Midterm results for gastric banding as salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass

Efficacy and safety of revisional treatments for weight regain or insufficient weight loss after Roux-en-Y gastric bypass: A systematic review and meta-analysis

Weight regain or inadequate weight loss following Roux-en-Y gastric bypass poses a significant clinical challenge. Our objective was to evaluate various revisional techniques for addressing weight regain and insufficient weight loss after Roux-en-Y gastric bypass through a systematic review and meta-analysis. We performed a literature search (in PubMed and Embase) on revisional interventions in collaboration with a medical information specialist. Measured outcomes included body mass index at intervention, total weight loss during follow-up, and complications. Random effects models were used to determine pooled effect size and corresponding 95% confidence intervals. Thirty-nine studies were included: four studies reported on argon plasma coagulation, four studies on transoral outlet reduction, nine studies on transoral outlet reduction + argon plasma coagulation, four studies on pouch/gastrojejunal anastomosis revision, five on laparoscopic gastric banding, two studies on laparoscopic gastric banding + pouch resizing, 10 on distalization-RYGB, and one on duodenal switch. All techniques resulted in short-term clinically relevant weight loss. Endoscopic procedures had a short follow-up and resulted in modest and temporary weight loss. Surgical revision techniques were successful for weight loss in longer term follow-up, at the expense of high complication rates.

Accuracy of prediction models for long-term type 2 diabetes remission after gastric bypass

AIM

To evaluate the accuracy of DiaBetter, DiaRem, Ad-DiaRem and 5y-Ad-DiaRem scores' at predicting T2D remission 10 or more years after surgery.

METHODS

Patients with obesity and T2D (n = 126) submitted to RYGB with 10 or more years of follow-up. It was a unicentric trial. Pre-operative anthropometric and clinical data was retrieved to calculate DiaRem, DiaBetter, Ad-DiaRem and 5y-Ad-DiaRem scores, while a hospital visit was conducted to assess current diabetes status. The area under the receiver operating characteristic (AUROC) curve was calculated as estimate of the scores' accuracy to predict long-term T2D remission.

RESULTS

Among the entire cohort (n = 126), 70 subjects (55.6%) achieved and maintained T2D remission 10 or more years after RYGB. The 5y-Ad-DiaRem score was the one that depicted the highest discriminative power (AUROC = 0.838) to predict long-term T2D remission when compared to DiaBetter (AUROC = 0.735), DiaRem (AUROC = 0.721) and Ad-DiaRem (AUROC = 0.720).

CONCLUSION

The score with highest accuracy to predict long-term T2D remission after RYGB surgery was the 5y-Ad-DiaRem. Yet, the available scores accuracy to predict T2D remission in the long term is still suboptimal, highlighting the unmet need for a better scoring system.

Weight Recidivism and Dumping Syndrome after Roux-En-Y Gastric Bypass: Exploring the Therapeutic Role of Transoral Outlet Reduction

Obesity is a chronic, relapsing disease representing a global epidemic. To date, bariatric surgery is the most effective treatment for morbid obesity in the long-term. Roux-en-Y gastric bypass (RYGB) is one of the most performed bariatric interventions, with excellent long-term outcomes. However, about one-third of patients may experience weight regain over time, as well as dumping syndrome. Both these conditions are challenging to manage and require a multidisciplinary and personalized approach. The dilation of the gastro-jejunal anastomosis is a recognized etiological factor for both weight regain and dumping syndrome. Dietary modifications, behavioral interventions, and medications represent the first therapeutic step. Revisional surgery is the traditional approach when non-invasive treatments fail. However, re-interventions may be technically difficult and are associated with increased morbidity and mortality. Transoral outlet reduction (TORe) is an endoscopic procedure aimed at reducing the size of the anastomosis and is proposed as a minimally invasive treatment of weight regain and/or dumping syndrome refractory to conservative therapies. This review is aimed at providing a narrative overview of the role of TORe as part of the multidisciplinary therapeutic toolkit nowadays available to approach weight regain and dumping syndrome after RYGB.

Gastric Banding with Previous Roux-en-Y Gastric Bypass (Band over Pouch): Not Worth the Weight

Background and Objectives:

Revisional bariatric surgery continues to increase. Laparoscopic adjustable gastric banding (LAGB) after previous Roux-en-Y gastric bypass (RYGB), known colloquially as “band-overpouch” has become an option despite a dearth of critically analyzed long-term data.

Methods:

Our prospectively maintained database was retrospectively reviewed for patients who underwent band-overpouch at our Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Center of Excellence in a 18-year period ending October 31, 2021. We evaluated: demographics, comorbidities, operative procedures, and outcomes (30-day and > 30-day).

Results:

During the study period, of 4,614 bariatric procedures performed, 42 were band-overpouch with 39 (93%) being women. Overall, mean age was 49.8 years (range 26–75), a mean weight 251 pounds (range 141–447), and mean body mass index 42.4 (range 26–62). Comorbidities included: hypertension (n = 31; 74%), diabetes (n = 27; 64%), obstructive sleep apnea (n = 26; 62%), gastroesophageal reflux disease (n = 26; 62%), and osteoarthritis (n = 25; 60%). All procedures were performed laparoscopically with no conversions to open. Mean length of stay was 1.2 days (range 1–3). Mean follow-up time was 4.2 years (range 0.5–11). Mean excess weight loss was 14.9%, 24.3%, and 28.2% at 6 months, 1 year and ≥ 3 years, respectively. There was one 30-day trocar-site hematoma requiring transfusion. Long-term events included: 1-year (1 endoscopy for retained food; 1 internal hernia), 3-year (1 LAGB erosion; 1 LAGB explant), 4-year (1 anastomotic ulcer), 6-year (1 LAGB explant and Roux-en-Y revision), and 8-year (1 LAGB erosion). One 5-year mortality occurred (2.4%), in association with hospitalization for chronic illness and malnutrition. Band erosions were successfully treated surgically without replacement.

Conclusion:

Band-overpouch is associated with moderate excess weight loss and has good short-term safety outcomes.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Revisional Bariatric Surgery

Revisional bariatric surgery is a growing subset of all bariatric procedures. Although revisions can be associated with higher morbidity rates and less optimal outcomes than those seen with primary procedures, they can be safely performed, with excellent outcomes and improved quality of life for patients. Facility and familiarity with revisional principles and techniques are necessary components of bariatric surgical practice.

Conversions of Roux-en-Y gastric bypass to duodenal switch (SADI-S and BPD-DS) for weight regain

BACKGROUND

Duodenal switch is a choice of conversion when patients fail to lose or regain weight after Roux-en-Y gastric bypass (RYGB). This study aims to evaluate the effectiveness and safety of duodenal switch as a secondary operation for patients who presented with insufficient weight loss or weight regain after a RYGB.

METHODS

A retrospective chart review was performed on 15 patients who underwent a conversion of RYGB to single anastomosis duodeno-ileal bypass with sleeve (SADI-S) or biliopancreatic diversion with duodenal switch (BPD-DS) due to weight regain between December 31, 2013 and October 31, 2018. For the body mass index (BMI) analysis, the multilevel model for change was used.

RESULTS

Of 15 patients, 10 underwent a conversion to SADI-S, and 5 underwent a conversion to BPD-DS. Also, 7 patients underwent the conversion in two-stages, while 8 did as single-stage. One patient had a duodenal stump leak after SADI-S, and another patient had a sleeve leak after BPD-DS. One patient underwent a reoperation to increase the common channel 20 months after the conversion to BPD-DS due to malnutrition. There was no mortality. Mean percentage of total weight loss (TWL) was 18.4% at 6 months, 25.0% at 12 months, 26.4% at 18 months, and 25.7% at 24 months after the conversion. The rate of decrease in BMI was slower in SADI-S patients than in BPD-DS patients (p < 0.01), adjusting for preoperative BMI.

CONCLUSION

Conversions of RYGB to SADI-S and BPD-DS can provide significant additional weight loss. However, complications and malnutrition can develop after the conversion, and further research is needed for evaluating safety.

Treatment Options for Poor Responders to Bariatric Surgery

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Revision of Roux-En-Y Gastric Bypass for Weight Regain: a Systematic Review of Techniques and Outcomes

BACKGROUND

Weight regain has led to an increase in revision of Roux-en-Y gastric bypass (RYGB) surgeries. There is no standardized approach to revisional surgery after failed RYGB. We performed an exhaustive literature search to elucidate surgical revision options. Our objective was to evaluate outcomes and complications of various methods of revision after RYGB to identify the option with the best outcomes for failed primary RYGB.

METHOD

A systematic literature search was conducted using the following search tools and databases: PubMed, Google Scholar, Cochrane Clinical Trials Database, Cochrane Review Database, EMBASE, and Allied and Complementary Medicine to identify all relevant studies describing revision after failed RYGB. Inclusion criteria comprised of revisional surgery for weight gain after RYGB.

RESULTS

Of the 1200 articles found, only 799 were selected for our study. Of the 799, 24 studies, with a total of 866 patients, were included for a systematic review. Of the 24 studies, 5 were conversion to Distal Roux-en-y gastric bypass (DRYGB), 5 were revision of gastric pouch and anastomosis, 6 were revision with gastric band, 2 were revision to biliopancreatic diversion/duodenal switch (BPD/DS), and 6 were revision to endoluminal procedures (i.e., stomaphyx). Mean percent excess body mass index loss (%EBMIL) after revision up to 1 and 3-year follow-up for BPD/DS was 63.7 and 76 %, DRYGB was 54 and 52.2 %, gastric banding revision 47.6 and 47.3 %, gastric pouch/anastomosis revision 43.3 and 14 %, and endoluminal procedures at 32.1 %, respectively. Gastric pouch/anastomosis revision resulted in the lowest major complication rate at 3.5 % and DRYGB with the highest at 11.9 % when compared to the other revisional procedures. The mortality rate was 0.6 % which only occurred in the DRYGB group.

CONCLUSION

All 866 patients in the 24 studies reported significant early initial weight loss after revision for failed RYGB. However, of the five surgical revision options considered, BPD/DS, DRYGB, and gastric banding resulted in sustained weight loss, with acceptable complication rate.

Laparoscopic Adjustable Gastric Banding After Failed Roux-En-Y Gastric Bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is associated with approximately 25 % weight loss failure, resulting in insufficient weight loss or weight regain. Strategies of revisional surgery focus on alteration of limb length, pouch or stoma size. Altering pouch size and outlet by adding laparoscopic adjustable gastric band (LAGB) might initiate further weight loss. The goal of this study is to review the safety and efficacy of LAGB after failed RYGB in a retrospective cohort of patients in our institute.

METHODS

Patients with secondary LAGB (n = 44) were studied between May 2012 and January 2015. Demographics, effects on weight loss and complications were analysed.

RESULTS

Mean age and body mass index (BMI) at time of LAGB was 45.8 ± 8.2 years and 37.2 ± 5.4 kg/m², respectively. Mean interval between RYGB and LAGB was 2.6 ± 1.3 years. Mean follow-up was 14 ± 7.9 months, with 25 % loss to follow-up at 12 months. Due to LAGB, patients lost an additional 17.6 % ± 28.3 % excess weight. Patients with weight regain after initial weight loss success showed more excess weight loss (EWL) compared to patients whom never reached 50% EWL after RYGB. Overall complication and reoperation rates were 30 and 21 %, respectively, with 16 % band removal. One fatality due to septic shock following band erosion was observed.

CONCLUSION

In this largest published cohort, secondary banding of failed RYGB provides only limited additional weight loss. Furthermore, this technique is associated with high morbidity and reoperation rates. A significant difference in effect was found between patients with weight loss failure and weight regain. Larger prospective series are necessary to evaluate if the modest benefits are worth the risks of secondary LAGB.

Treatment of weight regain following roux-en-Y gastric bypass: revision of pouch, creation of new gastrojejunostomy and placement of proximal pericardial patch ring

In the literature, weight regain or failure of weight loss has been reported in up to 35% of patients after Roux-en-Y gastric bypass (RYGB). Several revisional procedures have been suggested to reinitiate further weight loss in this group of patients, and placing a silastic ring around the pouch proximal to the gastrojejunostomy is one among those procedures. The aim of our study is to evaluate and compare the safety and efficacy of salvage banding using a pericardial patch after RYGB for further weight loss. Between December 2009 and April 2013, a total of 46 patients underwent revision with pericardial patch ring after RYGB for weight regain/failure of weight loss. A retrospective review of a prospectively collected database was performed, noting the outcomes and complications of the procedure. The mean body mass index at the time of revision was 40.1 ± 6.8 kg/m2. Mean percentage of excess weight loss was 23.4 ± 15.7%, 39.0 ± 27.4%, and 18.9 ± 20.5% at 6, 12 and 24 months after revision, respectively. Eight (17.4%) patients required a total of 11 readmissions due to nausea, vomiting, dysphagia and abdominal pain. Six (13.0%) patients underwent a total of six reoperations, including four patients with laparoscopic removal of the pericardial patch and another revision of RYGB, and two patients with repair of perforated ulcers. Revision with pericardial patch ring after gastric bypass for weight regain or failure of weight loss may not be feasible, safe and effective.

Midterm outcomes of revisional surgery for gastric pouch and gastrojejunal anastomotic enlargement in patients with weight regain after gastric bypass for morbid obesity

Reoperative surgery for the morbidly obese has become increasingly common due to postoperative weight regain. There are limited studies evaluating the effectiveness of revisional surgery. This study evaluates the weight loss outcomes of revisional surgery over a 2-year period at our University Hospital, USA. Of the 412 patients who underwent laparoscopic bariatric surgery between June 2009 and June 2011, we identified 25 patients who had Roux-en-Y gastric bypass (RYGB) originally, who underwent laparoscopic revisional surgery for weight regain. Preoperative and postoperative data were reviewed. Statistical analysis was performed using paired t test. This study includes 0 male and 25 female patients with an average age of 42 (range min to max: 28-58), mean original body mass index (BMI) of 54.6 kg/m(2) (r = 37.3-80.7), average lowest BMI achieved of 32.2 (r = 20.1-50.9), and average BMI at the time of revision of 41.0 kg/m(2) (r = 29.5-60.7, standard deviation (SD) = 8.5). All laparoscopic revisions consisted of resizing the gastric pouch by resection and recreating the gastrojejunostomy. Average hospital length of stay was 1.28 days (r = 1-4). Perioperative morbidity was 8 %; one patient developed a trocar site hernia which required repair, and another suffered postoperative bleeding requiring transfusion. There was no mortality. Postoperative BMI averages at 3, 6, 9, 12, and 24 months were 35.0 (SD = 7.15), 34.7 (SD = 4.26), 36.2 (SD = 7.63), 33.0 (SD = 6.58), and 44.2 (SD = 12.87), respectively. Statistically significant weight loss was achieved at 3 [t (10) = 6.74, p < 0.05], 6 [t (7) = 4.69, p < 0.05], 9 [t (9) = 2.94, p < 0.05], and 12 [t (6) = 3.78, p < 0.05] months. However, there was no statistically significant weight loss at 24 months postoperatively [t (4) = -0.16, p > 0.05]. Laparoscopic revisional bariatric surgery can be performed with significant weight loss up to 1 year postoperatively. However, additional studies are required to evaluate longer-term success.

Critical appraisal of salvage banding for weight loss failure after gastric bypass

BACKGROUND

Placement of an adjustable gastric band (AGB) over the gastric pouch after RYGB failure has had varied results. The aim of this study was to evaluate safety and outcomes of AGB after RYGB failure.

METHODS

Twenty-eight patients who underwent laparoscopic placement of an AGB around the gastric pouch as a revisional procedure for inadequate weight loss or recidivism after RYGB between 2008-2011 were identified.

RESULTS

Twenty-four (86%) patients had a dilated gastric pouch and/or stoma. The mean operative and adhesiolysis times were 137.9±52.3 minutes and 83±51 minutes, respectively. History of a previous open RYGB was associated with a longer adhesiolysis time (P = .03). Three (11%) major intraoperative and 5 (18%) early postoperative complications occurred. Late complications (all requiring band removal) were observed in 6 (21%) patients and included ineffectiveness (n = 2), dysphagia/esophageal dilation (n = 2), band erosion (n = 1), and peritonitis (n = 1). In all 4 patients with a normal-sized pouch and stoma at the time of band placement, the band was removed. After a mean follow-up of 38.3±14.8 months, the mean body mass index (BMI) change and median excess weight loss (EWL) after salvage banding were -3.6±4.5 kg/m(2) and 12.7%, respectively. In the subset of patients with a dilated pouch/stoma, BMI less than 42 kg/m(2) at the time of band placement was associated with a significantly higher EWL (41.4%±37.0%) compared with a baseline BMI>42 kg/m(2) (12.1%±7.2%, P = .03).

CONCLUSIONS

Salvage banding is technically challenging due to dense adhesions, carries significant morbidity, and is associated with only 13% additional EWL. However, this approach may still be an option in carefully selected patients, such as those with previous laparoscopic RYGB who have a dilated pouch and/or stoma and lower BMI.

Management of Failed Laparoscopic Roux-en-Y Gastric Bypass

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) has emerged as the gold standard for the management of morbid obesity. Accordingly, patients who fail to lose weight after LRYGB present a difficult problem for the bariatric surgeons. A literature review was performed to evaluate the management options for this select bariatric population. Methods: A literature search was conducted in the EMBASE and MEDLINE databases using the most comprehensive timeline. All relevant articles were identified and full texts were obtained and reviewed. Results: Thirteen articles were retrieved based on key word searches. Management for weight failure following LRYGB included revision using the following options: laparoscopic adjustable gastric banding, pouch/anastomotic revision with or without endoluminal techniques, laparoscopic distal Roux-en-Y gastric bypass, and laparoscopic biliopancreatic diversion with duodenal switch. Laparoscopic sleeve gastrectomy may be considered in patients who fail LRYGB with nutritional deficiencies. Conclusion: Failed LRYGB should be managed based on the patient presentation and diagnostic evaluation. Patients may present with significant nutritional deficiencies/complications, failure to lose weight, or weight recidivism. A treatment algorithm is proposed based on the literature to guide bariatric surgeons with respect to management options. However, given the paucity of research with respect to this problem, additional studies are needed to provide more insight on the optimal surgical management.

Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force

BACKGROUND

Reoperative bariatric surgery has become a common practice in many bariatric surgery programs. There is currently little evidence-based guidance regarding specific indications and outcomes for reoperative bariatric surgery. A task force was convened to review the current evidence regarding reoperative bariatric surgery. The aim of the review was to identify procedure-specific indications and outcomes for reoperative procedures.

METHODS

Literature search was conducted to identify studies reporting indications for and outcomes after reoperative bariatric surgery. Specifically, operations to treat complications, failed weight loss, and weight regain were evaluated. Abstract and manuscript reviews were completed by the task force members to identify, grade, and categorize relevant studies.

RESULTS

A total of 819 articles were identified in the initial search. After review for inclusion criteria and data quality, 175 articles were included in the systematic review and analysis. The majority of published studies are single center retrospective reviews. The evidence supporting reoperative surgery for acute and chronic complications is described. The evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. Procedure-specific outcomes are described. Complication rates are generally reported to be higher after reoperative surgery compared to primary surgery.

CONCLUSION

The indications and outcomes for reoperative bariatric surgery are procedure-specific but the current evidence does support additional treatment for persistent obesity, co-morbid disease, and complications.

Long-term follow-up evaluation of endoscopic sclerotherapy for dilated gastrojejunostomy after gastric bypass

BACKGROUND

Endoscopic sclerotherapy using sodium morrhuate has been used to treat patients with weight regain after Roux-en-Y gastric bypass whose presumed etiology is loss of restriction due to gastrojejunostomy dilation. Weight loss and stability have been demonstrated in several studies with short-term follow-up evaluation.

METHODS

This retrospective review evaluated all the patients who underwent sclerotherapy for a dilated gastrojejunostomy between 2007 and 2012.

RESULTS

The study identified 48 patients with a mean follow-up period of 22 months (range 12-60 months). The mean age of these patients was 47.5 ± 10.5 years, and 92 % were women. The average weight loss from the primary procedure was 132.5 ± 54.82 lb, and the average weight regain from the lowest weight to the maximum weight before sclerotherapy was 46 ± 40.32 lb. The median number of sclerotherapy sessions was two (range 1-4). The pre-procedure mean gastrojejunostomy diameter was 20 ± 3.6 mm, and the mean volume of sodium morrhuate injected per session was 12.8 ± 3.7 ml. The average weight loss from sclerotherapy to the final documented weight was 3.17 ± 19.70 lb, which was not statistically significant. The following variables in the multivariate analysis were not associated with statistically significant weight loss: volume of sodium morrhuate, patient age, gastrojejunostomy diameter, number of sclerotherapy sessions, decrease in gastrojejunostomy diameter between the first and second sessions, and number of follow-up years. Weight stabilization or loss was achieved by 58 % of our cohort, with a mean weight loss of 15.9 ± 14.6 lb in this subgroup.

CONCLUSION

The long-term follow-up evaluation of patients undergoing sclerotherapy of the gastrojejunostomy for weight regain after gastric bypass showed only a marginal weight loss, which was not statistically significant in our study population, although more than 50 % of the patients achieved weight loss or stabilization.

Outcomes of revisional procedures for insufficient weight loss or weight regain after Roux-en-Y gastric bypass

BACKGROUND

The Roux-en-Y gastric bypass (RYGB) performed laparoscopically (LRYGB) is the most frequently performed bariatric procedure in Belgium. However, late results in terms of weight loss or weight regain are inconsistent and may warrant a second procedure. This retrospective study analyzes the laparoscopic options for revisional surgery after LRYGB.

METHODS

Between January 1, 2001 and December 31, 2009, 70 patients underwent a new laparoscopic procedure for poor weight loss or weight regain after LRYGB. The revisional procedure was performed a median of 2.6 years after the initial bypass operation. Fifty-eight patients were available for follow-up (82.9 %); 19 underwent distalization; and 39 a new restrictive procedure.

RESULTS

The mean mass index (BMI) before the revisional procedure was 39.1 + 11.3 kg/m(2) (30.8-51.8), down from 42.7 + 19.7 kg/m(2) (33.0-56.6) initially, which corresponded to a percentage of excess weight loss (EWL) of 12.4 + 9.3 % (-1.0-29.1). After the corrective procedure, with a follow-up of approximately 4 years, mean BMI was 29.6 + 12.4 kg/m(2) (18.0-45.5), for a significant additional percentage of EWL of 53.7 + 9.8 % (2.0-65.8). The overall complication rate was 20.7 %, and the reoperation rate was 7.3 %. The overall leak rate was 12.1 %. Patients suffering from leaks could consistently be treated conservatively or by stent placement. Two patients needed reconversion after distal bypass. The satisfaction index was good in just over 50 % of the patients.

CONCLUSION

Revisional laparoscopic surgery after RYGB performed for weight issues provides good additional weight loss but carries significant morbidity. Leaks can usually be handled non-surgically. Patient satisfaction is only fair.