Revision and reversal after biliopancreatic diversion for excessive side effects or ineffective weight loss: a review of the current literature on indications and procedures

Gastro-Jejunal Ileal Interposition with Bipartition: A Salvage Procedure for Severe Protein-Energy Malnutrition After Transit Bipartition

BACKGROUND

Intractable diarrhea or excess weight loss associated with protein-energy malnutrition (PEM) can occur after Transit Bipartition (TB). This study evaluates the effect of transposing the alimentary limb to the proximal intestines.

METHODS

Between 2017 and 2024, ten patients with malnutrition and diarrhea underwent Gastro-Jejunal Ileal Interposition (GJIB) surgery after TB. We prospectively monitored protein-energy malnutrition postoperatively and retrospectively analyzed demographic data, laboratory findings, and anthropometric measurements. Gastric transit scintigraphy was performed on symptomatic and asymptomatic patients to evaluate gastric evacuation diversity between the pylorus and the gastro-ileostomy.

RESULTS

Ten patients (male/female, 6/4) were operated on. The preoperative mean age was 49.4 ± 9.19 years. The mean body mass index (BMI) was 22.19 ± 1.13 kg/m2, the mean excess BMI loss (%EBMIL) percentage was 123.26 ± 14.85%, and the total weight loss percentage (%TWL) was 42.35 ± 0.33. Eighty percent of food passed through the gastroileostomy in all patients. The mean follow-up period was 50.56 ± 57.28 months. Postoperatively, the mean BMI increased to 28.16 ± 2.2 kg/m2 (p = 0.001), %EBMIL decreased to 79.88 ± 21.53% (p = 0.001), and %TWL decreased to 27.31 ± 10.1. Albumin levels rose from a median of 2.1 mg/dl to an average of 3.8 ± 0.78 mg/dl (p = 0.001), and stool frequency decreased from 11.56 ± 0.71 to 2.1 ± 2.12 per day (p = 0.001). The excluded bowel length percentage (Exl.B%) decreased significantly from 72.4 ± 3.18% to 12.3 ± 1.99% after conversion (p = 0.005). All patients were diabetic before and had remission after TB. Glycemic control was preserved after the conversion, with a median HbA1c of 5.4% compared to 5.8% before conversion.

CONCLUSIONS

GJIB may be a viable revision procedure for resolving PEM and related complications without compromising the metabolic benefits of the initial surgery on diabetes resolution by decreasing the Exl.B%.

Loop duodenal switch confers more complications with little gain of weight loss compared to Roux-en-Y gastric bypass

BACKGROUND

There are several surgical options each with their potential for complications, differences in length of procedure, and in meaningful outcomes. This study aims to explore those outcomes after Roux-en-Y Gastric Bypass (RYGB) and Loop Duodenal Switch (LDS).

OBJECTIVE

The purpose of this project is to offer a comparative analysis of RYGB and LDS at the NorthShore University Health System for up to 4 years postoperatively.

METHODS

A retrospective review of a prospectively maintained database was queried for all patients who underwent RYGB and LDS from 2019 to 2023. Demographic, preoperative, post-operative data, and Quality of Life (QOL) data were included. χ2 and Kruskal-Wallis tests were used for comparison. Statistical significance was set at p < 0.05.

RESULTS

Patient database included 238 patients who underwent RYGB, and 54 who underwent LDS. Initial BMI was significantly higher in LDS compared to RYGB (56.9 ± 8.0; 46.5 ± 7.3; p < 0.01). There were no statistically significant differences between reported comorbidities. There were no differences in intraoperative complications between the two groups, however postoperative complications were significantly higher in the LDS population (16.7%, 7.1%; p < 0.01). Percent total body weight loss (%TBWL) was significantly different at 2 years post operatively with LDS having more %TBWL than RYGB (LDS: N = 10, %TBWL = 44.7 ± 14.1%; RYGB: N = 47) There were no statistically significant differences at any other postoperative time point. Subgroup analysis was completed in patients with initial BMI 50. There were no significant differences at any postoperative time point. QOL data showed no significant difference between both procedures at all postoperative timepoints.

CONCLUSION

Patients who undergo LDS are more likely to experience postoperative complications compared to RYGB with no added benefit in weight loss or comorbidity resolution up to 3 years post operatively.

Comparative effectiveness of metabolic and bariatric surgeries: a network meta-analysis

Bariatric surgery is recommended for patients with unhealthy weight. Our study aim to compare and rank different bariatric surgical approaches in reducing weight parameters. We searched MEDLINE, Cochrane CENTRAL, Scopus, and Web of Science databases from inception to September 2023. We extracted all outcomes as mean change from the baseline. The mean difference and 95% confidence interval were used as a summary measure. All analysis was conducted with R version 4.2.2 (2022-10-31) and R Studio version 2022.07.2 (2009-2022) (RStudio, Inc.). Included surgeries were: Biliopancreatic diversion (BPD-RYGB), Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Gastric Plication (LGP), Duodenal-Jejunal Bypass Sleeve (DJBS), Single-anastomosis gastric bypass (SAGB), Laparoscopic vertical banded gastroplasty (LVBG), Sleeve Gastrectomy (SG), Laparoscopic adjustable gastric banding (LAGB), Gastric plication, Biliopancreatic diversion (BPD), and Intra-gastric balloon (IGB). Only clinical trials were included, with outcomes focused on weight parameters such as reductions in BMI (kg/m²), weight (kg), waist circumference (cm), fat mass (kg), and excess weight loss (EWL) (%). Our analysis of 67 studies showed that SADI-S was the best surgical technique in decreasing BMI (kg/m2) (MD = -18.06; 95% CI [-25.31; -10.81]) and DS follows in efficacy with a P-score (MD = -18.88; 95% CI [-31.15; -6.62]) however the pooled analysis was heterogeneous (I2 = 98.5%). For weight (kg), waist circumference (cm), and fat mass (kg), BPD-RYGB was the best surgical technique to reduce these parameters (MD = -41.48; 95% CI [-47.80, -35.51], MD = -29.08; 95% CI [-37.16, -21.00], and MD = -31.11; 95% CI [-38.77, -23.46]; respectively). The pooled analysis was heterogeneous except in fat mass (I2 = 0%, p-value = 0.8). Our network meta-analysis showed that the best surgical technique in increasing EWL (%) was RY-DS (MD = -61.27; % CI [-91.72; -30.82]) the next one in efficacy according to P-score was LVBG (MD = -59.03; % CI [-84.47; -33.59]). SADI-S is most effective in reducing BMI followed by RYGB. DS was associated with most estimated weight loss %.

Decision-making Considerations in Revisional Bariatric Surgery

OBJECTIVE

With drastic variations in bariatric practices, consensus is lacking on an optimal approach for revisional bariatric surgeries.

MATERIALS AND METHODS

The authors reviewed and consolidated bariatric surgery literature to provide specific revision suggestions based on each index surgery, including adjustable gastric band (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS), single anastomosis duodenal-ileal bypass with sleeve (SADI-S), one anastomosis gastric bypass (OAGB), and vertical banded gastroplasty (VBG).

RESULTS

AGB has the highest weight recurrence rate and can be converted to RYGB, SG, and BPD-DS. After index SG, common surgical options include a resleeve or RYGB. The RYGB roux limb can be distalized and pouch resized in context of reflux, and the entire anatomy can be revised into BPD-DS. Data analyzing revisional surgery after a single anastomosis duodenal-ileal bypass with sleeve was limited. In patients with one anastomosis gastric bypass and vertical banded gastroplasty anatomy, most revisions were the conversion to RYGB.

CONCLUSIONS

As revisional bariatric surgery becomes more common, the best approach depends on the patient's indication for surgery and preexisting anatomy.

Challenges of Revisional Metabolic and Bariatric Surgery: A Comprehensive Guide to Unraveling the Complexities and Solutions of Revisional Bariatric Procedures

Revisional metabolic and bariatric surgery (RMBS) presents unique challenges in addressing weight loss failure or complications arising from initial bariatric procedures. This review aims to explore the complexities and solutions associated with revisional bariatric procedures comprehensively, offering insights into the evolving terrain of metabolic and bariatric surgery. A literature review is conducted to identify pertinent studies and expert opinions regarding RMBS. Methodological approaches, patient selection criteria, surgical techniques, preoperative assessments, and postoperative management strategies are synthesized to provide a comprehensive overview of current practices and advancements in the field, including institutional protocols. This review synthesizes key findings regarding the challenges encountered in RMBS, including the underlying causes of primary procedure failure, anatomical complexities, technical considerations, and assessments of surgical outcomes. Additionally, patient outcomes, complication rates, and long-term success are presented, along with institutional approaches to patient assessment and procedure selection. This review provides valuable insights for clinicians grappling with the complexities of RMBS. A comprehensive understanding of patient selection, surgical techniques, preoperative management, and postoperative care is crucial for enhancing outcomes and ensuring patient satisfaction in the field of metabolic bariatric surgery.

Management of Malnutrition and Hepatic Impairment After Duodenal Switch

BACKGROUND

Malnutrition and liver impairment after duodenal switch (DS) are possible and undesired complications, often conservatively treated. However, in specific cases, surgical revision may be necessary. This study aims to describe outcomes achieved by two bariatric surgery centers and address effectiveness and safety of revisional surgical procedures to resolve these complications.

METHODS

A retrospective chart review was performed in two bariatric surgery centers from 2008 to 2022. Patients who required revisional surgery to treat malnutrition and/or liver impairment refractory to nutritional and total parenteral nutrition intervention (TPN) after duodenal switch were included. No comparisons were performed due to the descriptive nature of this study.

RESULTS

Thirteen patients underwent revisional surgery, the mean age was 44.7, the 53.8% were females, and the mean preoperative BMI was 54.7 kg/m2; the mean time between DS and revisional procedure was 26.5 months, and 69.1% of patients were placed on TPN. One patient developed hepatic encephalopathy; one patient presented with ascites, pleural effusion, and renal insufficiency, undergoing reoperation after revisional procedure due to a perforated ileal loop. Mortality rate was 0%; all patients regained weight after the revisional procedure, and the mean total protein and albumin blood levels 12 months after surgery were 6.3 and 3.6 g/dl, respectively.

CONCLUSIONS

While refractory malnutrition and/or liver failure are rare among patients post-DS, if underdiagnosed and untreated, this can lead to irreversible outcomes and death. All revisional procedures included in this study resulted in improvement of the nutritional status and reversal of liver impairment, with low complication rates.

Optimal Small Bowel Limb Lengths of Roux-en-Y Gastric Bypass

PURPOSE OF REVIEW

Gastric bypass and biliopancreatic diversion (BPD) have come full circle, from a loop configuration to a Roux-en-Y and finally back to a loop configuration as one anastomosis gastric bypass and single-anastomosis duodenal switch. Most surgeons performing Roux-en-Y gastric bypass (RYGB) do not measure the common channel (CC) length and most surgeons performing BPD do not measure the biliopancreatic limb length (BPL).

RECENT FINDINGS

The small bowel length in humans is variable from as short as < 400 cm to as long as > 1000 cm. The combination of these two facts means that even if surgeons keep the limb lengths constant, surgeons will get variable limb length due to the variability of small bowel length in patients. Hence, outcomes of weight loss, resolution of medical problems, or developing nutritional deficiencies which are related to limb length are variable. In this article, we evaluate the published literature related to the effect of varying the Roux limb, BPL, CC, and total alimentary limb lengths on the outcomes of RYGB. We have focused on historical and current randomized controlled trials as well as systematic reviews and meta-analysis to outline the current literature and our interpretation of this literature.

Evolution of Bariatric Surgery in Italy in the Last 11 Years: Data from the SICOB Yearly National Survey

BACKGROUND

Bariatric surgery (BS) is a relatively novel surgical field and is in continuous expansion and evolution.

PURPOSE

Aim of this study was to report changes in Italian surgical practice in the last decade.

METHODS

The Società Italiana di Chirurgia dell'Obesità (SICOB) conducted annual surveys to cense activity of SICOB centers between 2011 and 2021. Primary outcome was to detect differences in frequency of performance of adjustable gastric banding (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB), bilio-pancreatic diversion (BPD), and gastric plication (GP). Secondary outcome was to detect differences in performance of main non-malabsorptive procedures (AGB + SG) and overall bypass procedures (RYGB + OAGB). Geographical differences were also investigated.

RESULTS

Median response rate was 92%. AGB declined from 36% of procedures in 2011 to 5% in 2021 (p < 0.0001). SG increased from 30% in 2011 to 55% in 2021 (p < 0.0001). RYGB declined from 25 to 12% of procedures (p < 0.0001). OAGB rose from 0% of procedures in 2011 to 15% in 2021 (p < 0.0001). BPD underwent decrease from 6.2 to 0.2% in 2011 and 2021, respectively (p < 0.0001). Main non-malabsorptive procedures significantly decreased while overall bypass procedures remained stable. There were significant differences among regions in performance of SG, RYGB, and OAGB.

CONCLUSIONS

BS in Italy evolved significantly during the past 10 years. AGB underwent a decline, as did BPD and GP which are disappearing and RYGB which is giving way to OAGB. The latter is rising and is the second most-performed procedure after SG which has been confirmed as the preferred procedure by Italian bariatric surgeons.

[Therapeutic Options for Regaining Weight after Bariatric Surgery]

PURPOSE

The purpose of this article is to create an overview of diagnostic and therapeutic options for weight regain (WR) and insufficient weight loss (IWL) after bariatric surgery (BS). With increasing popularity of BS, WR is becoming more relevant.

METHODS

We combined recent literature on WR and IWL with personal experience to suggest possible proceedings if WR or IWL is diagnosed.

RESULTS

If an anatomical-pathological cause can be detected, surgical therapy is the most effective. If WR or IWL is idiopathic, a multimodal therapeutic concept is necessary for sufficient therapeutic success. Depending on the initial BS, a combination of lifestyle intervention, medication and surgical therapy seems most effective.

CONCLUSIONS

Extensive diagnostic testing is necessary prior to any surgical intervention. In idiopathic WR after Roux-en-Y Gastric Bypass (RYGB), we suggest lengthening the biliopancreatic limb and shortening the common channel. After Sleeve-Gastrectomy (SG), we currently see RYGB as most effective in patients with gastroesophageal reflux disease (GERD) and SADI-S as a feasible option if no GERD is present.

Safety of biliopancreatic diversion with duodenal switch in patients with body mass index less than 50 kg/m2

INTRODUCTION

Biliopancreatic diversion with duodenal switch (BPD-DS) has often been reserved for patients with BMI > 50 kg/m². We aim to assess the safety of BPD-DS in patients with morbid obesity (BMI ³35 kg/m² and < 50 kg/m²) using a 150-cm common channel (CC), 150-cm Roux limb, and 60-fr bougie.

METHODS

A retrospective review was performed on patients with a BMI < 50 mg/k² who underwent a BPD-DS in 2016-2019 at a single institution. Limb lengths were measured with a laparoscopic instrument with minimal tension. Sleeve gastrectomy was created with 60-fr bougie. Variables were compared using paired t test, Chi-square analysis or repeated measures ANOVA where appropriate.

RESULTS

Forty-five patients underwent BPD-DS. CC lengths and Roux limb lengths were 158 ± 20 cm and 154 ± 18 cm, respectively. Preoperative BMI was 44.9 ± 2.3 kg/m² and follow-up was 2.7 ± 1.4 years. One patient required reoperation for bleeding and died from multiorgan failure and delayed sleeve leak. There was 1 (2.2%) readmission for contained anastomotic leak and 2 ED visits (4.5%) within 30 days. There were no marginal ulcers, limb length revisions, or need for parental nutrition. Percent excess weight loss was 67.2 ± 19.7%. 88.9% (N = 8), 86.6% (N = 13), and 55.5% (N = 5) of patients had resolution or improvement of their diabetes mellitus type II, hypertension, and hyperlipidemia, respectively. 40% (N = 4) of patients had resolution of their gastroesophageal reflux disease (GERD) and 11.4% (N = 5) developed de novo GERD. 32% (N = 14) of patients had vitamin D deficiency and 25% (N = 11) experienced zinc deficiency.

CONCLUSION

BPD-DS may be considered in patients with BMI < 50 kg/m² with 150-cm CC, 150-cm Roux limb, and a 60-fr bougie sleeve gastrectomy. There was sustained weight loss and no protein calorie malnutrition, but Vitamin D and zinc deficiency remained a challenge. Careful patient selection and proper counseling of the risks and benefits are necessary.

Endoscopic Management of Weight Recurrence Following Bariatric Surgery

Metabolic and bariatric surgery is the most effective therapy for weight loss and improving obesity-related comorbidities, comprising the Roux-en-Y gastric bypass (RYGB), gastric banding, sleeve gastrectomy (SG), and biliopancreatic diversion with duodenal switch. While the effectiveness of weight loss surgery is well-rooted in existing literature, weight recurrence (WR) following bariatric surgery is a concern. Endoscopic bariatric therapy presents an anatomy-preserving and minimally invasive option for managing WR in select cases. In this review article, we will highlight the endoscopic management techniques for WR for the most commonly performed bariatric surgeries in the United States -RYGB and SG. For each endoscopic technique, we will review weight loss outcomes in the short and mid-terms and discuss safety and known adverse events. While there are multiple endoscopic options to help address anatomical issues, patients should be managed in a multidisciplinary approach to address anatomical, nutritional, psychological, and social factors contributing to WR.

Postoperative morbidity and weight loss after revisional bariatric surgery for primary failed restrictive procedure: A systematic review and network meta-analysis

BACKGROUND

revisional bariatric surgery is gaining increasing interest as long term follow-up studies demonstrate an elevated failure rate of primary surgery due to insufficient weight loss, weight regain or complications. This particularly concerns restrictive bariatric surgery which has been widely adopted from the '80s till present through different procedures, notably vertical banded gastroplasty, laparoscopic adjusted gastric banding and sleeve gastrectomy. The aim of this study is to define which revisional bariatric procedure performs the best after failure of primary restrictive surgery.

METHODS

a systematic review and network meta-analysis of 39 studies was conducted following the PRISMA guidelines and the Cochrane protocol.

RESULTS

biliopancreatic diversion with duodenal switch guarantees the best results in terms of weight loss (1 and 3-years %TWL MD: 12.38 and 28.42) followed by single-anastomosis duodenoileal bypass (9.24 and 19.13), one-anastomosis gastric bypass (7.16 and 13.1), and Roux-en-Y gastric bypass (4.68 and 7.3) compared to re-sleeve gastrectomy. Duodenal switch and Roux-en-Y gastric bypass are associated to an increased risk of late major morbidity (OR: 3.07 and 2.11 respectively) compared to re-sleeve gastrectomy while no significant difference was highlighted for the other procedures. Re-sleeve gastrectomy is the revisional intervention most frequently burdened by weight recidivism; compared to it, patients undergoing single-anastomosis duodenoileal bypass have the lowest risk of weight regain (OR: 0.07).

CONCLUSION

considering the analyzed outcomes altogether, single-anastomosis duodenoileal bypass and one-anastomosis gastric bypass are the most performing revisional procedures after failure of restrictive surgery due to satisfying short and mid-term weight loss and low early and late morbidity. Moreover, single-anastomosis duodenoileal bypass has low risk of weight recidivism.

Sleeve gastrectomy with transit bipartition in a series of 883 patients with mild obesity: early effectiveness and safety outcomes

BACKGROUND

At least 25 metabolic/bariatric procedures have been proposed globally, 5 formally endorsed. A newer procedure, sleeve gastrectomy with transit bipartition (SG + TB), appears to markedly reduce weight and improve metabolic syndrome while being relatively simple technically and protective of long-term nutritional stability. We aimed to investigate SG + TB effectiveness and safety.

METHODS

In a single-center retrospective analysis of prospectively collected data, SG + TB patients were followed through 12 months. Primary outcomes were changes in weight [body mass index (BMI), total weight loss (TWL)], metabolic parameters [HbA1_C, LDL cholesterol, triglycerides (TG), hypertension], and nutritional status. Repeated-measures analysis of variance (ANOVA) was used to assess changes in weight and metabolic parameters at 1, 3, 6, 9, and 12 months after surgery.

RESULTS

Between 2015 and 2019, 883 patients (mean age 51.8 yrs, BMI 34.1 ± 5.0 kg/m²) underwent SG + TB. Mean operative time was 124 ± 25.4 min; hospitalization, 4.0 ± 2.5 days. ANOVA indicated significant reductions in weight and metabolic parameters (p < 0.005). In 646 patients with complete weight data at 12 months, mean BMI was reduced to 27.2 ± 3.4 kg/m² (p < 0.001), TWL 19.8 ± 6.0%. HbA1_C was normalized in 83.3% of SG + TB patients; hyperlipidemia, hypertension, and hypertriglyceridemia were significantly reduced (p < 0.001). Also, there was a significant reduction in the proportion of patients outside normal nutritional reference ranges. The overall complication rate was 10.2%. There was no mortality.

CONCLUSION

In a series of 833 lower-BMI patients who underwent SG + TB and were followed through 12 months (73.2% follow-up), significant weight loss, comorbidity reduction, and nutritional stability were attained with few major complications and no mortality.

Which predictors could effect on remission of type 2 diabetes mellitus after the metabolic surgery: A general perspective of current studies?

BACKGROUND

The alarming rise in the worldwide prevalence of obesity is paralleled by an increasing burden of type 2 diabetes mellitus (T2DM). Metabolic surgery is the most effective means of obtaining substantial and durable weight loss in individual obese patients with T2DM. There are randomized trials that justify the inclusion of metabolic surgery into the treatment algorithm for patients with T2DM, but remission rates of T2DM after metabolic surgery can display great variability.

AIM

To discuss the most commonly used surgical options including vertical sleeve gastrectomy, adjustable gastric banding, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch.

METHODS

We also report from observational and randomized controlled studies on rate of remission of T2DM after the surgical procedures.

RESULTS

In light of the recent findings, metabolic surgery is a safe and effective treatment option for obese patient with T2DM, but further studies are needed to clarify better the rate of diabetes remission.

CONCLUSION

In light of the recent findings, metabolic surgery is a safe and effective treatment option for obese patients with T2DM, but further studies are needed to clarify better the rate of diabetes remission.

Reluctance in duodenal switch adoption: an international survey among bariatric surgeons

BACKGROUND

Duodenal switch (DS) still comprises less than 1% of the overall primary procedures in the United States. Our aim is to explore the reasons behind surgeons' reluctance to DS adoption.

OBJECTIVES

To determine perceived reasons for the widespread lack of adoption of the DS.

SETTING

Worldwide survey of closed bariatric surgery social media groups.

METHODS

A standardized questionnaire was posted on 2 closed social media bariatric groups. DS was used as an umbrella term that includes traditional BPD with duodenal switch, single anastomosis duodeno-ileostomy (SADI) and loop DS. The questionnaire link was accessible to bariatric surgeons only for a period of 1 week.

RESULTS

Survey responses (n = 193) were analyzed. The majority (75%) were fellowship-trained bariatric surgeons, and 58% were practicing in the United States. Although 72.9% believed DS to be a good bariatric procedure, it was not being performed by 64% of the respondents. The main reasons behind DS nonadoption included a perceptible high long-term complication rate (43.5%), lack of training (38.1%), and procedure seldomly demanded by patients (31.5%). For surgeons who perform DS, 16.4% use it as a revisional procedure, mainly following sleeve gastrectomy (40.5%). Finally, 29.5% of surgeons believed that the American Society of Metabolic and Bariatric Surgery endorsement of SADI will encourage them to add DS to their practice. They are mostly planning to do so by visiting other surgeons and getting proctored (42.6%).

CONCLUSION

This survey will help guide bariatric societies and governing bodies in addressing the issues and concerns preventing surgeons from adopting DS in their practice by elucidating the chief reasons and circumstances behind this occurrence.

Roux-en-Y gastric bypass as revisional surgery

The Roux-en-Y gastric bypass (RYGB) is a worldwide-performed procedure as primary surgery, and as conversional procedure after complications and/or failure of other bariatric procedures. RYGB can be performed as revisional surgery after adjustable gastric banding, vertical banded gastroplasty, sleeve gastrectomy and one anastomosis gastric bypass. Each of these revisional procedures may be technically challenging, and accurate preoperative work-up and operative planning is required. If correctly performed, RYGB as revisional procedure is associated with satisfying outcomes and is indicated in the treatment of insufficient weight loss and postoperative complications of a primary bariatric procedure - such as chronic leak or gastroesophageal reflux after sleeve gastrectomy. The present article analyzes the most important indications, technical points and tips and tricks to safely perform RYGB as a secondary procedure.

Revisional surgery in severe nutritional complications after bariatric surgical procedures: report of four cases from a single institution and review of the literature

INTRODUCTION

bariatric surgery is currently the only treatment that leads to long-term and sustained weight loss and decreased morbidity and mortality in morbidly obese individuals. Roux-en-Y bypass causes weight loss by restricting food intake associated with reduced intestinal absorption, in addition to multiple endocrine and satiogenic effects. Biliopancreatic diversion promotes weight loss mainly due to poor absorption of the nutrients ingested. Both procedures exclude parts of the gastrointestinal tract.

OBJECTIVE

to describe four cases of revisional surgery after primary bariatric surgery, due to serious nutritional complications, and to review the literature regarding this subject.

METHODS

a retrospective analysis of patients of Unicamps bariatric center database and review of the literatures were performed.

RESULTS

four patients were identified, 2 women and 2 men, with a mean age of 48 years. The mean body mass index before revisional surgery was 23.7 kg/m2. Three patients underwent Scopinaro biliopancreatic diversion, and onde patient underwent Roux-en-Y gastric bypass. The revisional surgeries were revision, conversion, and reversion. One patient died. For the review of the literature 12 articles remained (11 case reports and 1 case series). Another five important original articles were included.

CONCLUSION

fortunately, revision surgery is rarely necessary, but when indicated it has increased morbidity, It can be revision, reverion or conversion according to the severity of the patient and the primary surgery performed.

Conversion from Duodenal Switch to Single Anastomosis Duodenal Switch to Deal with Postoperative Malnutrition

BACKGROUND

Duodenal switch (DS) is considered one of the most effective bariatric techniques for long-term weight and comorbidity control. After these operations, some patients may get severe complications related to malnutrition and a few of them may need surgical revision. Lengthening the common channel (CC) is usually the solution: changing the Roux anastomosis or with a side-to-side anastomosis (kissing X). We propose that when simplified construction of the DS is used, conversion to single anastomosis DS (SADI-S/OADS) is an easy and safe choice.

OBJECTIVES

To evaluate the safety and effectiveness of conversion from DS to SADI-S in cases of malnutrition.

METHODS

We report three patients with severe malnutrition after a DS at 9, 74, and 84 months. One of them had also liver failure related to alcohol abuse and malnutrition. Laparoscopic reoperations included a new ileo-ileal anastomosis and takedown of the Roux-en-Y anastomosis with the aim of lengthening the CC.

RESULTS

All three patients were successfully converted by laparoscopy. After a median follow-up of 54.6 months [32-76 months], all of them had moderate weight regain and returned to normal biochemical nutritional parameters. Two patients with type 2 diabetes (T2DM) before DS had complete remission before conversion; one of them had recurrence of T2DM after conversion. The patient with liver failure improved significantly after conversion.

CONCLUSIONS

Conversion from DS to SADI-S/OADS is a simple operation with excellent results in resolving malnutrition in those patients. However, weight regain and recurrence of comorbidities may arise.

Revisiting the Ghrelin Changes Following Bariatric and Metabolic Surgery

Since the description of ghrelin in 1999, several studies have dug into the effects of this hormone and its relationship with bariatric surgery. While some aspects are still unresolved, a clear connection between ghrelin and the changes after metabolic surgery have been established. Besides weight loss, a significant amelioration in obesity-related comorbidities following surgery has also been reported. These changes in patients occur in the early postoperative period, before the weight loss appears, so that amelioration may be mainly due to hormonal changes. The purpose of this review is to go through the current body of knowledge of ghrelin's physiology, as well as to update and clarify the changes that take place in ghrelin concentrations following bariatric/metabolic surgery together with their potential consolidation to outcomes.

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

BACKGROUND

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

OBJECTIVES

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

SETTING

Tertiary hospital.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Limb Length in Gastric Bypass in Super-Obese Patients-Importance of Length of Total Alimentary Small Bowel Tract

BACKGROUND

In super-obese patients, rates of weight loss failure and weight regain are high after RYGB. In order to improve weight loss, lengthening of the biliopancreatic limb is vital. In this study, efficacy and safety of two types of RYGB with 2-m BP-limb were assessed in improving weight loss and in the resolution of comorbidities compared with standard RYGB in a long-term follow-up.

METHODS

This is a retrospective cohort analysis on 671 super-obese patients operated in a 10-year period. Patients were classified into three groups: (1) 155 patients; roux limb 150 cm, BP-limb 60 cm; (2) 230 patients; roux limb 60 cm, BP-limb 200 cm; and (3) 286 patients; roux limb 150 cm, BP-limb 200 cm. EWL, TWL, BMI, failure, weight regain, comorbidity resolution, nutritional status, and complications were assessed.

RESULTS

Total alimentary limb length was shortened with 60 cm in group 1 and with 200 cm in groups 2 and 3. EWL, BMI change, and TWL were higher in the 2-m BP-limb groups vs group 1. No differences in complication rates were found, except higher frequency of marginal ulcers in patients with a shorter roux limb. EWL failure was higher in group 1 (10.3%) vs the other groups (4.3%; 5.2%). Group 3 had significantly less weight regain (26.6%). Remission of comorbidities was higher in the 2-m BP-limb groups at expense of nutritional and vitamin deficiencies (3.9%; 5.9%). No difference in hypoalbuminemia was noted.

CONCLUSION

Lengthening of the BP-limb gives significantly higher weight loss, lower rate of EWL failure, and lesser weight regain along with better resolution of obesity-associated comorbidities.

New Metrics to Assess Type 2 Diabetes After Bariatric Surgery: The "Time-Within-Remission Range"

Almost one third of patients do not achieve type 2 diabetes remission after bariatric surgery or are unable to sustain this effect long term. Our objective was to delve further into the dynamic responses of diabetes after bariatric surgery and to evaluate the "time-within-remission range" as a variable of metabolic control. A descriptive cohort study was done using a computerised multicentre and multidisciplinary registry. All data were adjusted by propensity score. A total of 1186 subjects with a follow-up of 4.5 ± 2.5 years were included. Type of surgery, diabetes remission, recurrence of diabetes, "time-within-remission range" and key predictors of diabetes outcomes were assessed. All patients (70% women, 51.4 ± 9.2 years old, body mass index (BMI) 46.3 ± 6.9 kg/m2) underwent primary bariatric procedures. "Time-within-remission range" were 83.3% (33.3-91.6) after gastric bypass, 68.7% (7.1-87.5) after sleeve gastrectomy and 90% (83.3-92.8) after malabsorptive techniques (p < 0.001 for all). Duration of diabetes, baseline HbA1c and insulin treatment were significantly negatively correlated with the "time-within-remission range". The association of bariatric techniques with "time-within-remission range", using gastric bypass as a reference, were: odds ratio (OR) 3.70 (2.34-5.84), p < 0.001 for malabsorptive techniques and OR 0.55 (0.40-0.75), p < 0.001 for sleeve gastrectomy. Characteristics of type 2 diabetes powerfully influence the outcomes of bariatric surgery. The "time-within-remission range" unveils a superiority of gastric bypass compared to sleeve gastrectomy.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Standardization of Bariatric Metabolic Procedures: World Consensus Meeting Statement

BACKGROUND

Standardization of the key measurements of a procedure's finished anatomic configuration strengthens surgical practice, research, and patient outcomes. A consensus meeting was organized to define standard versions of 25 bariatric metabolic procedures.

METHODS

A panel of experts in bariatric metabolic surgery from multiple continents was invited to present technique descriptions and outcomes for 4 classic, or conventional, and 21 variant and emerging procedures. Expert panel and audience discussion was followed by electronic voting on proposed standard dimensions and volumes for each procedure's key anatomic alterations. Consensus was defined as ≥ 70% agreement.

RESULTS

The Bariatric Metabolic Surgery Standardization World Consensus Meeting (BMSS-WOCOM) was convened March 22-24, 2018, in New Delhi, India. Discussion confirmed heterogeneity in procedure measurements in the literature. A set of anatomic measurements to serve as the standard version of each procedure was proposed. After two voting rounds, 22/25 (88.0%) configurations posed for consideration as procedure standards achieved voting consensus by the expert panel, 1 did not attain consensus, and 2 were not voted on. All configurations were voted on by ≥ 50% of 50 expert panelists. The Consensus Statement was developed from scientific evidence collated from presenters' slides and a separate literature review, meeting video, and transcripts. Review and input was provided by consensus panel members.

CONCLUSIONS

Standard versions of the finished anatomic configurations of 22 surgical procedures were established by expert consensus. The BMSS process was undertaken as a first step in developing evidence-based standard bariatric metabolic surgical procedures with the aim of improving consistency in surgery, data collection, comparison of procedures, and outcome reporting.

For whom the bell tolls? It is time to retire the classic BPD (bilio-pancreatic diversion) operation

With the culture of safety and lowering risks that took place 20 years ago, sleeve gastrectomy has emerged as a procedure of choice. Hence, for super- and super-super-obese patients, there is a tendency these days to perform surgeries in 2 stages, and sleeve is the procedure of choice. Because sleeve is not part of a classic bilio-pancreatic diversion, it is unlikely that this operation will be done as a second stage, making this operation obsolete.

Single- or double-anastomosis duodenal switch versus Roux-en-Y gastric bypass as a revisional procedure for sleeve gastrectomy: A systematic review and meta-analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) is one of the most commonly performed bariatric procedure worldwide. There is currently no consensus on which revisional procedure is best after an initial SG.

OBJECTIVES

To compare the efficacy and safety between single-anastomosis duodeno-ileal bypass (SADI) or biliopancreatic diversion with duodenal switch (BPD-DS) versus Roux-en-Y gastric bypass (RYGB) as a revisional procedure for SG.

SETTING

University Hospital, Canada.

METHODS

MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and PubMed were searched up to August 2018. Studies were eligible for inclusion if they compared SADI or BPD-DS with RYGB as a revisional bariatric procedure for SG. Primary outcome was absolute percentage of total weight loss. Secondary outcomes were length of stay, adverse events, and improvement or resolution of co-morbidities (diabetes, hypertension, or hypercholesterolemia). Pooled mean differences were calculated using random effects meta-analysis.

RESULTS

Six retrospective cohort studies involving 377 patients met the inclusion criteria. The SADI/BPD-DS group achieved a significantly higher percentage of total weight loss compared with RYGB by 10.22% (95% confidence interval, -17.46 to -2.97; P = .006). However, there was significant baseline equivalence bias with 4 studies reporting higher initial body mass index (BMI) in the SADI/BPD-DS group. There were no significant differences in length of stay, adverse events, or improvement of co-morbidities between the 2 groups.

CONCLUSION

SADI, BPD-DS, and RYGB are safe and efficacious revisional surgeries for SG. Both SADI and RYGB are efficacious in lowering initial BMI but there is more evidence for excellent weight loss outcomes with the conversion to BPD-DS when the starting BMI is high. Further randomized trials are required for definitive conclusions.

Does the RYGB common limb length influence hypertension remission and cardiometabolic risk factors? Data from the GATEWAY trial

BACKGROUND

Although Roux-en-Y gastric bypass (RYGB) results in significant weight loss and cardiometabolic risk factors improvements; there is no consensus whether limb lengths may influence these results.

OBJECTIVE

To evaluate the correlations between the common limb length (CLL) and hypertension remission rate, cardiometabolic risk factors, and nutritional parameters after RYGB.

SETTINGS

Private Hospital, Brazil.

METHODS

GATEWAY is a randomized trial designed to evaluate the efficacy of RYGB on hypertension improvement and other cardiometabolic risk factors in patients with grade I and II obesity compared with medical therapy. The follow-up was 1 year. We measured the entire bowel in all patients and used a 150-cm alimentary limb and a 100-cm biliopancreatic limb. Univariate logistic regression was used to estimate the relationship between CLL and hypertension remission. Pearson and Spearman correlation were used to evaluate the correlation between the CLL and the percentage changes of cardiometabolic risk factors and nutritional parameters.

RESULTS

From 100 randomized patients, 45 were submitted to RYGB and completed the follow-up. Mean CLL was 466.3 ± 86.4 cm. Of patients, 55.6% from the RYGB group showed remission of hypertension. CLL length was not significantly associated with hypertension remission (odds ratio [95% confidence interval] for 50 units increase in CLL: .97 [.68; 1.38], P = .88). Consistently, we found no correlations between CLL and all changes in cardiometabolic risk factors and nutritional parameters.

CONCLUSIONS

In a proximal RYGB, CLL does not influence hypertension remission, cardiometabolic risk factors, and nutritional parameters.

Optimisation of follow-up after metabolic surgery

Bariatric surgery has many benefits beyond weight loss, including improved control of glycaemia, blood pressure, and dyslipidaemia; hence, such surgery has been rebranded as metabolic surgery. The operations are, unfortunately, also associated with major surgical and medical complications. The medical complications include gastro-oesophageal reflux disease, malnutrition, and metabolic complications deriving from vitamin and mineral malabsorption. The benefits of surgery can be optimised by implementing specific protocols before and after surgery. In this Review, we discuss the assessment of the risk of major cardiac complications and severe obstructive sleep apnoea before surgery, and the provision of adequate lifelong postsurgery nutritional, vitamin, and mineral supplementation to reduce complications. Additionally, we examine the best antidiabetic medications to reduce the risk of hypoglycaemia after gastric bypass and sleeve gastrectomy, and the strategies to improve weight loss or reduce weight regain. Although optimising clinical pathways is possible to maximise metabolic benefits and reduce the risks of complications and micronutrient deficiencies, evolution of these strategies can further improve the risk-to-benefit ratio of metabolic surgery.

Technical Options for Malabsorption Issues After Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy

BACKGROUND

Laparoscopic single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) is a recently developed one- or two-stage operation based on biliopancreatic diversion that is used to treat morbid obesity. Some midterm outcomes suggest that malabsorption is a possible complication following the procedure. Therefore, conversion to a less malabsorptive procedure may be required. We aim to describe and analyze the outcomes after laparoscopic conversion of SADI-S to non-malabsorptive or less malabsorptive procedures.

METHODS

From January 2015 to April 2017, five patients underwent laparoscopic conversion to single anastomosis duodenojejunal bypass with sleeve gastrectomy (SADJ-S) (video) following SADI-S, and one female patient underwent laparoscopic conversion to gastric bypass (GBP) following SADI-S, after presenting with severe protein-calorie malnutrition, nutritional deficiencies, poor quality of life, or increased number of bowel movements.

RESULTS

Mean preoperative BMI was 24.0 kg/m² (20.4-27.5 kg/m²). Four patients underwent SADI-S to SADJ-S conversions and one underwent a SADI-S to Roux-en-Y duodenojejunal bypass. All cases were performed laparoscopically. No relevant postoperative complications or mortality was reported and the mean hospital stay was 4.6 days. Malabsorptive symptoms resolved in all patients. All patients experienced weight regain. Mean BMI increase was 7.1 kg/m² (5-10.8 kg/m²).

CONCLUSIONS

Outcomes of laparoscopic conversion to SADJ-S or GBP after SADI-S were acceptable, showing clinical improvement of malnutrition, nutritional deficiencies, and quality of life in all cases. Weight regain must be advised. These techniques appear feasible and free of severe long-term complications. Further investigation is warranted to understand the best common channel length for patients undergoing SADI-S.

[Efficacy of two bariatric surgeries in type 2 diabetic patients with a body mass index of 25-27.5]

OBJECTIVE

To evaluate the therapeutic effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic duodenal-jejunal bypass with sleeve gastrectomy (SADJB-SG) in patients with type 2 diabetes mellitus and a low body mass index (BMI) of 25-27.5.

METHODS

Thirty-one type 2 diabetic patients with a BMI of 25-27.5 underwent bariatric surgeries in the General Hospital of Guangzhou Military Command between August, 2013 and August, 2015. The patients receiving LRYGB (17 cases) and SADJB-SG (14 cases) were compared for physical indexes, glucose metabolism and of pancreatic islet function at 1 year after the surgeries.

RESULTS

No mortality occurred in the patients after the operations. At 1 year after the operation, the patients in LRYGB group showed significant improvements in body weight, BMI, glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), oral glucose tolerance test 2 h (OGTT2h), C-peptide, fasting insulin (FINS), and postprandial 2 hour insulin (2 hPINS) (P<0.05); in SADJB-SG group, significant improvements were observed in the body weigh, BMI, HbA1c, FPG, OGTT2h, and FINS after the operation (P<0.05). The postoperative improvements in body weigh, BMI, HbA1c, FPG, OGTT2h, C-peptide, and 2hPINS were comparable between SADJB-SG group and LRYGB group (P>0.05), but the incidence of postoperative anastomotic ulcer was lower in SADJB-SG group.

CONCLUSION

SADJB-SG and LRYGB produce similar therapeutic effects in type 2 diabetic patients with a low BMI, but SADJB-SG is associated with a low incidence of postoperative complications and is therefore more suitable in such patients.

Revision of Biliopancreatic Diversion for Side Effects or Insufficient Weight Loss: Codification of a New Procedure

PURPOSE

Addressing the problem of proctologic sequelae after Scopinaro's classical BPD, we elongated the common limb from 50 to 200 cm at the expense of the alimentary limb and simultaneously, with the aim of avoiding weight regain, reduced the gastric pouch from 500 to 40 ml. After increased experience with the new procedure, we observed a favourable tendency towards further weight loss. Thus, we subsequently extended the indication to the procedure to patients with unsatisfactory weight loss after Scopinaro's classical BPD (SBPD).

METHODS

We retrospectively reviewed our clinical experience with the new procedure.

RESULTS

From March 2008 to December 2014, 38 patients were submitted to the revisional procedure. The indication to surgical revision was proctologic in 26 patients and unsatisfactory weight loss in 12. After the revisional procedure, a significant reduction in bowel movements per day was observed, together with a significant reduction in body weight (from preoperative 87.1 ± 21 to 69.2 ± 13.5 kg at post-operative year 1 and 68.1 ± 11.9 kg at year 5; p < 0.001) and a parallel reduction in BMI (from preoperative 33.03 ± 7.6 to 26.8 ± 4.1 at post-operative year 1 and 26.9 ± 2.8 at year 5; p < 0.001). Mean excess BMI percent loss was 49.5 ± 94.6% at post-operative month 3, 76.51 ± 74.9% at year 1 and 76.2 ± 31.3% at year 5. Nutritional and metabolic parameters remained stable. Similar results were observed, analysing separately both groups of patients.

CONCLUSIONS

Our preliminary data suggest that the proposed procedure could represent a safe and effective revisional tool to treat invalidating proctologic sequelae after SBPD, or when weight loss may be deemed unsatisfactory.