Mid-long-term Revisional Surgery After Sleeve Gastrectomy: a Systematic Review and Meta-analysis

Trends in bariatric surgery revisions: a 25-year single-institution experience

BACKGROUND

Revisional bariatric surgery (RBS) is now the third most performed metabolic and bariatric surgery (MBS) in the USA. This study aims to describe trends in MBS revisions at a single large academic institution over 25 years.

METHODS

We identified patients who underwent an MBS revision between 2000 and 2024 at a single large quaternary referral center from a prospectively maintained database. We retrospectively reviewed the electronic medical records to collect pertinent data related to MBS history and conducted a descriptive review of the data to evaluate trends.

RESULTS

A total of 667 patients underwent a first-time bariatric surgery revision; 364 (54.5%) performed surgically and 303 (45.5%) endoscopically. There was a noticeable trend toward endoscopic revisions indicated for weight-related indications, particularly over the past decade. For surgical revisions, Roux-en-Y gastric bypass (RYGB) was the most revised primary MBS operation overall, surpassed by sleeve gastrectomy (SG) in recent years. A greater diversity of indications was observed for surgical compared with endoscopic revisions. Additionally, 14.9% of patients required more than one bariatric revision procedure.

CONCLUSION

Bariatric surgery revisions are increasingly common, highlighting the chronicity of obesity and the need for long-term management. We identified general trends over time toward therapeutic interventions increasingly utilizing minimally invasive surgery and transoral endoscopic techniques. Transoral endoscopic revisions were primarily used for weight-related indications after RYGB, with many other indications managed exclusively through surgery.

Gastroesophageal reflux disease symptoms after sleeve gastrectomy with anterior hemifundoplication: a pilot study

BACKGROUND

Gastroesophageal reflux disease (GORD) is a significant problem after laparoscopic sleeve gastrectomy (SG). This study aimed to assess the long-term effect of SG with an anterior fundoplication on GORD symptoms.

METHODS

A single-centre cohort study of all patients who underwent SG with anterior hemifundoplication (SGAF), with a 2:1 SG only comparison group. GORD symptoms were assessed using a structured symptom questionnaire.

RESULTS

SGAF was performed in 36 patients between 2010 and 2015; 26 patients were available for follow-up and 17 of these were followed up for more than 6 years. The comparison group included 53 consecutive contactable patients who underwent SG without fundoplication during the same period. The two patient groups were similar with regard to pre-operative factors, weight loss, and weight regain. After 6 years, 12 (71%) of SGAF patients reported no GORD symptoms compared to 9 (17%) of SG patients. GORD symptoms were no worse in 21 (81%) following SGAF, whereas GORD symptoms worsened (worse or new symptoms) in 22 (58.5%) of patients after SG. PPI use was similar in both groups. Eight of 26 (31%) SGAF patients had some degree of fundoplication dilatation and underwent conversion to SG or RYGB.

CONCLUSIONS

SGAF provided superior control of symptomatic GORD than SG in this study. Fundoplication dilatation treated by conversion to standard SG was not uncommon and was the reason for suspending this series. Reducing intragastric pressure and reducing fundoplication volume may alleviate this problem, which may also be overestimated in this pilot study.

Postoperative outcomes following revision or conversion surgery after primary sleeve gastrectomy: an analysis of the MBSAQIP database

BACKGROUND

A significant proportion of patients that undergo primary sleeve gastrectomy (SG) require revision or conversion metabolic and bariatric surgery (MBS). Despite various procedures performed in practice, comparative analyses of short-term outcomes remain limited.

OBJECTIVES

We conducted a retrospective comparative analysis of postoperative outcomes of revision or conversion MBS following primary SG.

SETTING

The 2020-2022 MBSAQIP database.

METHODS

We included patients who underwent any one of the following: revision SG (Re-SG), Roux-en-Y gastric bypass (SG-RYGB), biliopancreatic diversion/duodenal switch (SG-BPD/DS), single anastomosis duodenoileal bypass (SG-SADI), or one anastomosis gastric bypass (SG-OAGB). Our primary outcome was 30-day major complications, defined as Clavien-Dindo Grade≥ II.

RESULTS

Among 33,348 revision/conversion MBS, SG-RYGB was the most common (n = 27,393, 82.1%). Compared to SG-RYGB, the odds of 30-day major complications were lower in Re-SG (odds ratio [OR] .75, 95%- confidence interval [CI] .61-.90) and SG-SADI (OR .75, 95%-CI .57 - .97). However, both Re-SG and SG-SADI were associated with higher odds of anastomotic or staple line leak (OR 2.74; 95%-CI 1.78-4.12 and OR 2.44; 95%-CI 1.35-4.17, respectively). In addition, both Re-SG (mean difference 1.66 days, 95%-CI .44 - 2.88) and SG-SADI (MD 3.0 days, 95%-CI 1.31- 4.70) resulted in longer hospital stays upon readmission.

CONCLUSIONS

In our analysis, Re-SG and SG-SADI had lower odds of 30-day major complications compared to SG-RYGB, but had significantly higher odds of anastomotic or staple line leak and had longer hospital stays on readmission. Given its limited indications and significant potential morbidity, Re-SG should not be routinely offered as a revisional procedure for primary SG.

What Is Long-Term Follow-Up in Bariatric Surgery? A Proposal

Gastric bypass surgery is a highly effective treatment for morbid obesity, offering significant and sustained weight loss and improvement in comorbid conditions. However, the long-term success of this intervention is closely tied to robust postoperative follow-up care. Currently, there is a lack of consensus on the definitions of medium- and long-term follow-up, complicating the comparison of outcomes across studies. This inconsistency, coupled with challenges in patient adherence and healthcare infrastructure, emphasizes the need for better-defined follow-up periods and increased monitoring over time. This commentary addresses the critical need for standardized definitions and practices in medium- and long-term follow-up to optimize patient outcomes.

Investigating the Results of One Anastomosis Gastric Bypass After Primary Metabolic and Bariatric Restrictive Procedures

BACKGROUND

Previous studies showed a high conversion rate and failure of restrictive procedures, including sleeve gastrectomy (SG), adjustable gastric banding (AGB), gastric plication (GP), and vertical banded gastroplasty (VBG) in a long-term follow-up. The current study aims to evaluate the efficacy and safety of a revisional one anastomosis gastric bypass (OAGB) for weight loss and treatment of obesity-related problems after primary metabolic and bariatric restrictive procedures.

METHODS

A retrospective study on prospectively collected data was conducted on a sample of 151 patients who experienced insufficient weight loss or weight regain after primary restrictive surgeries and underwent OAGB as a revisional procedure.

RESULTS

A total of 151 patients with a history of previous restrictive metabolic and bariatric surgery who underwent a revisional OAGB were included in this study. The restrictive procedures consisted of SG (n = 79), AGB (n = 45), GP (n = 15), and VBG (n = 12). Total weight loss percent (%TWL) after the revisional OAGB was 27.03 ± 9.12, 27.74 ± 10.05, 24.62 ± 9.87, and 24.34 ± 8.05 after 12, 24, 60, and 84 months, respectively. After 24 months of follow-up, TWL was significantly higher in the GP group compared to the AGB group. However, weight loss outcomes were not significantly different after 60 months of follow-up. The revisional OAGB was associated with a significant resolution of obesity-related problems, including type 2 diabetes (55.55%), hypertension (50%), dyslipidemia (77%), and obstructive sleep apnea (100%) after 2 years of follow-up. There was no serious complication after the revisional OAGB in the short- and long-term follow-up.

CONCLUSION

OAGB is an efficient and safe option as a conversion surgery after restrictive procedures.

Long-term results of Roux-en-Y gastric bypass (RYGB) versus single anastomosis duodeno-ileal bypass (SADI) as revisional procedures after failed sleeve gastrectomy: a systematic literature review and pooled analysis

PURPOSE

Revisional bariatric surgery (RBS) has flourished during the last decades in many countries, due to suboptimal weight loss or long-term complications of primary bariatric surgery. Restrictive procedures, and in particular sleeve gastrectomy (SG), although widely performed as primary bariatric surgery, seems particularly prone to need surgical revision for the above-mentioned reasons during long-term follow-up. The aim of this systematic review was to compare the long-term (5-year) safety and efficacy between Roux-en-Y gastric bypass (RYGB) and single anastomosis duodeno-ileal bypass (SADI) after 'failed' SG.

METHODS

A systematic review was performed from 2007 to September 2024. Articles were included if SADI or RYGB were performed as RBS after 'failed SG' with follow-up at least 5 years. Pooled analysis was performed to summarize the data.

RESULTS

Among the seven studies eligible and included in this review, the SADI procedure showed comparable results to RYGB in terms of weight loss, nutritional deficiencies, and resolution of comorbidities during the long-term follow-up. However, RYGB proved superior in terms of remission of reflux disease and other functional problems after SG.

CONCLUSIONS

The present review found that SADI seems to be a promising and suitable method for suboptimal weight loss after SG, with comparable or even better results to RYGB after 5-year follow-up.

Surgical treatment strategies for gastroesophageal reflux after laparoscopic sleeve gastrectomy

Bariatric surgery has emerged as an effective therapeutic approach for combating obesity. As the most commonly performed bariatric surgery, laparoscopic sleeve gastrectomy (LSG) has a long-term and effective outcome in weight reduction. However, studies have reported an increased incidence of gastroesophageal reflux disease (GERD) among patients after LSG. For those who fail to respond to conventional oral acid-suppressing medication, surgical intervention comes into consideration. The most commonly performed revisional surgery for sleeve gastrectomy is the Roux-en-Y gastric bypass, which can effectively alleviate the symptoms of reflux in patients and also continues to promote weight loss in patients who have not achieved satisfactory results or have experienced weight regain. In addition to this established procedure, innovative techniques such as laparoscopic magnetic sphincter augmentation (MSA) are being explored. MSA is less invasive, has good reflux treatment outcomes, and its safety and efficacy are supported by the literature, making it a promising tool for the future treatment of gastroesophageal reflux. This article also explores the role of endoscopic interventions for GERD treatment of post-sleeve gastrectomy patients. Although these methods have shown some therapeutic effect, their efficacy still requires further study due to a lack of support from more clinical data. For patients with preoperative hiatal hernia or gastroesophageal reflux symptoms, some experts now consider performing LSG combined with hiatal hernia repair or fundoplication to alleviate or prevent postoperative reflux symptoms. Both of these surgical approaches have demonstrated favorable outcomes; however, the addition of fundoplication requires further investigation regarding its long-term effects and potential postoperative complications. This article gathers and examines the current laparoscopic and endoscopic treatments for refractory gastroesophageal reflux following LSG, as well as the concurrent treatment of LSG in patients with preoperative gastroesophageal reflux or hiatal hernia.

Comparative Safety and Efficacy of Roux-en-Y Gastric Bypass Versus One-Anastomosis Gastric Bypass: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Obesity has become a global epidemic, affecting both developed and developing nations. Despite extensive efforts, historical outcomes of medical interventions for obesity have been unsatisfactory. Bariatric surgeries, including sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB), are now recognized as the primary treatment for severe obesity. However, laparoscopic one-anastomosis gastric bypass (OAGB) has emerged as a promising alternative, offering simplified procedures compared to RYGB. While OAGB's initial outcomes are optimistic, concerns about biliary reflux persist. Our systematic review aims to compare the safety and efficacy outcomes of RYGB and OAGB to inform clinical decision-making in managing obesity. We searched five databases up to February 2024. We included randomized controlled trials (RCTs) comparing RYGB and OAGB in obese patients, focusing on safety and efficacy outcomes. Data extraction covered study details, participant demographics, interventions, and outcomes related to operative details, complications, follow-up results, and weight changes. The risk of bias was assessed using the Cochrane tool. The analysis involved risk ratios for dichotomous data and mean differences for continuous data, using fixed or random effects models based on heterogeneity. Analyses were performed with Review Manager software v5.4. A total of 1057 patients were included in the analysis, sourced from 12 distinct RCTs. The analysis indicated OAGB outperformed RYGB in BMI reduction (MD = -0.69, p = 0.005), whereas RYGB was more effective in excess weight loss (MD = 6.51, p < 0.0001) and excess BMI loss (MD = 3.91, p < 0.0001). OAGB led to shorter operation times (MD = -34.89 minutes, p < 0.0001) and shorter periods of hospital stays (MD = -0.27 days, p = 0.01), along with fewer overall complications (RR = 0.58, p = 0.02) and lower incidence of upper gastrointestinal endoscopy complications (RR = 2.98, p = 0.0001). On the other hand, RYGB showed higher remission rates for dyslipidemia (RR = 0.60, p = 0.0003) and higher remissions of hypertension (RR = 0.83, p = 0.04). The majority of results were homogenous. Both OAGB and RYGB have their respective advantages and limitations. OAGB appears to offer benefits in terms of operation efficiency and early postoperative recovery, making it a potentially preferable option for patients and surgeons focused on these aspects. On the other hand, RYGB might be more suitable for patients prioritizing long-term weight loss and remission of certain comorbidities like hypertension. Ultimately, the choice between OAGB and RYGB should be made on an individual basis, considering the specific needs, conditions, and goals of each patient.

Increased staple line leak rates following re-sleeve: analysis comparing re-sleeve versus Roux-en-Y gastric bypass conversion and primary sleeve gastrectomy

BACKGROUND

Sleeve gastrectomy is the most common bariatric procedure and its long-term complications include inadequate weight loss, weight regain, and de novo GERD, often requiring revisional surgery. Revisions, notably re-sleeve and conversion to Roux-en-Y gastric bypass (RYGB), are frequently performed, but safety data is limited. Herein, we used the MBSAQIP database to compare 30 day outcomes of primary sleeve gastrectomy (SG) with re-sleeve (RS) and SG to RYGB conversion.

METHODS

Patients who underwent primary SG, RS, and SG to RYGB conversion within the MBSAQIP data registry from January 1, 2020 to December 31, 2022 were included in this study. Using Propensity Score Matching analysis, the cohorts were matched for 23 preoperative characteristics. We then compared 30 day postoperative outcomes and bariatric-specific complications between primary SG and RS (analysis 1) and between RS and SG to RYGB conversion (analysis 2).

RESULTS

A total of 302,961 were included. The matched cohorts in analysis 1 (n = 1630) and analysis 2 (n = 1633) had similar pre-operative characteristics. Propensity-matched outcomes in analysis 1 showed that patients in the RS group had significantly higher staple line leak (1.3% vs. 0.1%, p < 0.001) when compared to primary SG. Similarly, longer operative times (90.16 ± 51.90 min vs. 68.32 ± 37.54 min, p < 0.001) and higher rates of readmissions (5.5% vs. 2.1%, p < 0.001), reoperations (2.3% vs. 0.6%, p < 0.001), interventions (2.5% vs. 0.4%, p < 0.001) were found in those who underwent RS. In analysis 2, RS showed higher leak rates (1.3% vs. 0.5%, p = 0.015) when compared to conversion from SG to RYGB.

CONCLUSION

The RS group has a higher risk of staple line leaks compared to primary SG and conversion from SG to RYGB. In our study, there was a 2.6-fold increase in staple line leak after re-sleeve compared to RYGB conversion and a 13-fold increase compared to primary SG.

Management of Gastroesophageal Reflux Disease after Sleeve Gastrectomy: Effectiveness of Medical, Endoscopic, and Surgical Therapies

Introduction: Sleeve gastrectomy (SG) has become the most frequently performed bariatric operation in the United States. One of the main disadvantages of this procedure is the risk of developing gastroesophageal reflux disease (GERD) after the operation. We aimed to analyze different approaches for the treatment of GERD after SG. Methods: A literature review was performed to identify all possible treatment options for post-SG GERD. All the studies were assessed for full eligibility by manual assessment of their aims, methodology, results, and conclusions. Records were individually reviewed by the authors comparing outcomes and complications between procedures. Results: Although some studies have shown improvement or even resolution of GERD symptoms after SG, most patients develop or worsen symptoms. Lifestyle modifications along with medical therapy should be started on patients with GERD after SG. For those who are refractory to medication, endoscopic and surgical therapies can be offered. Conversion to Roux-en-Y gastric bypass (RYGB) is consistently effective in treatment of GERD and is the ideal therapy in patients with associated insufficient weight loss. Endoscopic and alternative surgical procedures are also available and have shown acceptable short-term outcomes. Conclusions: Several treatment options exist for the treatment of GERD after SG. Although conversion to RYGB remains the most effective therapy, other emerging endoscopic and surgical procedures could avoid the potential morbidity of this procedure and should be further evaluated. An evidence-based algorithm for the management of GERD after SG is proposed to guide decision making.

Outcomes following reoperative bariatric surgery following laparoscopic sleeve gastrectomy at a tertiary care centre

INTRODUCTION

Laparoscopic sleeve gastrectomy (SG) is the most common bariatric surgical procedure worldwide. Approximately 20%-30% of patients present with weight loss failure or reflux following SG, which might require reoperative surgery. We present the surgical outcomes and complications following reoperative bariatric surgery at a tertiary care centre.

PATIENTS AND METHODS

Prospectively collected data of all patients undergoing reoperative bariatric surgery from 2008 to 2021 were analysed retrospectively. Weight loss, resolution of comorbidities and complications following reoperative surgery were evaluated.

RESULTS

Twenty-six patients were included in the study. The mean age was 38.8 (10.8) years. The primary procedure performed was laparoscopic SG in all cases. Nine patients underwent Roux en Y gastric bypass (RYGB) (one banded RYGB) and 14 underwent one anastomosis gastric bypass (OAGB) (three-banded OAGB). Three patients underwent resleeve. The most common indication was weight loss failure (65.3%). Fifteen patients were diagnosed to have hiatal hernia intraoperatively and concomitant repair was performed. The mean body mass index before revision surgery was 42.7 (9.8). It was 32.6 (5.7) kg/m2 and 33.0 (6.1) kg/m2 at 1 and 3 years, respectively. Age and pre-revision surgery excess weight correlated with weight loss (r = -0.79 and r = 0.99, respectively). Leak and bleeding occurred in one and two patients, respectively. There were two band-related complications and one 30-day mortality.

CONCLUSION

Re-operative bariatric surgery following SG has adequate weight loss with acceptable complication rates. Band placement in re-operative surgery might lead to a higher complication rate.

30-day morbidity and mortality of revisional bariatric surgery - An international multi-centre collaborative (BROAD) study

INTRODUCTION

Revisional bariatric surgery (RBS) for insufficient weight loss/weight regain or metabolic relapse is increasing worldwide. There is currently no large multinational, prospective data on 30-day morbidity and mortality of RBS. In this study, we aimed to evaluate the 30-day morbidity and mortality of RBS at participating centres.

METHODS

An international steering group was formed to oversee the study. The steering group members invited bariatric surgeons worldwide to participate in this study. Ethical approval was obtained at the lead centre. Data were collected prospectively on all consecutive RBS patients operated between 15th May 2021 to 31st December 2021. Revisions for complications were excluded.

RESULTS

A total of 65 global centres submitted data on 750 patients. Sleeve gastrectomy (n = 369, 49.2 %) was the most common primary surgery for which revision was performed. Revisional procedures performed included Roux-en-Y gastric bypass (RYGB) in 41.1 % (n = 308) patients, One anastomosis gastric bypass (OAGB) in 19.3 % (n = 145), Sleeve Gastrectomy (SG) in 16.7 % (n = 125) and other procedures in 22.9 % (n = 172) patients. Indications for revision included weight regain in 615(81.8 %) patients, inadequate weight loss in 127(16.9 %), inadequate diabetes control in 47(6.3 %) and diabetes relapse in 27(3.6 %). 30-day complications were seen in 80(10.7 %) patients. Forty-nine (6.5 %) complications were Clavien Dindo grade 3 or higher. Two patients (0.3 %) died within 30 days of RBS.

CONCLUSION

RBS for insufficient weight loss/weight regain or metabolic relapse is associated with 10.7 % morbidity and 0.3 % mortality. Sleeve gastrectomy is the most common primary procedure to undergo revisional bariatric surgery, while Roux-en-Y gastric bypass is the most commonly performed revision.

Laparoscopic sleeve gastrectomy vs one-anastomosis gastric bypass 5-year follow-up: a single-blinded randomized controlled trial

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is the most performed bariatric procedure worldwide, whereas one-anastomosis gastric bypass (OAGB) is the third most performed procedure. Both procedures have reported good weight loss (WL) and low complications. However, should both have differences in the durability of WL and malnutrition?

METHODS

A single-blinded, randomized controlled trial of 300 patients was conducted to compare the outcomes of LSG and OAGB over a 5-year follow-up. The primary endpoint was WL in percentages of total WL (%TWL) and excess WL (%EWL). The secondary endpoints were complications, gastroesophageal reflux disease (GERD), associated medical problems, bariatric analysis and reporting outcome system (BAROS) assessment, and weight recurrence (WR).

RESULTS

Overall, 201 patients (96 in the LSG group and 105 in the OAGB group) completed 5 years of follow-up. OAGB had significantly higher %TWL and %EWL than those of LSG throughout the follow-up. LSG had significantly higher WR and GERD. Both procedures had significant improvement in associated medical problems and BAROS scores compared with baseline, with no significant difference. WR was associated with higher relapse of associated medical conditions after initial remission and with lower BAROS scores regarding WL scores.

CONCLUSION

OAGB had significantly higher WL, less WR, and less GERD. However, it had a higher incidence of bile reflux. Both procedures had comparable complication rates, excellent remissions in associated medical problems, and improved quality of life. WR was associated with significantly more relapse of associated medical problems and significantly lower BAROS scores.

Outcomes of primary versus conversional Roux-En-Y gastric bypass after laparoscopic sleeve gastrectomy: a retrospective propensity score-matched cohort study

BACKGROUND

Conversional surgery is common after laparoscopic sleeve gastrectomy (LSG) because of suboptimal weight loss (SWL) or poor responders and gastroesophageal reflux disease (GERD). Roux-en-Y gastric bypass (RYGB) is the most common conversional procedure after LSG.

METHODS

A retrospective cohort study analyzed patients who underwent primary RYGB (PRYGB) or conversional RYGB (CRYGB) at three specialized bariatric centers between 2008 and 2019 and tested for weight loss, resolution of GERD, food tolerance (FT), early and late complications, and the resolution of associated medical problems. This was analyzed by propensity score matching (PSM).

RESULTS

In total, 558 (PRYGB) and 155 (CRYGB) completed at least 2 years of follow-up. After PSM, both cohorts significantly decreased BMI from baseline (p < 0.001). The CRYGB group had an initially more significant mean BMI decrease of 6.095 kg/m2 at 6 months of follow-up (p < 0.001), while the PRYGB group had a more significant mean BMI decrease of 5.890 kg/m2 and 8.626 kg/m2 at 1 and 2 years, respectively (p < 0.001). Food tolerance (FT) improved significantly in the CRYGB group (p < 0.001), while CRYGB had better FT than PRYGB at 2 years (p < 0.001). A GERD resolution rate of 92.6% was recorded in the CRYGB (p < 0.001). Both cohorts had comparable rates of early complications (p = 0.584), late complications (p = 0.495), and reoperations (p = 0.398). Associated medical problems at 2 years significantly improved in both cohorts (p < 0.001).

CONCLUSIONS

CRYGB is a safe and efficient option in non- or poor responders after LSG, with significant weight loss and improvement in GERD. Moreover, PRYGB and CRYGB had comparable complications, reoperations, and associated medical problem resolution rates.

Boosting weight loss after conversional Roux-en-Y Gastric Bypass with liraglutide and placebo use. A double-blind-randomized controlled trial

BACKGROUND

Conversional bariatric surgery inherently has less weight loss (WL) compared to primary procedures. Adjunctive use of the GLP-1 analog, liraglutide with conversional Roux-en-Y Gastric Bypass (cRYGB) may maximize the WL benefits of surgery.

MATERIAL AND METHODS

This single-center randomized double-blind placebo-controlled trial included 80 patients randomized into two groups; the liraglutide group (40 patients) who received daily injections of liraglutide, and the placebo group (40 patients) who received normal saline starting at 6 weeks from cRYGB and continued for 6 months. After discontinuing the drugs at 6 months and unblinding, the patient were followed up to 12 months. The endpoints were percentage of total weight loss (%TWL) and percentage of excess weight loss (%EWL), and changes in the metabolic biomarkers, and complications within 30 and 90 days according to the global outcome benchmark (GOB) stratification.

RESULTS

In total, 38 patients in the liraglutide group and 31 in the placebo group completed the 24 weeks. Liraglutide group experienced better WL with a significantly higher mean %TWL at 1 month (10.27±1.39 vs. 8.41±2.08), at 6 weeks (12.65±1.77 vs. 10.47±2.23), at 6 months (18.29 ±1.74 vs. 15.58 ±1.65), and at 12 months 24.15±2.35 versus 22.70±2.13 (all P <0.001). For %EWL, this was also significantly higher in the liraglutide group at all time points. A %TWL of greater than 20% at 6 months of treatment was recorded in six (15.8%) patients in the liraglutide group and none in the placebo group ( P =0.029). Both groups had comparable changes in metabolic biomarkers. Adverse events were recorded in 11 (27.5%) patients in the liraglutide, with no adverse events in the placebo group ( P <0.001). Both groups had Clavien-Dindo scores I and II (5.0 and 2.5%), and GOB values indicated that 90.0 and 97.5% were low-risk patients.

CONCLUSION

Adjunctive use of liraglutide with cRYGB gives significantly higher WL and resolution of associated medical problems.

One Anastomosis Gastric Bypass as Revisional Surgery Following Sleeve Gastrectomy: A Systematic Review and Meta-Analysis

BACKGROUND

Although sleeve gastrectomy (SG) is the most performed metabolic and bariatric surgery (MBS) worldwide, some patients require conversional procedures due to weight recurrence or late complications. Recently, one-anastomosis gastric bypass (OAGB) gained popularity as a viable option to address those problems. The aim of this meta-analysis is to assess the safety and efficacy of conversional OAGB after primary SG in the management of patients with obesity.

METHODS

Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to February 2023 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42023403528).

RESULTS

From 1,117 studies screened, twenty studies met the eligibility criteria, with a total of 1,057 patients with obesity undergoing conversional OAGB after primary SG. The mean age ranged from 28.2 to 49.5 years, and 744 patients (75.2%) were women. At one year after revisional OAGB, the pooled mean percent excess weight loss (%EWL) was 65.2% (95%CI: 56.9, 73.4, I2 = 97%). The pooled mean %EWL after conversional OAGB was 71.1% (95%CI: 62.2, 80.0, I2 = 90%) at two years and 71.6% (95%CI: 61.0, 82.2, I2 = 50%) at five years. Additionally, resolution rates of diabetes and hypertension were 65.4% (95%CI: 0.522, 0.785, I2 = 65%) and 58.9% (95%CI: 0.415, 0.762, I2 = 89%), respectively.

CONCLUSIONS

Our meta-analysis demonstrated OAGB as an effective conversional procedure after primary SG in terms of weight loss and obesity-associated medical problems for selected patients. Despite the promising results, further randomized controlled studies with larger sample sizes and more extended follow-up periods are necessary to determine if the OAGB is the best conversional surgery after SG.

ReSleeve or revisional one anastomosis gastric bypass for failed primary sleeve gastrectomy with dilated gastric tube: a retrospective study

BACKGROUND

Revisional bariatric surgery (RBS) has been increasingly performed due to weight loss failure (WLF). Many revisional procedures have been proposed after primary laparoscopic sleeve gastrectomy (pLSG) failure, including ReSleeve gastrectomy (ReLSG), and laparoscopic one anastomosis gastric bypass (LOAGB). Choosing the RBS post-pLSG failure represents a challenge. WLF without gastric tube (GT) dilation is undoubtedly converted to a malabsorptive procedure, but the presence of GT dilation makes it more difficult to select a RBS. This study aimed to compare two relatively simple revisional procedures after pLSG failure with dilated GT to help decision making on which procedure better done to which patient.

METHODS

Data of 52 patients who completed one year follow-up (FU) after their RBS (ReLSG: 27 or LOAGB: 25) for their failed pLSG were collected, assessed, correlated to weight loss (WL) and compared.

RESULTS

Mean operative time was 97 ± 18.4 min. with revisional LOAGB (RLOAGB) and 62 ± 11 min. with ReLSG. Six patients (11.5%) had seven postoperative procedure-specific complications. Significant hemorrhage occurred in three patients. Two cases of leakage were encountered with each procedure. LOAGB Patients had lower mean final weight (76.2 ± 10.5 vs 85.3 ± 13), lower mean Final BMI (26.4 ± 2.5 vs 29.7 ± 2.9) and higher mean percentage of excess weight loss (EWL%) (83.6 ± 13.5% vs 60.29 ± 14.6%). All RLOAGB patients and 77.8% of ReLSG patients had EWL% > 50%. RLOAGB patients had higher EWL% compared to ReLSG (p < 0.001). Insufficient WL (IWL) patients had higher EWL% compared to weight regain (WR) patients (p = 0.034).

CONCLUSION

Both procedures (RLOAGB and ReLSG) were relatively safe and effective in terms of WL. RLOAGB led to higher WL compared to ReLSG in all types of patients despite higher Caloric intake. IWL patients had more WL compared to WR patients. WL was not related to GT dilation type. Large-scale longer-FU studies are still needed.

TRIAL REGISTRATION

PACTR202310644487566 (retrospectively registered).

Bariatric Surgery in Obesity: Metabolic Quality Analysis and Comparison of Surgical Options

Obesity is a constantly growing health problem which reduces quality of life and life expectancy. Bariatric surgery (BS) for obesity is considered when all other conservative treatment modalities have failed. Comparison of the multidisciplinary programs with BS regarding to the weight loss showed that substantial and durable weight reduction have been achieved only with bariatric surgical treatments. Although laparoscopic sleeve gastrectomy is the most popular BS, it has high long-term failure rates, and it is claimed that one of every three patients will undergo another bariatric procedure within a 10-year period. Although BS provides weight loss and improvement of metabolic comorbidities, in long-term follow-up, weight gain is observed in half of the patients, while decrease in bone mass and nutritional deficiencies occur in up to 90%. Moreover, despite significant weight loss, several psychological aspects of patients are worsened in comparison to preoperative levels. Nearly one-fifth of postoperative patients with "Loss-of-eating control" meet food addiction criteria. Therefore, the benefits of weight loss following bariatric procedures alone are still debated in terms of the proinflammatory and metabolic profile of obesity.

The Efficacy and Safety of Laparoscopic Single-Anastomosis Duodeno-ileostomy with Sleeve Gastrectomy (SADI-S) in Mid- and Long-Term Follow-Up: a Systematic Review

This systematic review of 10 studies aimed to investigate the mid- and long-term results of duodeno-ileostomy with sleeve gastrectomy (SADI-S) according to the PRISMA guideline. Related articles, which reported outcomes of laparoscopic SADI-S with follow-up ≥ 3 years, were selected and analyzed. The percentage of excess weight loss (EWL) was 70.9-88.7%, and 80.4% at 6, and 10 years, respectively. The more common late complications were malabsorption (6.3%) and gastroesophageal reflux disease (GERD) (3.6%). The remission rates of hypertension, diabetes, GERD, obstructive sleep apnea, and dyslipidemia were 62.9%, 81.3%, 53.2%, 60.9%, and 69.7%, respectively. In conclusion, SADI-S is a safe and effective surgical technique with durable weight loss and a high rate of comorbidity resolution in mid and long term.

Trends and safety of bariatric revisional surgery in Italy: multicenter, prospective, observational study

BACKGROUND

Revisional bariatric surgery (RBS) represents a further solution for patients who experience inadequate weight loss (IWL) following primary bariatric surgery (BS) or significant weight regain (WR) following initial satisfactory response. RBS guidelines are lacking; however, an increased trend in further BS offerings has been reported recently.

OBJECTIVE

Analyze trend, mortality, complication, readmission, and reoperation rates for any reason at 30 days after RBS in Italy.

SETTING

Ten Italian high-volume BS centers (university hospitals and private centers).

METHODS

Prospective, observational, multicenter study enrolling patients undergoing RBS between October 1, 2021, and March 31, 2022, registering reasons for RBS, technique, mortality, intraoperative and perioperative complications, readmissions, and reinterventions for any reason. Patients undergoing RBS during the same calendar interval in 2016-2020 were considered control patients.

RESULTS

A total of 220 patients were enrolled and compared with 560 control-group patients. Mortality was .45% versus .35% (n.s), with an overall mortality of .25%, while open surgery or conversion to open surgery was registered in 1%. No difference was found for mortality, morbidity, complications, readmission (1.3%), and reoperation rates (2.2%). IWL/WR was the most frequent cause, followed by gastroesophageal reflux disease; Roux-en-Y gastric bypass was the most used revisional procedure (56%). Sleeve gastrectomy was the most revised procedure in the study group, while gastric banding was the most revised in the control group. RBS represents up to 9% of the total BS in the Italian participating centers.

CONCLUSIONS

Laparoscopy represents the standard approach for RBS, which appears safe. Current Italian trends show a shift toward sleeve gastrectomy being the most revised procedure and Roux-en-Y gastric bypass being the most frequent revisional procedure.

Outcome of Revisional Bariatric Surgery After Failed Sleeve Gastrectomy: a German Multicenter Study

PURPOSE

Sleeve gastrectomy (SG) is a common bariatric procedure that has been shown to be effective in both the short and long term, but it is not without risks, some of which necessitate revision or redo surgery (RS).

MATERIALS AND METHODS

GBSR (German Bariatric Surgery Registry) data were evaluated in this multicenter analysis. Short-term results (1-year follow-up) of RS (Re-Sleeve gastrectomy, Roux-en-Y gastric bypass, RYGB, Omega-loop gastric bypass, OLGB, and duodenal switch, DS) following primary SG (n = 27939) were evaluated.

RESULTS

Of PSG patients, 7.9% (n=2195) needed revision surgery. Nine hundred ninety-four patients underwent the aforementioned four surgical procedures (95 with R-SG, 665 with RYGB, 141 with OLGB, and 93 DS). Loss of follow-up within 1 year 52.44%. The most common reasons for RS were weight regain and/or a worsening of preexisting comorbidities. Regarding the operating time, R-SG was the shortest of the four procedures, and DS was the longest. In general, there were no significant advantages of one procedure over another in terms of complication incidence in these categories. However, certain complications were seen more often after R-SG and DS than with other redo procedures. There were significant differences in BMI reduction 1 year after surgery (RYGB: 5.9; DS: 10.1; OLGB: 9.1; and R-SG: 9.1; p<0.001). GERD, hypertension, and sleep apnea demonstrated statistically significant comorbidity remission. Diabetes exhibited non-significant differences.

CONCLUSION

According to the findings of our study, all revision surgeries effectively resolved comorbidities, promoted weight loss, and lowered BMI. Due to the disparate outcomes obtained by various methods, this study cannot recommend a particular redo method as the gold standard. Selecting a procedure should consider the redo surgery's aims, the rationale for the revision, the patient's current state, and their medical history.

Is one-anastomosis gastric bypass a good revisional bariatric surgery? A single-center retrospective cohort study

<b><br>Introduction:</b> The rate of revisional surgeries following sleeve gastrectomy (SG) has increased. One-anastomosis gastric bypass (OAGB) appears to have multiple advantages as a primary bariatric procedure. OAGB as revisional surgery is still being investigated.</br> <b><br>Aim:</b> Evaluation of the efficacy and safety of OAGB performed as a post-SG revisional surgery.</br> <b><br>Materials and methods:</b> A single-center, retrospective cohort study was conducted using a routinely collected database of adults undergoing revisional OAGB after SG. A survey of patients was conducted, obtaining information on changes in body weight and improvement in gastroesophageal reflux disease (GERD) and obesity-related diseases.</br> <b><br>Results:</b> The study group included 74 patients: 59 women (80%) and 15 men, mean age of 41.61 9.21 years. The most common indication for OAGB was weight regain. The follow-up was up to 7 years, the mean time was 3.58 1.21 years. The mean preoperative body mass index (BMI) was 40.38 6.15. All patients experienced significant weight loss, reaching a BMI of 33.61 (27.28- 37.13) at the last observation. After surgery, 35% of patients achieved successful weight loss and 48% of patients achieved remission or improvement of GERD.</br> <b><br>Conclusions:</b> Revisional OAGB seems to be a good alternative after a failed SG in terms of obesity-related disease recurrence, not of weight regain. Long-term follow-up revealed that only a third of patients achieved successful weight loss. When proposing revisional OAGB, the risk of complications - mainly anemia and the possibility of de novo GERD should be considered.</br>.

Barrett's esophagus and esophageal cancer after sleeve gastrectomy. Myth or reality?

Sleeve gastrectomy has become the most performed bariatric surgery technique in the world. This bariatric technique has been related to the appearance of gastroesophageal reflux and recently with de novo Barrett's esophagus. It is not clear that this leads to an increased incidence of esophageal adenocarcinoma. In this review we analyze the current scientific literature to try to answer the true incidence of Barrett's esophagus and adenocarcinoma after sleeve gastrectomy, and whether these data should make us change the indications for this technique.

Mid-Term Outcomes After Conversion Procedures Following Laparoscopic Sleeve Gastrectomy

PURPOSE

In the long term, laparoscopic sleeve gastrectomy (SG) may be associated with insufficient weight loss (IWL), gastroesophageal reflux disease (GERD), and persistence or relapse of associated medical problems. This study's objective is to present mid-term results regarding weight loss (WL), evolution of associated medical problems, and reoperation rate of patients who underwent a conversion after SG.

METHODS

Retrospective single-center analysis of patients with a minimal follow-up of 2 years after conversion.

RESULTS

In this series of 549 SGs, 84 patients (15.3%) underwent a conversion, and 71 met inclusion criteria. They were converted to short biliopancreatic limb Roux-en-Y gastric bypass (short BPL RYGB) (n = 28, 39.4%), biliopancreatic diversion with duodenal switch (BPD/DS) (n = 19, 26.8%), long biliopancreatic limb Roux-en-Y gastric bypass (long BPL RYGB) (n = 17, 23.9%), and re-sleeve gastrectomy (RSG) (n = 7, 9.9%). Indications were GERD (n = 24, 33.8%), IWL (n = 23, 32.4%), IWL + GERD (n = 22, 31.0%), or stenosis/kinking of the sleeve (n = 2, 2.8%). The mean pre-revisional body mass index (BMI) was 38.0 ± 7.5 kg/m2. The mean follow-up time after conversion was 5.1 ± 3.1 years. The overall percentage of total weight loss (%TWL) was greatest after BPD/DS (36.6%) and long BPL RYGB (32.9%) compared to RSG (20.0%; p = 0.004; p = 0.049). In case of GERD, conversion to Roux-en-Y gastric bypass (RYGB) led to a resolution of symptoms in 79.5%. 16.9% of patients underwent an additional revisional procedure.

CONCLUSION

In the event of IWL after SG, conversion to BPD/DS provides a significant and sustainable additional WL. Conversion to RYGB leads to a reliable symptom control in patients suffering from GERD after SG.

Two-Year Results of the Banded Versus Non-banded Re-sleeve Gastrectomy as a Secondary Weight Loss Procedure After the Failure of Primary Sleeve Gastrectomy: a Randomized Controlled Trial

BACKGROUND

Insufficient weight loss or weight regain has been reported in up to 30% of patients after laparoscopic sleeve gastrectomy (LSG). Approximately 4.5% of patients who undergo LSG need revisional surgery for a dilated sleeve.

METHODS

This randomized controlled trial compared the outcomes between banded (BLSG) and non-banded re-LSG (NBLSG) after weight regain. Percentage excess body weight loss (%EWL), percentage total weight loss (%TWL), associated medical problems, gastric volume measurement, and endoscopy were measured preoperatively and 1 and 2 years postoperatively.

RESULTS

Both groups (25 patients each) achieved similar % EWL and %TWL at six months, one year, and two years postoperatively (%EWL 46.9 vs. 43.6, 83.7 vs. 86.3, and 85.7 vs. 83.9) (p= > 0.151) (%TWL 23.9 vs. 21.8, 43.1 vs .43.3, 44.2 vs. 42.2) (p=>0.342), respectively. However, the body mass index was significantly lower with BLSG (24.9 vs. NBLSG, 26.9). Both groups showed a significant reduction in stomach volume after two years (BLSG -248.4 mL vs. NBLSG -215.8 mL). Food tolerance (FT) scores were significantly reduced in both groups, whereby BSLG had significantly lower FT with an average of -1.1 point. No significant differences were observed regarding improvement of the associated medical problems after the first and two years after revisional LSG or the postoperative complications between both groups.

CONCLUSION

Laparoscopic re-LSG is feasible and safe with satisfactory outcomes in patients with weight regain after LSG who have gastric dilatation without reflux esophagitis. Both groups had comparable significant weight loss effects and improvement of associated medical problems. The BLSG tends to have a more stable weight loss after two years with a significantly lower BMI, lower stomach volume, and less weight regain. Food tolerance decreased in both groups but reduced more in the BLSG group. After a 2-year follow-up, we may regard both procedures are safe, with no significant differences in the occurrence of complications and nutritional deficits.

How Good is Stratification and Prediction Model Analysis Between Primary and Revisional Roux-en-Y Gastric Bypass Surgery? A Multi-center Study and Narrative Review

INTRODUCTIONS

Revision surgery because of weight recurrence is performed in 2.5-33% of primary vertical banded gastroplasty (VBG), laparoscopic sleeve gastrectomy (LSG), and gastric band (GB) cases. These cases qualify for revisional Roux-en-Y gastric bypass (RRYGB).

METHODS

This retrospective cohort study analyzed data from 2008 to 2019. A stratification analysis and multivariate logistic regression for prediction modeling compared the possibility of sufficient % excess weight loss (%EWL) ≥ 50 or insufficient %EWL < 50 between three different RRYGB procedures, with primary Roux-en-Y gastric bypass (PRYGB) as the control during 2 years of follow-up. A narrative review was conducted to test the presence of prediction models in the literature and their internal and external validity.

RESULTS

A total of 558 patients underwent PRYGB, and 338 underwent RRYGB after VBG, LSG, and GB, and completed 2 years of follow-up. Overall, 32.2% of patients after RRYGB had a sufficient %EWL ≥ 50 after 2 years, compared to 71.3% after PRYGB (p ≤ 0.001). The total %EWL after the revision surgeries for VBG, LSG, and GB was 68.5%, 74.2%, and 64.1%, respectively (p ≤ 0.001). After correcting for confounding factors, the baseline odds ratio (OR) or sufficient %EWL ≥ 50 after PRYGB, LSG, VBG, and GB was 2.4, 1.45, 0.29, and 0.32, respectively (p ≤ 0.001). Age was the only significant variable in the prediction model (p = 0.0016). It was impossible to develop a validated model after revision surgery because of the differences between stratification and the prediction model. The narrative review showed only 10.2% presence of validation in the prediction models, and 52.5% had external validation.

CONCLUSION

Overall, 32.2% of all patients after revisional surgery had a sufficient %EWL ≥ 50 after 2 years, compared to PRYGB. LSG had the best outcome in the revisional surgery group in the sufficient %EWL group and the best outcome in the insufficient %EWL group. The skewness between the prediction model and stratification resulted in a partially non-functional prediction model.

Contemporary medical, device, and surgical therapies for obesity in adults

The goal of obesity management is to improve health. Sustained weight loss of more than 10% overall bodyweight improves many of the complications associated with obesity (eg, prevention and control of type 2 diabetes, hypertension, fatty liver disease, and obstructive sleep apnoea), as well as quality of life. Maintenance of weight loss is the major challenge of obesity management. Like all chronic diseases, managing obesity requires a long-term, multimodal approach, taking into account each individual's treatment goals, and the benefit and risk of different therapies. In conjunction with lifestyle interventions, anti-obesity medications and bariatric surgery improve the maintenance of weight loss and associated health gains. Most available anti-obesity medications act on central appetite pathways to reduce hunger and food reward. In the past 5 years, therapeutic advances have seen the development of targeted treatments for monogenic obesities and a new generation of anti-obesity medications. These highly effective anti-obesity medications are associated with weight losses of more than 10% of overall bodyweight in more than two-thirds of clinical trial participants. Long-term data on safety, efficacy, and cardiovascular outcomes are awaited. Long-term studies have shown that bariatric surgical procedures typically lead to a durable weight loss of 25% and rapid, sustained improvements in complications of obesity, although they have not yet been compared with new-generation highly effective anti-obesity medications. Further work is required to determine optimal patient-specific treatment strategies, including combinations of lifestyle interventions, anti-obesity medications, endoscopic and bariatric surgical procedures, and to ensure equitable access to effective treatments.

A Long-Term Comparative Study Between One Anastomosis Gastric Bypass and Sleeve Gastrectomy

BACKGROUND

One anastomosis gastric bypass (OAGB) has become increasingly accepted in bariatric surgery and meanwhile represents the third most common procedure worldwide. While it shows promising weight loss results and comorbidity resolution, questions about issues such as reflux or nutritional deficiencies (ND) persist in the long term. On the other hand, the most frequently performed sleeve gastrectomy (SG) has to accept growing criticism regarding long-term results and reflux issues. There is a particular lack of long-term comparative data for both procedures. This study presents our long-term experience.

METHODS

We evaluated OAGB and SG patients retrospectively comparing for weight loss and resolution of comorbidities as well as perioperative and long-term complications in a follow-up period of 5 years.

RESULTS

Nine hundred eleven OAGB and 241 SG were included in the study. OAGB had a shorter operation time and hospital stay. Overall complication rate did not differ in both groups. Ulcers were more frequent in OAGB (7.7% vs. 1.7%, p = 0.001), whereas insufficient weight loss (IWL)/weight regain (WR) proved to be more prevalent in SG (25.7% vs. 6.4%, p < 0.001). The same held true for reflux (17.8% vs. 8.3%, p < .001). On the other hand, ND were more common in OAGB (20.0% vs. 12.0%, p = 0.005). Revisional surgery was more often indicated after SG. Analysis by linear mixed model showed that OAGB achieved a lower BMI/higher loss of BMI. Improvement of T2DM (94.6% vs. 85.2%, p = 0.008) and sleep apnea (88.8% vs. 78.8%, p = 0.01) was superior in OAGB.

CONCLUSIONS

OAGB had a superior effect on weight loss as well as improvement of T2DM and sleep apnea. Furthermore, long-term problems such as IWL/WR and reflux were more related to SG. On the other hand, a malabsorptive procedure such as OAGB showed a higher risk for ND. Our findings support the available data in the literature.

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

Revisional Roux-en-Y Gastric Bypass Versus Revisional One-Anastomosis Gastric Bypass After Failed Sleeve Gastrectomy: a Randomized Controlled Trial

Background

High rates of revision surgery have been reported for laparoscopic sleeve gastrectomy (LSG), with weight regain (WR) as the most frequently reported cause. Roux-en-Y gastric bypass (RYGB) is the most commonly performed revision procedure, whereas one-anastomosis gastric bypass (OAGB) is a less popular approach.

Methods

A single-blinded randomized controlled trial was conducted. One hundred seventy-six patients were enrolled and randomized. After loss to follow-up, 80 patients for RYGB and 80 patients for OAGB were analyzed, with a 2-year follow-up. Patients with grade B or higher gastroesophageal reflux disease (GERD) were excluded. Early and late postoperative complications were recorded. Body mass index (BMI), percentage of excess BMI loss (%EBMIL), nutritional laboratory test results, and the resolution of associated medical problems were assessed after revision surgery.

Results

After 2 years, both groups achieved significantly lower BMI than their post-LSG nadir BMI (p < 0.001). The %EBMIL changes showed significantly faster weight loss in the OAGB group than in the RYGB at the 6-month follow-up (mean difference: 8.5%, 95% confidence interval [CI]: 0.2 to 16.9%). However, at 1-year and 2-year follow-ups, the differences were statistically insignificant (p > 0.05). Early and late complications were similar between two groups. Both groups showed improvement or resolution of associated medical problems, with no statistically significant differences after 2 years (p = 1.00).

Conclusion

Both revisional RYGB and OAGB have comparable significant weight loss effects when performed for WR after LSG. After a 2-year follow-up, both procedures were safe, with no significant differences in the occurrence of complications and nutritional deficits.

Graphical abstract

Bariatric Surgery Conversions in MBSAQIP Centers: Current Indications and Outcomes

BACKGROUND

The demand for revisional bariatric surgery has increased, and bariatric conversions (BC) to a different procedure represent most of the revisional cases. The 2020 Metabolic and Bariatric Surgery Accreditfnation and Quality Improvement Program (MBSAQIP) database was expanded to include additional variables on BC. This study aims to analyze the indications and outcomes of BC.

METHODS

A retrospective analysis of the 2020 MBSAQIP database was performed. Patients who underwent BC were included in the analysis. Index procedures, rates, and indications for BC of the different bariatric operations were described. Outcomes of the most frequent BC were analyzed.

RESULTS

A total of 168,548 bariatric surgeries were done; 20,387 (12.1%) were revisional, and from those 15,031 (73.7%) were BC. The most converted index operations were sleeve gastrectomy (SG) (49.3%) and adjustable gastric banding (AGB) (45.9%). The most frequent conversions were SG to Roux-en-Y gastric bypass (RYGB) (40.3%) for gastroesophageal reflux disease (GERD) (54.2%) and weight loss failure (WLF) (35.8%), AGB to SG (27%) or RYGB (16.2%) for WLF (67% and 61.3%, respectively), and SG to biliopancreatic diversion with duodenal switch (3.2%) or single anastomosis duodeno-ileal bypass (2%) for WLF (91.2% and 92.4%, respectively). Postoperative overall morbidity, serious morbidity, reoperation, and mortality rates ranged from 5.3 to 20.8%, 2.3 to 19.2%, 1.5 to 10%, and 0 to 0.8%, respectively.

CONCLUSIONS

BC represents the most frequent revisional bariatric procedure. GERD and WLF are the main causes for BC. Further research is needed to define the ideal BC according to the index procedure and indication.

Reference Values for Weight Loss During 1 Year After Sleeve Gastrectomy: a Multicenter Retrospective Study in Japan

INTRODUCTION

This study aimed to provide reference values for the percentage total weight loss during 1 year after laparoscopic sleeve gastrectomy associated with primary response in Japan.

METHODS

This multicenter retrospective study comprised 248 patients with severe obesity who underwent laparoscopic sleeve gastrectomy at five institutions in Japan. A percentage total weight loss < 20% at 1 year was defined as primary non-response. Parsimonious predictive models were developed based on the results of multiple regression analyses. A receiver operating characteristic curve analysis was used to assess the discriminative performance for primary non-response.

RESULTS

The median age, initial body mass index, and percentage total weight loss at 1 year were 41 years, 41.4 kg/m², and 30.1%, respectively. There were 28 (11.3%) primary non-responders. For discriminating primary non-responders, the areas under the receiver operating characteristic curve of the parsimonious model and actual percentage of total weight loss at 3 months after laparoscopic sleeve gastrectomy were 0.846 and 0.803, respectively. Cutoffs for the predicted percentage total weight loss using the model and actual value of percentage total weight loss at 3 months attaining 80% sensitivity were 30% and 22%, and those attaining 98% specificity were 22% and 15%, respectively.

CONCLUSIONS

Reference values for the percentage total weight loss at 3 months were obtained using the predictive model and actual value of percentage total weight loss at 3 months. Patients at risk for primary non-response can be determined at 3 months with these values, which can help in considering earlier interventions.

Long-Term Outcomes of Revisional Malabsorptive Bariatric Surgery: Do the Benefits Outweigh the Risk?

Purpose

To evaluate the long-term outcomes of revisional malabsorptive bariatric surgery.

Materials and Methods

Malabsorptive bariatric procedures are increasingly performed in the revisional setting. We collated and analysed prospectively recorded data for all patients who underwent a revisional Biliopancreatic diversion + / − duodenal switch (BPD + / − DS) over a 17-year period.

Results

We identified 102 patients who underwent a revisional BPD + / − DS. Median follow-up was 7 years (range 1–17). There were 21 (20.6%) patients permanently lost to follow-up at a median of 5 years postoperatively. Mean total weight loss since the revisional procedure of 22.7% (SD 13.4), 20.1% (SD 10.5) and 17.6% (SD 5.5) was recorded at 5, 10 and 15 years respectively. At the time of revisional surgery, 23 (22.5%) patients had diabetes and 16 (15.7%) had hypercholesterolaemia with remission of these occurring in 20 (87%) and 7 (44%) patients respectively. Nutritional deficiencies occurred in 82 (80.4%) patients, with 10 (9.8%) patients having severe deficiencies requiring periods of parenteral nutrition. Seven (6.9%) patients required limb lengthening or reversal procedures. There were 16 (15.7%) patients who experienced a complication within 30 days, including 3 (2.9%) anastomotic leaks. Surgery was required in 42 (41.2%) patients for late complications.

Conclusion

Revisional malabsorptive bariatric surgery induces significant long-term weight loss and comorbidity resolution. High rates of temporary and permanent attrition from follow-up are of major concern, given the high prevalence of nutritional deficiencies. These data question the long-term safety of malabsorptive bariatric procedures due to the inability to ensure compliance with nutritional supplementation and long-term follow-up requirements.

Graphical abstract

Key points

• Revisional bariatric surgery workload is increasing

• Revisional malabsorptive surgery is efficacious for weight loss and comorbidity resolution

• Revisional malabsorptive surgery is associated with high rates of nutritional deficiencies

• Attrition from follow-up in this specific cohort of patients is of particular concern due to the risk of undiagnosed and untreated nutritional deficiencies

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-022-06019-7.

Current Status of Robot-Assisted Revisional Bariatric Surgery

Bariatric surgery has been demonstrated to be effective in achieving significant weight loss and remission of obesity-related comorbidities. However, a percentage of patients fail to lose enough weight, regain weight, or experience postoperative complications, requiring additional interventions. Revisional bariatric surgeries (RBS) involve the wide spectrum of procedures that aim to treat complications of the index operation or achieve further weight loss. These are technically challenging procedures due to adhesions of the internal organs, reduced working space, and a distorted anatomy. Indications, timing, and type of operation for RBS are not standardized, and there is no consensus on the best surgical approach. Some authors claim a robotic platform could be advantageous in these types of procedures that are performed in reduced, deep operating fields, or those requiring precision and accuracy. This review examines the most current and representative literature on the outcomes of robot-assisted RBS. Included studies demonstrate the safety and feasibility of the robotic approach for RBS. However, long operative times and high costs remain major drawbacks of the device. Finally, if we consider that many centers have not yet completed the learning curve for robot-assisted RBS, the potential for improved outcomes seems promising.

Roux-en-Y Versus One Anastomosis Gastric Bypass as Redo-Operations Following Sleeve Gastrectomy: A Retrospective Study

BACKGROUND

Aim of this study was to improve knowledge about the best conversional bariatric procedure following sleeve gastrectomy (SG).

METHODS

Data of conversional Roux-en-Y gastric bypass (RYGB) and of one anastomosis gastric bypass (OAGB) after SG were collected prospectively and analyzed retrospectively. Weight loss parameters, gastroesophageal reflux disease (GERD) and comorbidities outcomes were recorded.

RESULTS

Total of 123 patients (90 female, mean age 44 ± 0.9 years, mean body mass index (BMI) 42 ± 0.8 kg/m²) had either RYGB (n = 68) or OAGB (n = 55). Perioperative mortality was zero. Mean surgery time was significantly shorter for OAGB (168 ± 7.2 vs. 201 ± 6.8 min). Perioperative complication rates were not significantly (ns) different between RYGB and OAGB. Total body weight loss (TBWL) in RYGB and OAGB was 18 ± 2.2% and 18 ± 1.9% (12 months) and 18 ± 3.0% and 23 ± 2.6% (24 months; ns), respectively. Length of (individualized) biliopancreatic limb (BPL) correlated significantly with weight loss. Remission rates after 12 months of RYGB and OAGB for arterial hypertension (aHt) were 89% and 92%, for obstructive sleep apnea (OSAS) 56% and 82%, for Type 2 diabetes mellitus (T2DM) 100% and 92%, for osteoarthritis 64% and 85% and for GERD 89% versus 87% (ns), respectively. Nutritional deficiencies were comparable in RYGB (n = 11) and OAGB (n = 14) group (ns).

CONCLUSION

Both RYGB and OAGB are effective conversional procedures after SG, leading to comparable TBWL, BMI-loss and high remission rates of comorbidities including GERD. Significantly shorter operation times were in favor of OAGB. BPL, which was longer in OAGB was significantly related to higher %TBWL and %BMI-loss compared to RYGB.

Endoscopic therapy of weight regain after bariatric surgery

Weight regain following primary bariatric surgery occurs in a significant proportion of patients and is attributed to epidemiological, anatomical and metabolic factors. Surgical revision of these patients has significant risks and limited benefits. Endoscopic revisions that reduce gastric pouch size and diameter of the gastrojejunal anastomosis may offer an effective, safe, less invasive and even reproducible treatment. We herein discuss the indication, selection and feasibility of different endoscopic techniques that could be used in the management of weight regain following primary bariatric surgery. Future research could optimize a personalized approach not only in the endoscopic management but also in combination with other therapeutic modalities for weight regain after bariatric surgery.

Gastroesophageal Reflux Disease and the Patient with Obesity

Patients with obesity who present with gastroesophageal reflux disease (GERD) require a nuanced approach. Those with lower body mass index (BMI) (less than 33) can be counseled on weight loss, and if successful may be approached with laparoscopic fundoplication. Those who are unable to achieve weight loss or those who present with a BMI greater than or equal to 35 should proceed with laparoscopic Roux-en-Y gastric bypass (LRYGB). Conversion to LRYGB from sleeve gastrectomy is a safe and effective way to manage GERD after sleeve gastrectomy.

Laparoscopic Sleeve Gastrectomy Versus Laparoscopic Greater Curvature Plication: a Long-Term Follow-up Study on the Complications, Body Mass Index Changes, Endoscopic Findings and Causes of Revision

BACKGROUND

Bariatric surgery has been increasingly becoming popular due to the advancements in minimally invasive approaches and techniques. The aim of this study was to compare the long-term outcomes and clinical relevance of laparoscopic sleeve gastrectomy (LSG) and laparoscopic greater curvature plication (LGCP) in a matched controlled single-bariatric centre study.

METHODS

We collected data from 163 patients who underwent either LSG or LGCP over a period of at least 5 years. The outcome parameters included body mass index (BMI) changes, causes of revision surgery, endoscopic findings and effects on obesity-related comorbidities.

RESULTS

A total of 79 patients underwent LGCP, while 84 underwent LSG for morbid obesity. At the fifth year of follow-up, a BMI of < 30 was achieved in 1% of patients who underwent LGCP (n = 1) compared with more than 80% of patients who underwent LSG (n = 70). Revision was mainly due to gastroesophageal reflux disease (GERD) or bile reflux in the LSG group and due to weight gain in the LGCP group. LSG was superior in improvements in comorbidities. The most observed endoscopic finding was GERD (grade a, b) in the LSG group and unfolding of part of or the whole stomach in the LGCP group. Early minor postoperative complications occurred at a significantly lower frequency in the LSG group.

CONCLUSIONS

LGCP has a higher rate of complications, a much less durable effect on weight loss, a higher rate of revision surgery and a higher cost burden to the health care system than LSG.

GERD and Barrett's esophagus as indications for revisional surgery after sleeve gastrectomy: experience of a bariatric center of excellence IFSO-EC and narrative review

INTRODUCTION

Laparoscopic sleeve gastrectomy is the most commonly performed bariatric procedure worldwide; due to its extensive impact and analysis, multiple procedure-related early and late complications have been described. Gastroesophageal reflux and Barrett's esophagus are highly debated issues related to sleeve gastrectomy in long-term follow-up. This review aims to explore the association between sleeve gastrectomy and gastroesophageal reflux in terms of their occurrence, and to analyze the protective or affecting factors.

AREAS COVERED

Gastroesophageal reflux and Barrett's esophagus after laparoscopic sleeve gastrectomy.

EXPERT OPINION

Gastroesophageal reflux is the Achilles' heel of sleeve gastrectomy and is affected by multiple procedure-related functional or mechanical factors (intrathoracic migration, stenosis, lower esophageal sphincter incompetence). Its postoperative incidence is about 30% with significant variability among groups, especially in terms of preoperative workup (lack of routine upper gastro-intestinal endoscopy and symptom assessment). Strict patient selection and mandatory pre-operative endoscopy are the primary steps taken to prevent and reduce the incidence of post-operative severe gastroesophageal reflux. However, patients should also be informed of the possibility of the 'de novo gastroesophageal reflux disease' (incidence - 22-50%) and the need for surgical revision in selected cases (0.5-7%).

Single Anastomosis Duodenoileal Bypass or Roux-en-Y Gastric Bypass After Failed Sleeve Gastrectomy: Medium-Term Outcomes

Background

Although the sleeve gastrectomy (SG) has good short-term results, it comes with a significant number of patients requiring revisional surgery because of insufficient weight loss or functional complications.

Objective

To investigate the effectiveness of the single anastomosis duodenoileal bypass (SADI-S) versus the Roux-en-Y gastric bypass (RYGB) on health outcomes in (morbidly) obese patients who had previously undergone SG, with up to 5 years of follow-up.

Methods

Data from patients who underwent revisional SADI-S or RYGB after SG were retrospectively compared on indication of surgery, weight loss, quality of life, micronutrient deficiencies, and complications.

Results

From 2007 to 2017, 141 patients received revisional laparoscopic surgery after SG in three specialized Dutch bariatric hospitals (SADI-S n=63, RYGB n=78). Percentage total weight loss following revisional surgery at 1, 2, 3, 4, and 5 years was 22%, 24%, 22%, 18%, and 15% for SADI-S and 10%, 9%, 7%, 8%, and 2% for RYGB (P<.05 for 1–4 years). Patients who underwent RYGB surgery for functional complications experienced no persistent symptoms of GERD or dysphagia in 88% of cases. No statistical difference was found in longitudinal analysis of change in quality of life scores or cross-sectional analysis of complication rates and micronutrient deficiencies.

Conclusion

Conversion of SG to SADI-S leads to significantly more total weight loss compared to RYGB surgery with no difference in quality of life scores, complication rates, or micronutrient deficiencies. When GERD in sleeve patients has to be resolved, RYGB provides adequate outcomes.

Graphical abstract

Indications and Outcomes of Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass: a Systematic Review and a Meta-analysis

PURPOSE

Sleeve gastrectomy (SG) is the most performed bariatric procedure. Conversion to Roux-en-Y gastric bypass (RYGB) for SG-related complications such as gastroesophageal reflux disease (GERD), insufficient weight loss (ISWL), and weight regain (WR) is increasing. Our aim was to investigate the safety, efficacy, and outcomes of conversion from SG to RYGB.

METHODS

A literature search was performed from database inception to May 2020. Eligible studies must report indications for conversion, %total body weight loss (%TWL), and/or complications. The pooled mean or proportion were analyzed using a random-effects model.

RESULTS

Seventeen unique studies (n = 556, 68.7% female, average age at time of conversion 42.6 ± 10.29 years) were included. The pooled conversion rate due to GERD was 30.4% (95% CI 23.5, 38.3%; I² = 63.9%), compared to 52.0% (95% CI 37.0, 66.6%; I² = 85.89%) due to ISWL/WR. The pooled baseline BMI at conversion was 38.5 kg/m² (95% CI 36.49, 40.6 kg/m²; I² = 92.1%) and after 1 year was 32.1 kg/m² (95% CI 25.50, 38.7 kg/m²; I² = 94.53%). The pooled %TWL after 1 year was 22.8% (95% CI 13.5, 32.1%; I² = 98.05%). Complication rate within 30 days was 16.4% (95% CI 11.1, 23.6%; I² = 57.17%), and after 30 days was 11.4% (95% CI 7.7, 16.7%; I² = 0%).

CONCLUSION

This meta-analysis showed that conversion from SG to RYGB is an option for conversion at a bariatric care center that produces sufficient weight loss outcomes, and potential resolution of symptoms of GERD. Further indication-based studies are required to obtain a clearer consensus on the surgical management of patients seeking RYGB following SG.

Efficacy and Drawbacks of Single-Anastomosis Duodeno-Ileal Bypass After Sleeve Gastrectomy in a Tertiary Referral Bariatric Center

BACKGROUND

The need for revisional procedures after sleeve gastrectomy (SG) for insufficient weight loss or weight regain, gastroesophageal reflux, or other complications is reported to be 18-36% in studies with 10-year follow-up. Single-anastomosis duodeno-ileal bypass (SADI) may be performed as a revisional procedure after SG. This study aims to evaluate the short- and mid-term outcomes of SADI after SG in a referral center for bariatric surgery.

MATERIALS AND METHODS

Data of patients who underwent SADI between March 2015 and March 2020 were collected prospectively and analyzed retrospectively. Follow-up comprised clinical and biochemical assessment at 1, 3, 6, 12, 18, and 24 months postoperatively, and once a year thereafter.

RESULTS

Overall, 106 patients underwent SADI after a previous SG. The timeframe between SG and SADI was 50 ± 31.3 months. Postoperative mortality was observed in two cases (1.8%) and morbidity in 15.1% of patients. At 24 months, %total weight loss was 37.6 ± 12.3 and %excess weight loss 76.9 ± 25.2 (64 patients). Three patients were treated for malnutrition during follow-up, two with medical treatment and one with SADI reversal.

CONCLUSION

SADI after SG provides effective weight loss results in the short-term, even if in the present series the postoperative complication rate was non-negligible. Further trials are needed to establish the more advantageous revisional bariatric procedure after failed SG.

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.

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

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