery. The incidence of post-OAGB GERD and BR was determined in all the patients using the GERD symptom questionnaire, GerdQ. RESULTS The mean age of the patients was 41.0 ± 11.6 years. A hernia was observed in 56 (29.2%) cases and GERD in 37 (19.3%). Hernia was small in 44 (22.9%) cases, medium in 11 (5.7%), and large in 1 (.5%). HH was found to be significantly correlated with GERD (P = .012). CONCLUSION The important post-OAGB complications, such as GERD and BR, have not been adequately addressed in literature. The present study found moderate and large HHs to be important factors for de novo GERD and repairing a HH during OAGB may be essential for preventing GERD-like symptoms.
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Affiliation(s)
- Mohammad Kermansaravi
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran; Center of Excellence of European Branch of International Federation for Surgery of Obesity, Hazrat_e Rasool Hospital, Tehran, Iran.
| | - Ali Kabir
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Ali Mousavimaleki
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Abdolreza Pazouki
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran; Center of Excellence of European Branch of International Federation for Surgery of Obesity, Hazrat_e Rasool Hospital, Tehran, Iran
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Kassir R, Petrucciani N, Debs T, Juglard G, Martini F, Liagre A. Conversion of One Anastomosis Gastric Bypass (OAGB) to Roux-en-Y Gastric Bypass (RYGB) for Biliary Reflux Resistant to Medical Treatment: Lessons Learned from a Retrospective Series of 2780 Consecutive Patients Undergoing OAGB. Obes Surg 2020; 30:2093-2098. [DOI: 10.1007/s11695-020-04460-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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