Proximal Roux-en-Y gastric bypass: Addressing the myth of limb length

Revisional One-Step Bariatric Surgical Techniques After Unsuccessful Laparoscopic Gastric Band: A Retrospective Cohort Study with 2-Year Follow-up

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) has high reported rates of revision due to poor weight loss (WL) and high complication rates. Yet, there is yet to be a consensus on the best revisional procedure after unsuccessful LAGB, and studies comparing different revisional procedures after LAGB are still needed.

METHODS

This was a retrospective cohort study that compared the outcomes of one-step revisional Roux-en-Y gastric bypass (rRYGB), one-anastomosis gastric bypass (rOAGB), or laparoscopic sleeve gastrectomy (rLSG) after LAGB. WL, complications, resolution of associated medical conditions, and food tolerance were assessed with a post hoc pairwise comparison one-way analysis of variance (ANOVA) throughout a 2-year follow-up.

RESULTS

The final analysis included 102 (rRYGB), 80 (rOAGB), and 70 (rLSG) patients. After 2 years, an equal percentage of excess weight loss was observed in rOAGB and rRYGB (both >90%; p=0.998), significantly higher than that in rLSG (83.6%; p<0.001). In our study, no leaks were observed. rRYGB had higher complication rates according to the Clavien-Dindo classification (10.8% vs. 3.75% and 5.7% in rOAGB and rLSG, respectively, p=0.754), and re-operations were not statistically significant. Food tolerance was comparable between rOAGB and rRYGB (p = 0.987), and both had significantly better food tolerance than rLSG (p<0.001). The study cohorts had comparable resolution rates for associated medical problems (p>0.60).

CONCLUSION

rOAGB and rRYGB had better outcomes after LAGB than rLSG regarding WL, feasibility, food tolerance, and safety. rOAGB had significantly higher rates of nutritional deficiencies.

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.

Optimal common limb length in Roux‐en‐Y gastric bypass surgery: is it important for an ideal outcome? – a systematic review

BACKGROUND

In Roux-en-Y gastric bypass (RYGB) surgery the common limb length (CLL) is thought to significantly impact on nutritional and metabolic outcomes. However, there has been little focus on establishing routine standardized CLL measurements and its subsequent effect on weight loss and nutritional status. This review aimed to determine the effect of variations of CLL in RYGB surgery on post-operative outcomes, particularly nutritional status, while considering the need for routine CLL measurements in addition to measuring biliopancreatic limb and alimentary limb lengths.

METHODS

A systematic review was performed in accordance with the PRISMA guidelines. All English language articles addressing CLL and impact on weight loss, nutritional and metabolic outcomes were retrieved and reviewed.

RESULTS

Thirteen relevant studies were identified with CLLs varying from 76 to >600 cm. No significant difference in total body weight loss or excess weight loss was observed. Significant metabolic improvements occurred with shorter CLLs. Nutritional deficiencies were more severe when the CLL was <400 cm.

CONCLUSION

The data from this systematic review suggests that reasonable weight loss and positive impacts on metabolic outcomes can be achieved with CLLs of >400 cm.

How accurate is the visual estimation of bowel length by endoscopic surgeons?

Background

Measurement of small bowel length is an essential step in performing bariatric surgery. Surgeons need to measure bowel length in order to create alimentary and biliopancreatic limbs. Inaccurate bowel measurement may affect the outcome of surgery. However, it is not clear how accurate the measurement of bowel length is by surgeons.

Methods

Two image quizzes marking certain lengths of jejunum were sent to participants. They were asked to estimate the length of marked bowels in maze quizzes. The Error of estimation, prevalence of significant error (error greater than 30 percent of actual length), and the relationship between different participant characteristics was investigated.

Results

A total of 86 participants answered the questionnaire. The mean error of estimation was 4.62 cm (27%). Twenty-eight participants (33%) had significant errors in estimation of bowel length.

Conclusion

While there are surgeons that can estimate bowel length with decent accuracy, significant errors in estimation of bowel length are not uncommon among surgeons. Surgeons should consider adopting techniques for accurate measurement of the small intestine.

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

Background

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

Methods

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

Results

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

Conclusion

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

Graphical abstract

Excessive weight loss after bariatric surgery: a prediction model retrospective cohort study

Bariatric surgery has been recognized as the most effective long-term treatment for morbid obesity. Despite the considerable positive results, adverse consequence can develop. Excessive Weight Loss (EXWL), a rare consequence of bariatric surgery, can lead to a broad adverse consequence. The aim of this study was determining of prevalence and the predicting model of EXWL in patient underwent bariatric surgery until 24 months after surgery. Data have been extracted from the National Obesity Surgery Database in obesity clinic of Iran University of Medical Sciences. The subjects of this retrospective cohort study were morbid obese individuals who underwent three various types of bariatric surgery [One Anastomosis Gastric Bypass (OAGB), Roux-en-Y Gastric Bypass (RYGB), or Sleeve Gastrectomy (SG)] in period of 24 months ago. EXWL has been defined as reaching to less than or equal to BMI 18.5 at any time until 24 months after surgery. SPSS was used in data analysis. Among 4214 subjects of this study, most excess weight loss after surgery has taken place in 18 months after surgery. 11.4% (n = 495) of patients experienced EXWL with highest percentage among OAGB patients (15.1%) at time of 24 months after surgery. The females (20.4% vs.9.9%) and younger persons (35.45 ± 10.25 vs. 39.06 ± 10.76) were more susceptible to EXWL. Patients with EXWL had significantly lower BMI (body mass index) (41.11 ± 4.51 vs. 46.73 ± 6.26) (Kg/m²), and were less probable to had emotional eating. Visceral fat level, fat percentage, and BMI were the best predictor of EXWL (P value for all < 0.05). So that per level increase in visceral fat, decreases the probability of EXWL as 47% and 61% in SG and OAGB. Moreover, each unit lower BMI leads to 25% higher susceptibility to experience EXWL. Surgery should be adjusted in younger females with a lower BMI and healthy metabolic status who are more prone to EXWL. In such a way that minimize weight loss speed/value. It may be possible by selection of other surgery procedures, rather than OAGB, tighter follow-ups, and consultations of patients after surgery is emphasized for more EXWL vulnerable patients.

Standard Biliopancreatic Limb (50 cm) Roux-en-Y Gastric Bypass Versus Long Biliopancreatic Limb (100 cm) Roux-en-Y Gastric Bypass in Patients with Body Mass Index 40-50 kg/m2: a Randomized Prospective Study

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is a widely performed procedure worldwide especially with the presence of associated medical conditions. Patients with body mass index (BMI) 40-50 kg/m² are at more risk of weight regain and relapse of comorbidities. There is a controversy on the optimum alimentary (AL) and biliopancreatic (BPL) limb lengths to be used in RYGB to achieve weight loss and remission of comorbidities without causing nutritional deficiencies in those patients.

STUDY DESIGN

hundred-and-fifty patients with BMI between 40 and 50 kg/m² were divided equally into 2 groups undergoing standard RYGB (S-RYGB) with AL:150 cm and BPL: 50 cm and long biliopancreatic RYGB (L-RYGB) with AL: 100 cm and BPL: 100 cm. BMI, % of total weight loss (%TWL), effect on diabetes (DM), hypertension (HTN), dyslipidemia, and nutritional statuses were recorded at 1, 2, and 3 years.

RESULTS

Only 64/75 patients in S-RYGB and 57/75 patients in L-RYGB completed the study. L-RYGB had faster weight loss, higher %TWL, and less BMI than S-RYGB with the maintenance of achieved weight. L-RYGB had better control of DM and dyslipidemia than S-RYGB. There were no significant differences in nutritional status between S-RYGB and L-RYGB rather than lower levels of calcium and Hb and higher levels of PTH in L-RYGB yet they remain within the normal range.

CONCLUSION

The application of L-RYGB helps in achieving faster weight loss for a longer period with better remission of associated comorbidities as DM, HTN, and dyslipidemia in patients with BMI 40-50 kg/m² but with effects on the nutritional status.

One Anastomosis Gastric Bypass Versus Long Biliopancreatic Limb Roux-en-Y Gastric Bypass

Background

Roux-en-Y gastric bypass (RYGB) is one of the most effective bariatric procedures. The study aimed to explore the value of lengthening the biliopancreatic limb (BPL) in RYGB compared to the outcome of one-anastomosis gastric bypass (OAGB).

Methods

This prospective study included morbidly obese patients divided into two groups. The RYGB group (n = 36) was subjected to long biliary limb Roux-en-Y gastric bypass (LPRYGB), and the OAGB Group (n = 36) had one anastomosis gastric bypass. During follow-up, weight, BMI, percentage of excess body weight loss (%EBWL), resolution of obesity-related comorbidities, and quality of life (QoL) were evaluated.

Results

There was no significant difference in weight and BMI after 3 and 6 months. At 12-month follow-up, weight loss was significantly higher in the OAGB group. After 12 months, the two groups showed significant improvement of comorbid conditions without significant difference between the two groups. The Qol was significantly higher in the LPRYGB group 3, 6, and 12 months after surgery compared to the OAGB group.

Conclusions

Extending the BPL length in RYGB to 150 cm is as effective as OAGB in remission of comorbidities, including diabetes. It was also equally effective in weight reduction in the short term. OAGB was more efficient in weight reduction and a significantly faster operation. LPRYGB showed a better QoL of life 1 year after surgery.

Graphical abstract

Midterm Results from the Dutch Common Channel Trial (DUCATI): Superior Weight Loss Results of the Long Roux Limb Gastric Bypass in Comparison to the Standard Bypass at 3-Year Follow-Up

In the multi-center Dutch Common Channel Trial (DUCATI), a very long Roux limb Roux-en-Y gastric bypass (VLRL-RYGB: BP-limb 60 cm, Roux limb variable, and common channel 100 cm) was compared to a standard Roux-en-Y gastric bypass (S-LRYGB: BP-limb 60 cm, Roux limb 150 cm, and common channel variable) in the treatment of morbidly obese patients. As all trial patients are beyond 3-year follow-up a midterm analysis was performed to investigate the effect of the VLRL-RYGB.

METHODS

A total of 444 patients were randomized (1:1) to receive either a VLRL-RYGB or a S-LRYGB. Follow-up results for weight loss, effect on obesity-related comorbid conditions, complications, reoperation, and malnutrition are investigated.

RESULTS

At 3-year follow-up a significant difference in %TWL (34.0% vs. 31.4%, p = 0.017) and %EWL (84.7% vs. 76.6%, p = 0.043) was observed in favor of VLRL-LRYGB group. Overall complication rate 3-years after surgery was 15.8% in the VLRL-LRYGB group vs. 9% in the S-LRYGB group (p = 0.031). Eight (3.6%) patients in the VLRL-LRYGB group versus 2 (0.9%) in the S-LRYGB group (p = 0.055) required revisional surgery for malabsorption. In the VLRL-LRYGB group 71.9% of patients had resolution of T2DM versus 48.9% in the S-LRYGB group (p = 0.044).

CONCLUSION

At midterm FU a considerable, significantly increased effect on weight loss of the VLRL-LRYGB was observed compared to the S-LRYGB, with a higher risk of overall complications, but no significant nutritional side effects. These results might impact the current view on the value of the Roux limb in the discussion on optimum limb lengths in Roux-en-Y gastric bypass surgery.

Long versus short biliopancreatic limb in Roux-en-Y gastric bypass: short-term results of a randomized clinical trial

BACKGROUND

The Roux-en-Y gastric bypass continues to be one of the most performed bariatric surgeries because of its adequate balance of outcomes, complications, and durability. Recently, the role of the biliopancreatic limb on weight loss and co-morbidity control has gained attention because it seems to have a positive impact based on limb length.

OBJECTIVE

To compare results at 12 months of a "standard" (group 1) versus a long (group 2) biliopancreatic limb bypass. Biliopancreatic limbs were 50 cm and 200 cm, and alimentary limbs were 150 cm and 50 cm, respectively.

SETTING

Academic Referal Center; Mexico City; Public Seeting.

METHODS

Randomized study with patients undergoing both types of surgeries at a single academic center from 2016 to 2018. The analysis included weight loss, co-morbidity control (diabetes and hypertension), biochemical panel, operative outcomes, and complications.

RESULTS

Two-hundred ten patients were included (105 in each group). Almost all data were homogenous at baseline. Female sex comprised 86.1% of cases, with a mean body mass index of 43.5 kg/m². Excess weight loss (77.6 ± 15.7% versus 83.6 ± 16.7%; P = .011) and total weight loss (33.5 ± 6.4% versus 37.1 ± 7.1%; P < .001) was higher in group 2; better HbA1C levels were also observed. Co-morbidity outcomes, operative data, and complications were similar between groups.

CONCLUSION

The Roux-en-Y gastric bypass with 200 cm of biliopancreatic limb length induces more weight loss at 12 months than a 50 cm limb length. Better HbA1C levels were also observed, but similar effects on co-morbidities and complications were noted.

Long-Term Outcome of Proximal Versus Very-Very Long Limb Roux-en-Y Gastric Bypass: the Roux-Limb to Common Channel Ratio Determines the Long-Term Weight Loss

BACKGROUND

The influence of the Roux limb (RL) length on weight loss in Roux-en-Y (RYGB)-type gastric bypass procedures is still unclear. This study analyzes the true impact of RL length by comparing the long-term outcomes of proximal RYGB (PRYGB) and very-very long limb RYGB (VVLL-RYGB).

METHODS

RL length in PRYGB was 150 cm. In VVLL-RYGB, common channel length was 100 cm. In both groups, biliopancreatic limbs measured 50-60 cm, resulting in equal total alimentary limb lengths. To adjust for pre-operative differences between groups, and to predict the long-term outcome, a mixed model analysis was performed.

RESULTS

Two hundred thirty-two patients with VVLL-RYGB (73.7% female, mean age 41.1 ± 10 years, initial BMI 45.8 ± 6.3 kg/m²) and 223 with PRYGB (83.9% female, mean age 38.5 ± 11 years, initial BMI 42.9 ± 4.9 kg/m²) were included. Mean follow-up was 9.4 ± 4 years in VVLL-RYGB and 5.3 ± 1.9 years in PRYGB. After 5 years, mean BMI reduction was 15.7 ± 5.9 kg/m² in VVLL-RYGB and 11.9 ± 4.1 kg/m² in PRYGB (p < 0.001), and mean %EWL was 78.3 ± 23.1% and 70.2 ± 23.7% (p = 0.002) with a follow-up rate of 78% and 75.9%, respectively. The mixed model analysis showed a significantly higher weight rebound after PRYGB. Frequency of revisional surgery (i.e., limb length alteration, pouch banding) was similar between VVLL-RYGB and PRYGB (25 vs. 29 revisions, p = 0.463).

CONCLUSION

The VVLL-RYGB has a significantly higher long-term BMI reduction and a significantly lower weight rebound. The length of the Roux limb significantly influences long-term outcome.

The Influence of Different Alimentary and Biliopancreatic Limb Lengths in Gastric Bypass Patients

PURPOSE

The aim of this study was to compare the effect of two different limb lengths after RYGB on weight loss, postoperative gastro-intestinal complications, and vitamin deficiencies.

MATERIALS AND METHODS

A retrospective analyses of 100 patients after RYGB with 2 different limb lengths were done. Group A (50 patients) had a biliopancreatic limb (BPL) of 75 cm and an alimentary limb (AL) of 150 cm. Group B (50 patients) had a BPL of 150 cm and an AL of 75 cm. The effect on weight loss, body mass index, excess weight loss (EWL), total weight loss (TWL), and postoperative complications was analyzed up to 2 years postoperatively.

RESULTS

Patients with a longer BPL achieved significantly more %EWL compared to a shorter BPL 2 years postoperatively (82.8 ± 31.2 versus 93.8 ± 15.1; p = 0.038). A significant difference was also seen in %TWL after 1 year (30.3 ± 10.1 versus 37.4 ± 6.9; p < 0.01) and 2 years (31.6 ± 7.5 versus 35.6 ± 8.6; p = 0.022), both in favor of group B. However, patients with a longer BPL (group B) showed significant more diarrhea and steatorrhea compared to group A (p < 0.01).

CONCLUSION

BPL of 150 cm is associated with more %EWL and %TWL 2 years after RYGB. However, it is accompanied by an increase of diarrhea and steatorrhea to disadvantage off group B. Future studies need to focus on further tailoring BPL and AL lengths to achieve the best possible outcomes for patients with morbid obesity.