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

Roux limb revision for recalcitrant bile reflux after total gastrectomy

BACKGROUND

Bile reflux is a postgastrectomy syndrome that impacts quality of life. Management includes lifestyle modifications and medical therapy; however, the efficacy of operative intervention for refractory bile reflux is unknown. We aimed to characterize outcomes of Roux limb lengthening for management of recalcitrant bile reflux after total gastrectomy.

METHODS

Retrospective analysis of 159 individuals with germline CDH1 mutations who underwent prophylactic total gastrectomy with Roux-en-Y reconstruction. Patient demographics, frequency of recalcitrant bile reflux, type of medical management, operative details, and clinical outcomes were measured.

RESULTS

Fourteen (8.8%, 14/159) individuals developed bile reflux recalcitrant to medical therapy after prophylactic total gastrectomy and elected for operative Roux limb lengthening of 20-25 cm. Median time from prophylactic total gastrectomy to Roux limb revision was 2.6 years (interquartile range, 2.1-2.9). After revisional surgery, all patients self-reported improvement in bile reflux symptoms. Post-Roux limb revision, almost all (86%, 12/14) patients reported rare or no bile reflux symptoms. Bile reflux severity scores improved to no symptoms in 3 patients (21%), followed by mild (50%, 7/14) or moderate (29%, 4/14) symptoms after Roux limb revision. All individuals (100%, 14/14) who underwent Roux limb revision reported "major improvement" in bile reflux symptoms with a median follow-up of 16 months (interquartile range, 7.5-21.5). Most patients regained weight post-Roux limb revision (+3.3 kg, standard deviation 4.7, P = .02) with a mean percentage weight gain of 5.9% (standard deviation, 7.4). There were no intraoperative or postoperative complications with revisional surgery.

CONCLUSION

Roux limb revision is effective for management of recalcitrant bile reflux. Additional study to identify potential risk factors for bile reflux after total gastrectomy is warranted.

Total Alimentary Limb Length Is Not Associated with Weight Loss Following Proximal Roux-en-Y Gastric Bypass

BACKGROUND

Standard Roux-en-Y gastric bypass (RYGB) typically manipulates the proximal portion of the small intestine, leaving a variable and unknown common channel and total alimentary limb length (TALL). Despite high variability in postoperative weight loss, the factors contributing to this variability remain unknown. Given the known variability in small intestinal length, this unmeasured variability in TALL may be associated with weight loss responses.

OBJECTIVE

To test the hypothesis that TALL is associated with postoperative weight loss following primary laparoscopic Roux-en-Y gastric bypass (RYGB).

SETTING

Vanderbilt University Medical Center; Nashville, Tennessee, USA.

METHODS

A total of 329 patients were recruited for this observational study and consented to laparoscopic measurement of the entire small intestinal length at the time of primary RYGB. Of these patients, 208 had successful measurement of the small bowel length (SBL) and underwent RYGB with a fixed biliopancreatic limb length (BPL, 50 cm). Common channel length (CCL) was allowed to vary normally to test the association between TALL and postoperative weight loss.

RESULTS

Follow-up rates were 77% at 6 months and 41% at 24 months. Average SBL was 592 cm (min = 390 cm, max = 910 cm), with a standard deviation of 107 cm that led to significant variation in CCL (shortest 190 cm, longest 730 cm). Regression was used to model weight loss and body mass index, as well as percent change from baseline, for each patient given the measured TALL and CCL. Despite significant variation in TALL, there were no clinically significant effects of TALL or CCL on weight loss up to 24 months.

CONCLUSIONS

With a fixed BPL, normal variation in TALL does not significantly contribute to weight loss variability following RYGB. Future studies are needed to better understand the importance of intestinal limb lengths in primary and revisional RYGB surgery.

Revisional Roux-en-Y gastric bypass after gastric banding leads to sustainable and significant additional weight loss regardless of Roux limb length

INTRODUCTION

The aim of this study is to compare the outcomes between patients undergoing very-very long limb RYGB (VVLL-RYGB) and proximal RYGB (PRYGB) after adjustable gastric banding (LAGB).

METHODS

All patients undergoing conversion from LAGB to RYGB in a bariatric reference center between 2010 and 2016 were analyzed.

RESULTS

Sixty-six patients (80 ​% female, mean age 44.5 ​± ​9 years, pre-revisional BMI 40.2 ​± ​7.4 ​kg/m2) underwent conversion from LAGB to VVLL-RYGB, and 26 patients (88 ​% female, mean age 46.9 ​± ​7.6 years, pre-revisional BMI 37.2 ​± ​5.3 ​kg/m2) to PRYGB. ΔBMI 5 years after conversion was 8.2 ​± ​6.1 ​kg/m2 in VVLL-RYGB compared to 6.7 ​± ​5.1 ​kg/m2 in PRYGB (p ​= ​0.35). There was no significant difference in long-term morbidity. Further revisional procedures after VVLL-RYGB occurred in 10 (15.1 ​%) and 8 (30.8 ​%) after PRYGB (p ​= ​0.136).

CONCLUSION

VVLL-RYGB and PRYGB after LAGB are safe and lead to significant and sustainable additional weight loss without difference in BMI loss between the procedures after 5 years.

Bariatric nutrition and evaluation of the metabolic surgical patient: Update to the 2022 Obesity Medicine Association (OMA) bariatric surgery, gastrointestinal hormones, and the microbiome clinical practice statement (CPS)

Background

In 2022, the Obesity Medicine Association (OMA) published a Clinical Practice Statement (CPS) which provided an overview of bariatric surgery and related procedures, a discussion on gastrointestinal hormones and a review of the microbiome as it relates to patients with obesity. This update to the 2022 OMA CPS provides a focus on nutrition as it relates to the adult bariatric surgery patient, incorporating a detailed discussion on how to conduct a bariatric nutrition assessment and manage patients seeking metabolic and bariatric surgery (MBS) and postoperative nutrition care. In particular, the section on macronutrients, micronutrients, and bariatric surgery has been updated, highlighting practical approaches to nutrient deficiencies typically encountered in the bariatric surgery patient. Also included is a section on how to envision and develop an interdisciplinary team of medical providers with evidence-based nutrition knowledge and consistent information that improves the quality of nutrition care provided to MBS patients. This CPS adds to the series of OMA CPSs meant to provide guidance to clinicians in their care of patients with obesity.

Methods

The foundation of this paper is supported by scientific evidence in the medical literature and expert opinion derived from several bariatric nutrition resources, as well as from the 2022 OMA CPS focused on bariatric surgery.

Results

This OMA Clinical Practice Statement provides an overview of the current bariatric nutrition clinical guidelines and nutrition tools adapted for clinicians who may not have access to an MBS team or a registered dietitian knowledgeable about bariatric nutrition.

Conclusions

This evidence-based review of the literature includes an overview of current bariatric nutrition recommendations. It is intended to provide clinicians with more advanced knowledge and skills in nutrition assessment and management of the preoperative and post-surgical MBS patients. This CPS also addresses macronutrient and micronutrient deficiencies common in MBS patients, and treatment recommendations designed to help the clinician with clinical decision making.

Addressing recurrent weight gain after Roux-en-Y gastric bypass: efficacy of a dual surgical approach-short-term results of a single-center cohort study

BACKGROUND

There is no gold standard for recurrent weight gain following Roux-en-Y gastric bypass (RYGB). Combining jejuno-jejunostomy distalization type 1 (JJD1) and sleeve resection of the gastrojejunostomy and gastric pouch (GJ-P) may be a potential approach for these patients.

OBJECTIVES

To describe 1-year perioperative and nutritional outcomes of patients who underwent JJD1 with sleeve resection of the GJ-P.

SETTING

High-volume academic bariatric center of excellence.

METHODS

Patients with recurrent weight gain after RYGB who underwent JJD1 with sleeve resection of the GJ-P from 2020 to 2022 were included and studied for 1 year postoperatively. During the procedure, we aimed for a total alimentary limb length (TALL) of 350-500 cm, a new common channel (CC) of 200-350 cm, and a gastrojejunostomy <2 cm in diameter.

RESULTS

A total of 61 patients underwent this combined revisional procedure. The median preoperative body mass index (BMI) was 42.59 kg/m2. The median lengths of the biliopancreatic limb (BPL) before and after distalizatiovn were 50 cm (interquartile range [IQR]: 42.5-75) and 175 cm (IQR: 150-200), respectively. After revision, the median new CC was 270 cm (IQR: 250-300) and the median TALL was 400 cm (interquartile range [IQR]: 362.5-450). The median total small bowel length (TSBL) was 580 cm (IQR 550-640 cm), and the median BPL/TSBL ratio was .32 (IQR .29-.34). At 1, 6, and 12 months, the median BMI of the cohort was reduced to 39.14, 35.55, and 32.9 kg/m2, respectively. At 1 year, the total weight loss (%TWL) was 22.18%. Only 3 (n = 3) patients developed major complications at 1 year. After distalization, the resolution of all obesity-related co-morbidities improved, including type 2 diabetes (3.2%), sleep apnea (13.1%), hypertension (HTN) (11.4%), and hyperlipidemia (HLD) (1.6%).

CONCLUSIONS

The combination of JJD1 and sleeve resection of the GJ-P for RYGB revision was safe and effective, with substantial improvement in weight loss at 1 year.

Long-term Outcome of the Dutch Common Channel Trial (DUCATI): Preservation of Superior Weight Loss Results Without Significant Malnutrition Side Effects

PURPOSE

The optimal bowel limb lengths for laparoscopic Roux-en-Y gastric bypass (LRYGB) to maximize weight loss while minimizing nutritional deficiencies in severe obesity treatment remain a topic of debate. The multi-center Dutch Common Channel Trial (DUCATI) aims to compare the outcomes of a very long Roux Limb Roux-en-Y gastric bypass (VLRL-LRYGB) with a standard Roux-en-Y gastric bypass (S-LRYGB).

METHODS

A total of 444 patients were randomly assigned in a 1:1, double-blind manner to undergo either VLRL-RYGB or S-LRYGB. Five-year follow-up data were assessed, concentrating on weight loss, obesity-related medical conditions, complications, re-operations, and malnutrition.

RESULTS

Both groups had comparable total alimentary lengths (RL + CC). The VLRL-LRYGB group demonstrated significantly greater %TWL (32.2% vs. 28.6%, p = 0.002) and %EWL (81.2% vs. 70.3%, p = 0.002) at 5 years. Eight (3.6%) patients in the VLRL-LRYGB group versus 2 (0.9%) in the S-LRYGB group (p = 0.055) needed modification surgery for malabsorption. Suboptimal clinical response rate was significantly higher (22.0% vs. 8.3%) in S-LRYGB group. No significant differences for nutrient deficiencies in favor of the S-LRYGB group were found.

CONCLUSION

A 100-cm common channel with a relatively long Roux limb provides superior, sustainable weight loss over 5 years, without significantly increased rate of malabsorption-related re-operations. These results suggest that a longer Roux limb can still ensure adequate micronutrient uptake in the total alimentary tract. These findings should be considered in discussions regarding the optimal Roux-en-Y limb length for severe obesity treatment.

American society for metabolic and bariatric surgery: intra-operative care pathway for minimally invasive Roux-en-Y gastric bypass

BACKGROUND

Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB).

OBJECTIVE

This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU).

METHODS

PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee.

RESULTS

Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures.

CONCLUSIONS

This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB.

Revisional Bariatric Surgery After Roux-en-Y Gastric Bypass for Bile Reflux: a Single-Center Long-Term Cohort Study

PURPOSE

Revisional bariatric surgery (RBS) after primary Roux-en-Y gastric bypass (RYGB) is indicated for the efficient management of specific complications such as bile reflux. Published literature on this topic remains scarce as we aim to evaluate the long-term outcomes (10 years) of RBS for bile reflux after RYGB.

MATERIAL AND METHODS

We conducted a single-center retrospective study of patients who underwent primary RYGB complicated by bile reflux and had RBS between 2008 and 2023. Our cohort was divided into two groups based on the etiology of bile reflux. Long-term surgical outcomes and nutritional status were reported and compared between the groups.

RESULTS

A total of 41 patients (100% primary RYGB; 90.2% female, 97.6% white) were included. 56.1% (n = 23) of patients underwent Roux limb lengthening and the remaining 43.9% (n = 18) had a gastrogastric fistula takedown, with no significant differences in terms of intraoperative complications, estimated blood loss (p = 0.616), length of hospital stay (p = 0.099), and postoperative complications between the two groups. Long-term resolution of obesity-related medical conditions was demonstrated for all the evaluated comorbidities. Lastly, there was no reported mortality, bile reflux recurrence, or micro- and macro-nutrient deficiencies over the total follow-up period of 10 years.

CONCLUSION

In our cohort, RBS after a primary RYGB for bile reflux management demonstrated safe and efficient short- and long-term surgical outcomes without any reported bile reflux recurrence or mortality. Adequate supplementation and close patient follow-up remain essential to decrease the morbidity and mortality associated with RBS as further studies are required to support our findings.

Laparoscopic Roux-Y-gastric bypass versus laparoscopic one-anastomosis gastric bypass for obesity: clinical & metabolic results of a prospective randomized controlled trial

BACKGROUND

One anastomosis gastric bypass (OAGB) has been proposed as an effective alternative to the current standard procedure in Switzerland, Roux-en-Y gastric bypass (RYGB). Prospective data comparing both procedures are scarce. Therefore, we performed a non-inferiority randomized controlled trial assessing the effectiveness and safety of these 2 operative techniques.

METHOD

Eighty patients were randomized 1:1. OAGB consisted of a very long gastric pouch with a 200 cm biliopancreatic limb, RYGB of a 150 cm ante-colic alimentary and a 60 cm biliopancreatic limb, respectively. Primary endpoint was the percent excess weight loss (%EWL) at 12 months after surgery.

RESULTS

Mean %EWL at 12 months was 87.9% (SD24.4) in the RYGB group and 104.1% (SD24.6) in the OAGB group (p = 0.006). There was no mortality. The rate of marginal ulcers was higher in patients with OAGB compared to those with RYGB (p = 0.011), while the total number of late complications did not statistically differ between the two groups. Except for the remission of GERD, which was higher in the RYGB group compared to OAGB, there was no difference between the groups regarding the remission of comorbidities. OAGB showed improved glucose control compared to the RYGB after 1 year (p = 0.001). Furthermore, glucagon-like peptide-1 increase was significantly higher in OAGB at 6 weeks (p = 0.041) and 1 year after surgery (p = 0.029). Quality of life improved after both surgeries, without differences between the groups.

CONCLUSIONS

%EWL 1 year after surgery was higher in OAGB than in RYGB. A better glycemic control with a higher increase in GLP-1 was observed after OAGB compared to RYGB.

TRIAL REGISTRATION

This trial is registered on ClinicalTrials.gov under the identifier NCT02601092.

Safety of limb lengthening after Roux-en-Y gastric bypass: an analysis of the MBSAQIP database

BACKGROUND

Roux-en-Y gastric bypass (RYGB) effectively treats severe obesity, but some patients may require revisional surgery like limb lengthening (LL) for postoperative weight gain.

OBJECTIVES

This study aims to compare 30-day serious complications and mortality rates between LL and primary RYGB, given limited safety data on LL.

METHODS

Patients who underwent LL and RYGB were identified from the 2020 and 2021 MBSAQIP databases, the only years in which LL data were available. Baseline characteristics and 30-day rates of serious complications and mortality were analyzed.

RESULTS

A total of 86,990 patients underwent RYGB and 455 underwent LL. Patients undergoing RYGB were younger (44.4 versus 49.8 yr, P < .001), had a higher body mass index (BMI) (45.5 versus 41.8 kg/m2, P < .001) and higher rates of comorbidities including diabetes (30.0 versus 13.6%, P < .001). RYGB and LL had similar operative duration (125.3 versus 123.2 min, P = .5). There were no statistical differences between cohorts for length of stay (LOS) (1.6 RYGB versus 1.6 LL d, P = .6). After LL, there were higher 30-day rates of reoperation (3.3 versus 1.9%, P = .03) and deep surgical site infections (1.3 versus .5%, P = .03) compared to RYGB. There were no differences in overall serious complications (5.1 LL versus 5.0% RYGB, P = 1.0) and mortality (.2 LL versus .1% RYGB, P = .5). Multivariable logistic regression adjustment found that previous venous thromboembolism was associated with serious complications after LL.

CONCLUSIONS

When compared to primary RYGB, LL has a favorable safety profile with similar 30-day rates of serious complications and mortality.

Enteroendocrine Reprogramming by Altered Epithelial-Mesenchymal Crosstalk in Metabolic Surgery

Metabolic surgery is an effective treatment option for type 2 diabetes. However, the therapeutic scope has been limited by unexpected inconsistent outcomes. This study aims to overcome these obstacles by determining fundamental mechanisms from a novel perspective by analyzing and comparing the surgical anatomy, clinical characteristics, and outcomes of metabolic surgery, including duodenal-jejunal bypass, Roux-en-Y gastric bypass, biliopancreatic diversion, one anastomosis gastric bypass, and their modified procedures, predominantly focusing on nonobese patients to mitigate confounding effects from overweighted type 2 diabetes. Regional epithelial cell growth and unique villus formation along the anterior-posterior axis of the small intestine depend on crosstalk between the epithelium and the underlying mesenchyme. Due to altered crosstalk between the epithelium and the opposite mesenchyme at the anastomotic site, the enteroendocrine lineage of the distal intestine is replaced by the proximal epithelium after the bypass procedure. Subsequent intestinal compensatory proliferation accelerates the expansion of the replaced epithelium, including enteroendocrine cells. The primary reasons for unsatisfactory results are incomplete duodenal exclusion and insufficient biliopancreatic limb length. We anticipate that this novel mechanism will have a significant impact on metabolic surgery outcomes and provide valuable insight into optimizing its effectiveness in type 2 diabetes.