The Role of Total Alimentary Limb Length in Roux-En-Y Gastric Bypass – A Systematic Review

Surgical Management of Bariatric Complications and Weight Regain

The history and evolution of bariatric/metabolic surgical procedures allows for only a brief introduction to complications and surgical approaches for improved weight loss. Our specialty lacks standardization of our operations such as gastric pouch size, intestinal bypass lengths, and consensus on which procedure is best for each individual patient. Anatomic construct as well as adherence to lifestyle modifications can affect short- and long-term outcomes.

Do all roads lead to Rome?: A retrospective analysis on surgical technique in Roux-en-Y gastric bypass

BACKGROUND

New York University Langone Health has three accredited bariatric centers, with altogether ten different bariatric surgeons. This retrospective analysis compares individual surgeon techniques in laparoscopic or robotic Roux-en-Y gastric bypass (RYGB) to identify potential associations with perioperative morbidity and mortality.

METHODS

All adult patients who underwent RYGB between 2017 and 2021 at NYU Langone Health campuses were evaluated via electronic medical records and MBSAQIP 30-day follow-up data. We surveyed all ten practicing bariatric surgeons to analyze the relationship between their techniques and total adverse outcomes. Bleeding, SSI, mortality, readmission, and reoperation were specifically sub-analyzed via logistic regression.

RESULTS

54 (7.59%) out of 711 patients who underwent laparoscopic or robotic RYGB encountered an adverse outcome. Lower adverse outcomes were observed with laparoscopic approach, creating the JJ anastomosis first, flat positioning, division of the mesentery, Covidien™ laparoscopic staplers, gold staples, unidirectional JJ anastomosis, hand-sewn common enterotomy, 100-cm Roux limb, 50-cm biliopancreatic limb, and routine EGD. Lower bleeding rates were observed with flat positioning, gold staples, hand-sewn common enterotomy, 50-cm biliopancreatic limb, and routine EGD. Lower readmission rates were observed in laparoscopic, flat positioning, Covidien™ staplers, unidirectional JJ anastomosis, and hand-sewn common enterotomy. Gold staples had lower reoperation rates. Otherwise, there was no statistically significant difference in SSI.

CONCLUSION

Certain surgical techniques in RYGB within our bariatric surgery group had significant effects on the rates of total adverse outcomes, bleeding, readmission, and reoperation. Our findings warrant further investigation into the aforementioned techniques via multivariate regression models or prospective study design.

LIMITATIONS

This study was limited by the inherent nature of its retrospective and univariate statistical design. We did not account for the interaction between techniques. The sample size of surgeons was small, and follow-up of 30 days was relatively short. We did not include patient characteristics in the model or control for surgeon skill.

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.

American Society for Metabolic and Bariatric Surgery literature review on the effect of Roux-en-Y gastric bypass limb lengths on outcomes

This literature review is issued by the American Society for Metabolic and Bariatric Surgery regarding limb lengths in Roux-en-Y gastric bypass (RYGB) and their effect on metabolic and bariatric outcomes. Limbs in RYGB consist of the alimentary and biliopancreatic limbs and the common channel. Variation of limb lengths in primary RYGB and as a revisional option for weight recurrence after RYGB are described in this review.

Mucosal and hormonal adaptations after Roux-en-Y gastric bypass

The aim of this study was to perform a comprehensive literature review regarding the relevant hormonal and histologic changes observed after Roux-en-Y gastric bypass (RYGB). We aimed to describe the relevant hormonal (glucagon-like peptides 1 and 2 [GLP-1 and GLP-2], peptide YY [PYY], oxyntomodulin [OXM], bile acids [BA], cholecystokinin [CCK], ghrelin, glucagon, gastric inhibitory polypeptide [GIP], and amylin) profiles, as well as the histologic (mucosal cellular) adaptations happening after patients undergo RYGB. Our review compiles the current evidence and furthers the understanding of the rationale behind the food intake regulatory adaptations occurring after RYGB surgery. We identify gaps in the literature where the potential for future investigations and therapeutics may lie. We performed a comprehensive database search without language restrictions looking for RYGB bariatric surgery outcomes in patients with pre- and postoperative blood work hormonal profiling and/or gut mucosal biopsies. We gathered the relevant study results and describe them in this review. Where human findings were lacking, we included animal model studies. The amalgamation of physiologic, metabolic, and cellular adaptations following RYGB is yet to be fully characterized. This constitutes a fundamental aspiration for enhancing and individualizing obesity therapy.

[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.

Effects of short or long biliopancreatic limb length after laparoscopic Roux-en-Y gastric bypass surgery for obesity: a propensity score-matched analysis

Purpose

Although recent studies reported superior weight reduction in patients undergoing Roux-en-Y gastric bypass (RYGB) with long biliopancreatic limb (BPL), no recommendation regarding limb lengths exists. This study compares weight loss and resolution of obesity-related comorbidities in patients undergoing RYGB with either long or short BPL.

Methods

A retrospective data search from medical records was performed. A total of 308 patients underwent laparoscopic RYGB with a BPL length of either 100 cm or 50 cm. Data was analyzed before and after propensity score matching.

Results

No statistically significant difference in weight reduction between long and short BPL RYGB in terms of percentage of excess weight loss (%EWL) (86.4 ± 24.5 vs. 83.4 ± 21.4, p = 0.285) and percentage of total weight loss (%TWL) (32.4 ± 8.4 vs. 33.0 ± 8.3, p = 0.543) was found 24 months after surgery. Propensity score–matched analysis did not show any statistically significant difference between groups in both %EWL and %TWL. No significant difference between long and short BPL RYGB in the resolution of obesity-related comorbidities was noted 24 months after surgery.

Conclusion

Weight loss and resolution of obesity-related comorbidities were not significantly different between long and short BPL RYGB 24 months after surgery.