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Five-year results after resleeve gastrectomy
Abstract
Introduction
Laparoscopic sleeve gastrectomy (LSG) has rapidly become increasingly popular in bariatric surgery. However, in the long-term follow-up, weight loss failure and intractable severe acid reflux after primary LSG can necessitate further interventions.
Objectives
The aim of our study was to evaluate long term results (5 years) following resleeve gastrectomy (ReSG).
Setting
Private hospital, France
Methods
The study included all patients with failure after LSG who underwent ReSG between October 2008 and January 2014. The patients underwent radiological evaluation and an algorithm of treatment was proposed. We have analyzed the 5-years outcome concerning weight loss and long-term complications after ReSG.
Results
Fifty-two patients (46 women; mean age 40.2 years) with a mean Body Mass Index (BMI) of 39.4 Kg/m² underwent ReSG. The mean interval time from the primary LSG to ReSG was of 27.8 months (11-72 months). The indication for ReSG was inadequate weight loss - 28 patients (53.8 %), weight regain – 22 patients (42.3%), and gastroesophageal reflux disease (GERD) - 2 patients. In 35 cases the gastrografin swallow results were interpreted as primary dilatation and in the remaining 17 cases as secondary dilatation. One patient died from gynecological cancer. Of the remainder, 3 patients underwent Single Anastomosis Duodeno-Ileal Bypass (SADI), 5 patients underwent a Roux en Y Gastric Bypass (RYGB), 1 patient underwent a second ReSG for reflux. Thirty-nine out of 42 patients with ReSG as definitive procedure had available data at 5 years-follow-up. The mean percentage of excess BMI loss was 63.7%. Out of the 39 patients, 28 patients (71.8 % of patients) had >50% Excess BMI Loss (EBMIL) at 5 years. Eight out of the 11 patients with weight loss failure (<50% EBMIL) after ReSG were diagnosed with secondary or diffuse dilation on preoperative imaging; the remaining 3 patients had been operated in our early initial experience with the resleeve procedure. All cases were completed by laparoscopy with no intraoperative incidents. In terms of complications we recorded: one leak, two stenosis and two bleedings with no mortality.
Conclusions
At 5 years postoperative, the ReSG as a definitive bariatric procedure remained effective for 53.8 %. The results appear to be more favorable especially for the non-super-obese patients and for those with primary dilatation. ReSG is a well-tolerated bariatric procedure with a low long-term complication rate. Further prospective clinical trials are required to compare the outcomes of ReSG with those of RYGB or SADI for weight loss failure after LSG.
... Several different secondary interventions, such as revisional sleeve gastrectomy (ReSG) [4], RYGB [5], or biliopancreatic diversion with DS [6] or its variant single-anastomosis duodenoileal bypass (SADI) [7], can be proposed Key Points • We present the first larger series of endoscopic revisional gastroplasty for patients with previous bariatric surgery: 14 cases of LSG (77.8%), 9 cases of RYGBP (19.4%) and 3 cases with previous gastric band. • Endoscopic revisional gastroplasty represents a safe minimal invasive approach with no complications. ...
... each with their own inherent risk of postoperative complications and sequelae. Patients who have had multiple [3,4] different previous revisional procedures assume a greater risk and carry a much greater complication rate. The management of these patients with further surgical endeavors is challenging, and the risk of postoperative complications cannot be underestimated. ...
... Almost half of them (43) had intact gastroplasty at 6 months and only in six cases (6.9%) the ESG had fallen apart. Similarly for bariatric surgery the gastrojejunal anastomosis following RYGB not infrequently will dilate in time [19] and the gastric tube will be enlarged following sleeve gastrectomy [4]. ...
Background
Less invasive endoscopic bariatric procedures are under development for the management of recurrence of obesity. The purpose of the current manuscript was to evaluate the safety of the endoscopic revisional gastroplasty (ERG) for patients with recurrence of weight gain following different bariatric procedures.
Materials and Methods
This is a retrospective single-center study over 22 patients using the ERG between January 2020 to July 2022 at Bouchard Private Hospital (Marseille, France). The demographic data, past surgical history, obesity complications, time interval between the surgical and endoscopic procedures, and intra and postoperative parameters and outcomes were analyzed.
Results
A total of 22 patients underwent ERG: 19 female (86.4%) with a mean age of 34.2 years and a mean BMI of 32.9 kg/m² (± 3.4). Average time between the revisional bariatric surgery and ERG was 14.4 months (range 5–36). There were 14 cases of LSG (77.8%), 9 cases of RYGBP (19.4%), and 3 cases with previous gastric band. All procedures were completed by endoscopy with no complication and a mean length of hospital stay of 1.1 days (± 0.9). The weight loss results at 1-year follow-up were available for 17 of the 22 patients: two patients were lost to follow-up (4%) and 3 patients had less than a 1-year follow-up from the ERG. The mean BMI, 1 year after ERG, was 28.7 kg/m² (± 7.4); the mean BMI loss and %EWL were, respectively, 4.2 kg/m² (± 4.7) and 53.1% (± 17).
Conclusion
Endoscopic revisional gastroplasty represents a safe minimal invasive approach that can be considered an effective and well-tolerated procedure for patients with previous bariatric surgery.
Graphical Abstract
... The maximal weight loss after the initial sleeve was achieved at 19.8 months (mean time when the lowest weight was observed, range: [14][15][16][17][18][19][20][21][22][23][24][25][26][27] (Table 1). At 7 years following the initial SG, the mean weight loss decreased from 130.8 to 91.2 kg after the ReSG (Fig. 2), and the mean BMI decreased from 47 to 33.1 kg/m 2 (Fig. 3) (Table 1). ...
... In an interesting paper, Braghetto et al. [23] showed that mean gastric volume increases 36 months after initial SG (from 108 to 250 cc) and that none of the 15 patients' experiences weight regain whereas Langer et al. [24] have noted many weight regainers without evidence of stomach dilation at a mean follow-up of 20 months. As others, we are convinced that patients eating habits and behavior along with psychological assessment are of importance [25] . The multidisciplinary evaluation before redo-surgery is the cornerstone of a good indication. ...
Introduction
Sleeve gastrectomy (SG) is a good treatment intervention to control metabolic syndrome in patients with obesity worldwide. However, weight regain is of great concern and would usually necessitate a re-intervention. In recent years, re-sleeve gastrectomy (ReSG) has been proposed to treat weight regain in the context of a large residual stomach. Our objective was to analyze the long-term results and safety profile of this intervention in a large case series.
Methods
From September 2010 to March 2021, a retrospective cohort study in a tertiary non-university hospital was performed. Seventy-nine patients received a ReSG by laparoscopy. Pre-operative radiologic imaging showed a dilation of the gastric pouch exceeding 250 cc in all cases.
Results
A total of seventy-nine patients (87% females) with a mean age of 44.8 years old and a mean Body Mass Index (BMI) of 40.0 kg/m ² were enrolled in the study. The mean follow-up was 44.8 months. The ReSG indication was insufficient weight loss in 37 patients (46.8%) and weight regain in 39 patients (53.2%). We noticed a 10.1% complications rate: gastric stenosis (5.1%), bleeding (2.5%), and incisional site hernia in 2.5%, with no death. There was no gastric fistula detected. The mean BMI decreased to 33.1 kg/m ² after ReSG (a decrease of 6.9 kg/m ² ).
Conclusion
After insufficient weight loss or weight regain following sleeve gastrectomy and in presence of localized or global gastric tube dilation, ReSG seems to be a good treatment choice and a safe procedure.
... Consideration of re-sleeve has been based on radiographic criteria where evidence of persistent gastric fundus or diffuse dilation on an upper gastrointestinal series is present [21] . In addition, prior reports have set criteria for re-sleeve as either weight regain or less than < 50% excess weight loss at 1 year after initial sleeve gastrectomy [23] . Dilation of the gastric sleeve is classified into primary and secondary dilation. ...
... Complications have been uncommon in reported literature, though this is likely because this procedure is currently only performed in a few select centers. In general additional weight loss occurs, though the degree varies [20][21][22][23][24][25][26] . ...
Bariatric surgery continues to grow as a treatment modality for obesity and weight-related comorbidities. The anatomic rearrangement can produce unique anatomic complications, as well as functional problems that are correctible with revisional operations. Understanding the unique subset of complications and the options available for correction can allow surgical solutions to be tailored to both the patient’s anatomy, and the symptoms or pathologies they are targeting. Revisional operations are becoming increasingly common, as the proportion of the general population who have previously undergone bariatric surgery continues to increase. Revisional bariatric operations are associated with an increased risk of complications and longer hospital stays, but in experienced centers can be performed safely, and often using minimally invasive approaches.
... 1 Obesity increases the risk of diabetes, hyperlipidemia, hypertension, heart disease, gallbladder disease, sleep apnea, osteoarthritis, and premature death. 2 Laparoscopic sleeve gastrectomy (LSG) is currently the most common bariatric surgery for morbid obesity worldwide. 3,4 LSG has many advantages compared with other bariatric surgeries such as Roux-en-Y gastric bypass. LSG has a relatively simple and easy technique, lack of anastomoses, easier learning curve, and lower major morbidity (0.2-10%) and mortality (<1%). ...
Abstract
Itroduction: Although theoretically a simple procedure, laparoscopic sleeve gastrectomy (LSG) can be followed by life-threatening complications. Early postoperative complications include staple line bleeding and leakage. Staple line reinforcement (SLR) has been used to decrease these complications. There are various methods for reinforcement of staple line such as suture over sewing, placing omental flap, using buttressing material, and spraying fibrin glue along the staple line. However, it is controversial whether SLR reduces the rate of staple line complications or not.
Materials and methods: A prospective randomized clinical trial included 200 super morbidly obese patients randomized into two groups: Group 1 with reinforcement of the staple line by SEAMGUARD® (Gore Medical, Newark, Delaware) and Group 2 with reinforcement of the staple line using suture over sewing.
Results: The mean operative time was significantly shorter in Group 1 than Group 2 (62.6 ± 14.5 vs. 84.7 ±15.8 min, p=0.02). Intraoperative blood loss was significantly lower in Group 1 than Group 2 (17.1± 19.1 vs. 56.8 ± 27.9ml, p=0.00). Staple line hematomas were significantly higher in Group 2. There was no difference in postoperative bleeding between the two groups. No leak was reported in both groups. The cost was higher in Group 1.
Conclusion: Reinforcing the staple line in laparoscopic sleeve gastrectomy using suturing is equal to SEAMGUARD® in all aspects except shorter operative time and lower intraoperative blood loss with SEAMGUARD®.
... However, 1 year after the procedure, Re-SG attained a significant BMI reduction and complete remission of SA in approximately 30% of patients and arterial hypertension in 22% of patients. According to the literature, R-SG is recommended for patients with dilatation of the sleeve stomach or weight loss failure [26,27]. In the presence of reflux disease, other procedures such as RYGB should be used [28]. ...
Purpose
Sleeve gastrectomy (SG) is a common bariatric procedure that has been shown to be effective in both the short and long term, but it is not without risks, some of which necessitate revision or redo surgery (RS).
Materials and Methods
GBSR (German Bariatric Surgery Registry) data were evaluated in this multicenter analysis. Short-term results (1-year follow-up) of RS (Re-Sleeve gastrectomy, Roux-en-Y gastric bypass, RYGB, Omega-loop gastric bypass, OLGB, and duodenal switch, DS) following primary SG (n = 27939) were evaluated.
Results
Of PSG patients, 7.9% (n=2195) needed revision surgery. Nine hundred ninety-four patients underwent the aforementioned four surgical procedures (95 with R-SG, 665 with RYGB, 141 with OLGB, and 93 DS). Loss of follow-up within 1 year 52.44%. The most common reasons for RS were weight regain and/or a worsening of preexisting comorbidities. Regarding the operating time, R-SG was the shortest of the four procedures, and DS was the longest. In general, there were no significant advantages of one procedure over another in terms of complication incidence in these categories. However, certain complications were seen more often after R-SG and DS than with other redo procedures. There were significant differences in BMI reduction 1 year after surgery (RYGB: 5.9; DS: 10.1; OLGB: 9.1; and R-SG: 9.1; p<0.001). GERD, hypertension, and sleep apnea demonstrated statistically significant comorbidity remission. Diabetes exhibited non-significant differences.
Conclusion
According to the findings of our study, all revision surgeries effectively resolved comorbidities, promoted weight loss, and lowered BMI. Due to the disparate outcomes obtained by various methods, this study cannot recommend a particular redo method as the gold standard. Selecting a procedure should consider the redo surgery’s aims, the rationale for the revision, the patient’s current state, and their medical history.
Graphical Abstract
... Hence, it is not surprising that GBP is even regarded to be the preferable approach to treat primary or secondary non-response as well as relapse or persistence of obesity-related comorbidity after previous SG [6]. In addition, alternative approaches have recently been raising attention: re-sleeve gastrectomy (re-SG) [7], conversion to one anastomosis gastric bypass (OAGB) [8], duodenal switch with biliopancreatic diversion (DS) [9], or single anastomosis duodeno-ileal bypass (SADI) [10]. So far, there is a lack of evidence to support decision-making and the surgical approach is often rather based on local or individual protocols than on evidence-based guidelines. ...
Weight non-response after sleeve gastrectomy is an emerging issue. This systematic review compared revisional procedures for weight-related outcomes. We searched several databases for relevant articles and included adult patients with revisional bariatric procedures after primary sleeve gastrectomy. Twelve trials with 1046 patients were included, covering five revisional procedures. There were no randomised controlled trials, and 10 studies had a critical risk of bias. Significant variations in inclusion criteria, therapy benchmarks, follow-up schemes, and outcome measurements were observed, preventing meaningful comparison of results. Evidence-based treatment strategies for weight non-response after sleeve gastrectomy cannot be deduced from the current literature. Prospective studies with well-defined indications, standardised techniques, and strict adherence to outcome measurements are needed.
... All these factors may lead to divergent interpretations of the operation outcomes, erroneous conclusions about the presence of WR, and, consequently, influence patients' healthcare decisions. As such, the lack of specific criteria might result in over or undertreatment of this patient population [38]. ...
Background:
Weight recurrence (WR) after bariatric surgery occurs in nearly 20% of patients. Revisional bariatric surgery (RBS) may benefit this population but remains controversial among surgeons.
Objectives:
Explore surgeon perspectives and practices for patients with WR after primary bariatric surgery (PBS).
Setting:
Web-based survey of bariatric surgeons.
Methods:
A 21-item survey was piloted and posted on social media closed groups (Facebook) utilized by bariatric surgeons. Survey items included demographic information, questions pertaining to the definition of suboptimal and satisfactory response to bariatric surgery, and general questions related to different WR management options.
Results:
One hundred ten surgeons from 19 countries responded to the survey. Ninety-eight percent responded that WR was multifactorial, including behavioral and biological factors. Failure of PBS was defined as excess weight loss < 50% by 31.4%, as excess weight loss <25% by 12.8%, and as comorbidity recurrence by 17.4%. Surgeon responses differed significantly by gender (P = .036). 29.4% believed RBS was not successful, while 14.1% were unsure. Nevertheless, 73% reported that they would perform RBS if sufficient evidence of benefit existed. Most frequently performed revisional procedures included conversion of sleeve gastrectomy to Roux-en-Y gastric bypass (RYGB), adjustable gastric band to RYGB, and RYGB revision (21.9% versus 18.2% versus 15.3%, respectively).
Conclusions:
This survey demonstrates significant variability in surgeon perception regarding causes and the effectiveness of RBS. Moreover, they disagree on what constitutes a nonsatisfactory response to PBS and to whom they offer RBS. These findings may relate to limited available clinical evidence on best management options for this patient population. Clinical trials investigating the comparative effectiveness of various treatment options are needed.
... Several studies report a significant increase in the incidence of GERD after LSG and worsening of underlying symptomatic GERD with more complications and esophagitis or Barrett's esophagus ( Table 7) [12][13][14][15][16][17][18]. ...
Background
Laparoscopic sleeve gastrectomy (LSG) is a common bariatric procedure for weight loss. LSG is becoming prevalent worldwide because it is a relatively simple procedure with high efficacy. Reduced intraabdominal pressure may improve gastroesophageal reflux disease (GERD) symptoms and reduce the GERD medication needed following LSG. However, the main long-term drawback of LSG is the development of de novo GERD. Therefore, we conducted this study to determine the relationship between GERD symptoms and LSG.
Methods
We conducted a retrospective chart review involving 390 patients who underwent LSG. Study participants were evaluated for GERD symptoms six months before and three, six, and nine months after the procedure, and proton-pump inhibitors (PPIs) were used to control the symptoms. Participants were distributed into two groups: one group for patients with GERD symptoms (36.1%) and one group for asymptomatic patients (62.8%). We collected demographic data and assessed PPI use in both groups after three, six, and nine months postoperatively. Data were collected using Microsoft Excel (Microsoft Corporation, Redmond, WA) and analyzed using IBM SPSS Statistics for Windows, Version 20.0 (Armonk, NY: IBM Corp.). We compared data using the student's t-test for independent groups. The quantitative data were summarized using mean and standard deviation (SD), and p < 0.05 was considered statistically significant.
Results
Of the 390 participants who underwent LSG, 83.8% were women (n=327) and 16.2% were men (n=63), with a median age of 42 ± 11.9 years. PPI use was statistically significantly greater after LSG (34.1%) than before LSG (24.6%, p=0.019). The difference in PPI use between symptomatic and asymptomatic groups was not statistically significant three months after LSG.
Conclusions
Our study focuses on using PPI after LSG due to GERD symptoms. We found GERD symptoms improved three months following LSG, but de novo GERD symptoms occurred nine months after the surgery. Health providers need to discuss with their patients the potential outcomes of the surgery and manage patient expectations. Physicians should work with their patients to assess whether the benefits of bariatric surgery in controlling overweight-associated conditions, such as blood pressure, diabetes, sleep apnea, and weight loss, outweigh the risk of GERD symptoms and PPI use.
... Some authors suggest that revisional surgery with reduction of the gastric volume by performing a resleeve gastrectomy (RSG) is a viable option [9,10,31]. However, the long-term results have not been encouraging with only 28% of the patients having a persistent weight loss [32]. Similar to sleeve failure, mechanisms for failure after a RYGB have been proposed and have some degree of overlap, which center around dilatation of the gastric pouch and the gastrojejunal anastomosis. ...
Background
Sleeve gastrectomy (SG) is the most common bariatric procedure performed worldwide. It accounts for more than 50% of primary bariatric surgeries performed each year. Recent long-term data has shown an alarming trend of weight recidivism. Some authors have proposed the concurrent use of a non-adjustable gastric band to decrease long-term sleeve failure.
Objective
To compare the outcomes (weight loss) and safety (rate of complication and presence of upper GI symptoms) between SG and BSG.
Methods
A systematic search with no language or time restrictions was performed to identify relevant observational studies and randomized controlled trials (RCT) evaluating people with morbid obesity undergoing SG or SGB for weight loss. An inverse-of-the-variance meta-analysis was performed by random effects model. Heterogeneity was assessed using Cochrane X² and I² analysis.
Results
A total of 7 observational studies and 3 RCT were included in the final analysis. There were 911 participants pooled from observational studies and 194 from RCT. BSG showed a significant higher excess of weight loss (% EWL). The difference among groups was clinically relevant after the third year where the weighted mean difference (SMD) was 16.8 (CI 95% 12.45, 21.15, p < 0.0001), while at 5 years, a SMD of 25.59 (16.31, 34.87, p < 0.0001) was noticed. No differences related to overall complications were noticed. Upper GI symptoms were up to three times more frequent in the BSG group (OR 3.26. CI 95% 1.96, 5.42, p < 0.0001).
Conclusions
According to the results, BSG is superior to SG in weight loss at 5 years but is associated with a higher incidence of upper GI symptoms. However, these conclusions are based mainly on data obtained from observational studies. Further RCT are needed to evaluate the effect and safety of BSG.
Graphical abstract
... Clapp et al. showed that the weight loss failure rate was found to be higher than expected after LSG, and that it increased accordingly to the length of the analysed follow-up period [24]. The procedure, in fact, could require revisional surgery as Re-Sleeve gastrectomy, RYGB or one anastomosis gastric by-pass exposing patients to a further intervention and eventual complications [16,25,26]. It is worth to comment that the high absolute number of patients experiencing not satisfying results (insufficient EWL or WR) after LSG are related, on the other hand, to the widespread diffusion of the latter technique among obese patients. ...
After the initial widespread diffusion, laparoscopic adjustable gastric banding (LAGB) has been progressively abandoned and laparoscopic sleeve gastrectomy (LSG) has become the worldwide most adopted procedure. Nevertheless, recent reports raised concerns about the long-term weight regain after different bariatric techniques. Considering the large LAGB series recorded in our multicentric bariatric database, we analysed the anthropometric and surgical outcomes of obese patients underwent LAGB at a long-term follow-up, focusing on LAGB management. Between January 2008 to January 2018, demographics, anthropometric and post-operative data of obese patients undergone LAGB were retrospectively evaluated. To compare the postoperative outcomes, the cohort was divided in two groups according to the quantity of band filling (QBF): low band filling group (Group 1) with at most 3 ml of QBF, and patients in the high band filling group (Group 2) with at least 4 ml. 699 obese patients were considered in the analysis (351 in Group 1 and 348 in Group 2). Patients in Group 1 resulted significantly associated ( p < 0.05) to higher % EWL and quality of life score (BAROS Score), 49.1 ± 11.3 vs 38.2 ± 14.2 and 5.9 ± 1.8 vs 3.8 ± 2.5, respectively. Moreover, patients with lower band filling (Group 1) complained less episodes of vomiting, epigastric pain and post-prandial reflux and significantly decreased slippage and migration rate ( p < 0.001 for all parameters). LAGB is a safe and reversible procedure, whose efficacy is primarily related to correct postoperative handling. Low band filling and strict follow-up seem the success’ key of this technique, which deserves full consideration among bariatric procedures.
... Many documents have indicated that Re-LSG is a feasible and safe surgical approach for weight regain post-LSG, remains effective for 53.8% after 5 years, and is best used when the gastric pouch is extremely large or when the gastric tube is dilated after original LSG. 44,[48][49][50][51] Besides, SADI extends the common limb length and reduce the long-term complication rate, while BPD/DS performs a better outcome than SADI when the starting BMI is high. 46,47 Further trials and meta-analyses of ReSG are necessary to prove the efficiency and compare the outcomes of Re-LSG with those of RYGB, DS, or SADI. ...
Bariatric surgery has become increasingly common due to the worldwide obesity epidemic. A shift from open to laparoscopic surgery, specifically, laparoscopic sleeve gastrectomy (LSG), has occurred in the last two decades because of the low morbidity and mortality rates of LSG. Although LSG is a promising treatment option for patients with morbid obesity due to restrictive and endocrine mechanisms, it requires modifications for a subset of patients because of weight regain and tough complications, such as gastroesophageal reflux, strictures, gastric leak, and persistent metabolic syndrome., Revision surgeries have become more and more indispensable in bariatric surgery, accounting for 7.4% in 2016. Mainstream revisional bariatric surgeries after LSG include Roux-en-Y gastric bypass, repeated sleeve gastrectomy, biliopancreatic diversion, duodenal switch, duodenal-jejunal bypass, one-anastomosis gastric bypass, single anastomosis duodeno-ileal bypass (SAID) and transit bipartition. This review mainly describes the revisional surgeries of LSG, including the indication, choice of surgical method, and subsequent effect.
Gastroesophageal reflux disease (GERD) and sleeve gastrectomy (SG) have a complex relationship, with outcomes ranging from symptom resolution to the development of de novo GERD. The impact of SG on GERD is influenced by factors such as amelioration of obesity, disruption of the angle of His, increased intragastric pressure, and intrathoracic sleeve migration. However, the variability
in reported outcomes underscores the need for improved patient selection, robust preoperative evaluation, and long-term research to refine management strategies. A multidisciplinary approach integrating medical, endoscopic, and surgical expertise is essential to optimize outcomes for SG patients with GERD.
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Obesity remains a pressing global health concern, and bariatric surgeries, particularly sleeve gastrectomy (SG), have gained popularity as effective weight loss interventions. However, a significant challenge in post-surgical management is insufficient weight loss (IWL) and weight recurrence (WR) that can be observed in a subset of patients after bariatric surgery especially those who have undergone SG. Causes for WR after SG remain multifactorial and may include anatomic/technical considerations such as initial sleeve size, retained fundus, and sleeve dilation, inadequate follow-up support and education, increased ghrelin levels, and maladaptive lifestyle behaviors. The repercussions of WR after surgery can be profound, leading to the resurgence of comorbidities, a compromised quality of life, and potential negative economic implications. The gravity of this issue is underscored by reoperation rates, which can climb as high as 28% up to seven years after SG. Understanding the intricate reasons for WR after bariatric surgery is pivotal for the advancement of the field. This knowledge will not only shed light on the complexities of post-surgical weight management but also lays the foundation for the development of targeted techniques for identifying, treating, and preventing obesity recurrence. This chapter focuses on the topic of poor weight outcome after SG as the most common bariatric procedure worldwide, reviews its causes and potential therapeutic options to address it.
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.
Introduction: Despite addressing to high risk population, we can propose laparoscopic bariatric surgery to super-super-obese (SSO) patients (body mass index [BMI] ≥60 kg/m2). The aim of this study was to report our experience in terms of weight loss and improvement of medical comorbidities after a follow-up of 5 years in the SSO population who underwent different bariatric procedures. Methods: This retrospective study includes all SSO patients who underwent bariatric surgery (sleeve gastrectomy [SG] and/or gastric bypass) between 2006 and 2017. The population was divided in three groups (SG alone; Roux-en-Y gastric bypass [RYGB] alone and SG+RYGB). The rate of complication and the weight-loss results were analyzed. Results: Among 43 patients who underwent surgery, the mean age was 42[31-54]. There were more women (72%) with the mean preoperative BMI of 64.9 kg/m2 [59.6-70.1]. There were 9 SGs, 26 RYGB, and 8 SG revised to gastric bypass (SG+RYGB) after a median delay of 23.5 months [16.5-32]. The perioperative complication rate was 25%, and there was 1 postoperative death. The median follow-up was 69 months [1-128]. The mean percentage of excess weight loss (%EWL) was 39.2% [18.2-60.3] after 5 years. For the SG group, the %EWL was inferior -27.1 [-3.6 to 57.8], but with no significant difference. An improvement of comorbidities' rate was recorded in all groups of patients. Conclusion: Bariatric surgery in SSO patients leads to an improvement of comorbidities even if the weight-loss results, especially in the SG group, are less favorable. The two steps approach should be re-evaluated by shortening the interval between. Other surgical strategies than RYGB are needed to be evaluated to improve long-term weight loss.
In many countries, one anastomosis gastric bypass (OAGB) is considered as one of the options in bariatric surgery. It involves creating a long, narrow gastric tube anastomosed inside the small intestine at 150–200 cm downstream of the Treitz angle. In the short, mid-, and long term, OAGB with biliopancreatic limb (BPL) length of 200 cm appears to be more effective on weight loss than the Roux-en-Y gastric bypass. When comparing different lengths of BPL, 150 cm BPL or tailored limb have similar results in terms of weight loss compared to 200 cm BPL but with decreased rate of nutritional deficiency. Probably, a modification of the length of BPL is necessary when performing OAGB compared to its original description (biliopancreatic limb of 200 cm). Randomized studies with long-term follow-up along with data regarding digestive symptoms (e.g., gastroesophageal reflux disease) and nutritional symptoms (e.g., malnutrition) are necessary to determine the place of this technique in revisional settings.
Background: With the increase in utilization of laparoscopic sleeve gastrectomy (LSG), intrathoracic sleeve migration (ITSM) has introduced a novel challenge for bariatric surgeons. Despite being an underreported complication, effective and safe solutions for ITSM are being sought. The aim of this study is to present our center's experience as well as a comprehensive review of the literature on ITSM. Accordingly, we propose an algorithm for the surgical management of ITSM. Methods: We conducted a retrospective chart review of 4000 patients who underwent LSG at our center. ITSM was clinically suspected with gastroesophageal reflux disease (GERD) symptoms and/or epigastric pain resistant to proton pump inhibitors. Diagnosis of ITSM was confirmed in all patients by three-dimensional computed tomography (3D-CT) volumetry. Several corrective procedures were offered based on the findings of the 3D-CT volumetry, esophagogastroduodenoscopy, and the diaphragmatic pillars' condition: cruroplasty with gastropexy, one anastomosis gastric bypass (OAGB), or Roux-en-Y gastric bypass (RYGB) with or without re-sleeve gastrectomy, omentopexy, or ligamentum teres augmentation. We conducted a literature review of ITSM using several databases. Results: Fifteen patients were diagnosed with postoperative ITSM. The most common presenting complaint was severely worsened GERD symptoms not responding to medical treatment. The mean time interval between the primary operation and diagnosis of ITSM was 38.8 ± 29.1 months. Three patients had re-sleeve gastrectomy and gastropexy, 5 patients had OAGB, and 7 patients had RYGB. The mean postoperative body mass index was 31.2 ± 4.9 kg/m2. No case of recurrent ITSM was detected during follow-up. Our electronic database search yielded 19 studies to be included in our review, which included 201 patients. Conclusion: A high index of suspicion is required to diagnose ITSM. CT volumetry with 3D reconstruction may be the most sensitive diagnostic modality. ITSM management should depend on the results of the diagnostic workup and the condition of the diaphragmatic pillars during surgery.
Purpose
Staple line reinforcement (SLR) during laparoscopic sleeve gastrectomy (LSG) is controversial. The purpose of this study was to perform a comprehensive evaluation of the most commonly utilized techniques for SLR.
Materials and Methods
Network meta-analysis of randomized controlled trials (RCTs) to compare no reinforcement (NR), suture oversewing (SR), glue reinforcement (GR), bioabsorbable staple line reinforcement (Gore® Seamguard®) (GoR), and clips reinforcement (CR). Risk Ratio (RR), weighted mean difference (WMD), and 95% credible intervals (CrI) were used as pooled effect size measures.
Results
Overall, 3994 patients (17 RCTs) were included. Of those, 1641 (41.1%) underwent NR, 1507 (37.7%) SR, 689 (17.2%) GR, 107 (2.7%) GoR, and 50 (1.3%) CR. SR was associated with a significantly reduced risk of bleeding (RR=0.51; 95% CrI 0.31–0.88), staple line leak (RR=0.56; 95% CrI 0.32–0.99), and overall complications (RR=0.50; 95% CrI 0.30–0.88) compared to NR while no differences were found vs. GR, GoR, and CR. Operative time was significantly longer for SR (WMD=16.2; 95% CrI 10.8–21.7), GR (WMD=15.0; 95% CrI 7.7–22.4), and GoR (WMD=15.5; 95% CrI 5.6–25.4) compared to NR. Among treatments, there were no significant differences for surgical site infection (SSI), sleeve stenosis, reoperation, hospital length of stay, and 30-day mortality.
Conclusions
SR seems associated with a reduced risk of bleeding, leak, and overall complications compared to NR while no differences were found vs. GR, GoR, and CR. Data regarding GoR and CR are limited while further trials reporting outcomes for these techniques are warranted.
Graphical abstract
Laparoscopic sleeve gastrectomies (LSGs) can experience weight-loss failure and conversion to another bariatric procedure. An analysis of the bariatric literature concerning the single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) as revisional surgery after LSG in terms of safety and efficacy identified 607 studies. Fifty-nine studies were analyzed for full content review and 9 primary studies (398 patients) were included. Revisional single anastomosis duodeno-ileal bypass (SADI) was performed in 294 patients at a mean interval of 37.7 months (range 11-179). Total weight loss (%) varies from 20.5% to 46.2%. Early complications after surgery occurred in 4.1% surgeries including leak (7 cases -1.9%). Mortality was nil. SADI after LSG, after failed sleeve gastrectomy or as a sequential procedure, offers a satisfactory weight loss result. Both early and late term complications are acceptable.
Sleeve gastrectomy continues to be the most commonly performed bariatric operation worldwide. Development or worsening of pre-existing GERD has been recognized as a significant issue postoperatively. There is a paucity of information concerning the most appropriate preoperative workup and the technical and anatomical factors that may or may not contribute to the occurrence of reflux symptoms. Contemporary data quality is deficient given the predominantly retrospective nature, limited follow-up time, and heterogeneous outcome measures across studies. This has produced mixed results regarding the postoperative incidence and severity of GERD. Ultimately, better-constructed investigations are needed in order to offer evidence-based recommendations that may guide preoperative workup and improved patient selection criteria.
Despite excellent long-term results, insufficient weight loss, weight regain, and pathologic Gastroesophageal Reflux Disease (GERD) may require revisional procedures after Laparoscopic Sleeve Gastrectomy (LSG). Re-sleeve gastrectomy (ReSG) for failed LSG, has been proposed as an alternative to more complex malabsorptive procedures. The aim of this systematic review and meta-analysis is to examine the current evidence on the therapeutic role and outcomes of ReSG for failed LSG. PubMed, EMBASE, and Web of Science datasets were consulted. A systematic review and Frequentist meta-analysis were performed. Ten studies published between 2010 and 2019 met the inclusion criteria for a total of 300 patients. The age of the patient population ranged from 20 to 66 year-old and 80.5% were females. The elapsed time between the LSG and ReSG ranged from 9 to 132 months. The estimated pooled prevalence of postoperative leak and overall complications were 2.0% (95% CI=0.5-4.7%) and 7.6% (95% CI=3.1-13.4%). The estimated pooled mean operative time and hospital length of stay were 51 minutes (95% CI=49.4-52.6) and 3.3 days (95% CI=3.13-3.51). The postoperative follow-up ranged from 12 to 36 months and the estimated pooled mean percentage Excess Weight Loss (%EWL) was 61.46% (95% CI=55.9-66.9). The overall mortality ranged from 0 to 2.2%. ReSG after failed LSG seems feasible and safe with acceptable postoperative leak rate, overall complications, and mortality. The effectiveness of ReSG in term of weight loss seems promising in the short-term but further studies are warranted to explore its effect on patients’ quality of life, postoperative GERD, and long-term weight loss.
Background
There is little robust data on weight regain (WR) after bariatric surgery making it difficult to counsel patients regarding long-term outcomes of different bariatric procedures. The purpose of this study was to see WR in medium and long term after SG, RYGB, and OAGB in Indian population.
Methods
In a multicentre study, data on preoperative and postoperative weights over 5 years were collected. Multiple definitions were applied to find the proportion of patients with significant WR increase of 25% of lost weight from nadir (definition 1), weight gain of > 10 kg from nadir (definition 2), and BMI gain of > 5 kg/m² from nadir (definition 3). The proportion of those with significant WR was compared across sub-groups.
Results
A total of 9617 patients were included. Median WR at 5 years was 14.1% of lost weight, 1.92 kg/m², and 5 kg. Significant WR using definition 1 was 35.1%, 14.6%, and 3% after sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and mini-one anastomosis gastric bypass (OAGB) respectively. Severe albumin deficiency was highest in OAGB (5.9%) patients followed by SG (2.9%) and RYGB (2.2%) at 5 years(p = 0.023). Haemoglobin levels < 10 g/dL were seen in 8.2%, 9.0%, and 13.9% of SG, RYGB, and OAGB patients respectively (p = 0.041).
Conclusions
In the first comparative study of WR, OAGB had lesser WR in comparison to SG and RYGB but had the most impact on Hb and albumin levels in the long term. Definition selection for reporting WR has a significant impact on the results. There is a need for standardising the reporting of WR in bariatric literature.
Importance
Laparoscopic sleeve gastrectomy for treatment of morbid obesity has increased substantially despite the lack of long-term results compared with laparoscopic Roux-en-Y gastric bypass.
Objective
To determine whether laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass are equivalent for weight loss at 5 years in patients with morbid obesity.
Design, Setting, and Participants
The Sleeve vs Bypass (SLEEVEPASS) multicenter, multisurgeon, open-label, randomized clinical equivalence trial was conducted from March 2008 until June 2010 in Finland. The trial enrolled 240 morbidly obese patients aged 18 to 60 years, who were randomly assigned to sleeve gastrectomy or gastric bypass with a 5-year follow-up period (last follow-up, October 14, 2015).
Interventions
Laparoscopic sleeve gastrectomy (n = 121) or laparoscopic Roux-en-Y gastric bypass (n = 119).
Main Outcomes and Measures
The primary end point was weight loss evaluated by percentage excess weight loss. Prespecified equivalence margins for the clinical significance of weight loss differences between gastric bypass and sleeve gastrectomy were −9% to +9% excess weight loss. Secondary end points included resolution of comorbidities, improvement of quality of life (QOL), all adverse events (overall morbidity), and mortality.
Results
Among 240 patients randomized (mean age, 48 [SD, 9] years; mean baseline body mass index, 45.9, [SD, 6.0]; 69.6% women), 80.4% completed the 5-year follow-up. At baseline, 42.1% had type 2 diabetes, 34.6% dyslipidemia, and 70.8% hypertension. The estimated mean percentage excess weight loss at 5 years was 49% (95% CI, 45%-52%) after sleeve gastrectomy and 57% (95% CI, 53%-61%) after gastric bypass (difference, 8.2 percentage units [95% CI, 3.2%-13.2%], higher in the gastric bypass group) and did not meet criteria for equivalence. Complete or partial remission of type 2 diabetes was seen in 37% (n = 15/41) after sleeve gastrectomy and in 45% (n = 18/40) after gastric bypass (P > .99). Medication for dyslipidemia was discontinued in 47% (n = 14/30) after sleeve gastrectomy and 60% (n = 24/40) after gastric bypass (P = .15) and for hypertension in 29% (n = 20/68) and 51% (n = 37/73) (P = .02), respectively. There was no statistically significant difference in QOL between groups (P = .85) and no treatment-related mortality. At 5 years the overall morbidity rate was 19% (n = 23) for sleeve gastrectomy and 26% (n = 31) for gastric bypass (P = .19).
Conclusions and Relevance
Among patients with morbid obesity, use of laparoscopic sleeve gastrectomy compared with use of laparoscopic Roux-en-Y gastric bypass did not meet criteria for equivalence in terms of percentage excess weight loss at 5 years. Although gastric bypass compared with sleeve gastrectomy was associated with greater percentage excess weight loss at 5 years, the difference was not statistically significant, based on the prespecified equivalence margins.
Trial Registration
clinicaltrials.gov Identifier: NCT00793143
Importance
Sleeve gastrectomy is increasingly used in the treatment of morbid obesity, but its long-term outcome vs the standard Roux-en-Y gastric bypass procedure is unknown.
Objective
To determine whether there are differences between sleeve gastrectomy and Roux-en-Y gastric bypass in terms of weight loss, changes in comorbidities, increase in quality of life, and adverse events.
Design, Setting, and Participants
The Swiss Multicenter Bypass or Sleeve Study (SM-BOSS), a 2-group randomized trial, was conducted from January 2007 until November 2011 (last follow-up in March 2017). Of 3971 morbidly obese patients evaluated for bariatric surgery at 4 Swiss bariatric centers, 217 patients were enrolled and randomly assigned to sleeve gastrectomy or Roux-en-Y gastric bypass with a 5-year follow-up period.
Interventions
Patients were randomly assigned to undergo laparoscopic sleeve gastrectomy (n = 107) or laparoscopic Roux-en-Y gastric bypass (n = 110).
Main Outcomes and Measures
The primary end point was weight loss, expressed as percentage excess body mass index (BMI) loss. Exploratory end points were changes in comorbidities and adverse events.
Results
Among the 217 patients (mean age, 45.5 years; 72% women; mean BMI, 43.9) 205 (94.5%) completed the trial. Excess BMI loss was not significantly different at 5 years: for sleeve gastrectomy, 61.1%, vs Roux-en-Y gastric bypass, 68.3% (absolute difference, −7.18%; 95% CI, −14.30% to −0.06%; P = .22 after adjustment for multiple comparisons). Gastric reflux remission was observed more frequently after Roux-en-Y gastric bypass (60.4%) than after sleeve gastrectomy (25.0%). Gastric reflux worsened (more symptoms or increase in therapy) more often after sleeve gastrectomy (31.8%) than after Roux-en-Y gastric bypass (6.3%). The number of patients with reoperations or interventions was 16/101 (15.8%) after sleeve gastrectomy and 23/104 (22.1%) after Roux-en-Y gastric bypass.
Conclusions and Relevance
Among patients with morbid obesity, there was no significant difference in excess BMI loss between laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass at 5 years of follow-up after surgery.
Trial Registration
clinicaltrials.gov Identifier: NCT00356213
Background
Laparoscopic sleeve gastrectomy (LSG) became the most frequent bariatric procedure performed in France (2011) and in the United States (2013), but studies reporting long-term results are still rare.
Setting
Private hospital, France.
Methods
This is a retrospective analysis of a prospective cohort of 168 patients who underwent LSG between 2005 and 2008. The objective of this study was to present the 8-year outcome concerning weight loss, modification of co-morbidities, and to report the revisional surgery after sleeve.
Results
The preoperative mean body mass index was 42.8 kg/m2 (31.1–77.9), 35 patients were super obese, and 64 patients had a previous gastric band. For LSG as a definitive bariatric procedure, 8 years of follow-up data were available for 116 patients (follow-up: 69%). Of the remainder, 23 patients underwent revisional surgery and 29 were lost to follow-up. For the entire cohort, the mean excess weight loss (EWL) was 76% (0–149) at 5 years and 67% (4–135) at 8 years, respectively. Of the 116 patients with 8 years of follow-up, 82 patients had>50% EWL at 8 years (70.7%). Percentages of co-morbidities resolved were hypertension, 59.4%; type 2 diabetes, 43.4%; and obstructive sleep apnea, 72.4%. Twenty-three patients had revisional surgery for weight regain (n = 14) or for severe reflux (n = 9) at a mean period of 50 months (9–96). Twelve patients underwent resleeve gastrectomy, 6 patients underwent conversion to a bypass, and 5 patients to duodenal switch (1 single anastomosis duodeno-ileostomy). A total of 31% of patients reported gastroesophageal reflux symptoms at 8 years.
Conclusions
At 8 years postoperatively, the LSG as a definitive bariatric procedure remained effective for 59% of cases. The results appear to be more favorable especially for the non-super-obese patients and primary procedures. LSG is a well-tolerated bariatric procedure with low long-term complication rates.
Background:
Laparoscopic sleeve gastrectomy (LSG) is increasing worldwide; however, long-term follow-up results included insufficient weight loss and weight regain. This study aims at assessing the outcomes of converting LSG to laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic re-sleeve gastrectomy (LRSG).
Methods:
A total of 1300 patients underwent LSG from 2009 to 2012, of which 12 patients underwent LRYGB and 24 patients underwent LRSG in Al-Amiri Hospital alone. Data included length of stay, percentage excessive weight loss (EWL%), and body mass index (BMI).
Results:
Twenty-four patients underwent conversion from LSG to LRSG, and 12 patients underwent conversion from LSG to LRYGB due to insufficient weight loss and weight regain. Eighty-five percent were females. The mean weight and BMI prior to LSG for the LRYGB and LRSG patients were 136.5 kg and 52, and 134 kg and 50, respectively. The EWL% after the initial LSG was 37.9 and 43 %, for LRYGB and LRSG, respectively. There were no complications recorded. Results of conversion of LSG to LRYGB involved a mean EWL% 61.3 % after 1 year (p value 0.009). Results of LRSG involved a mean EWL% of 57 % over interval of 1 year (p value 0.05). Comparison of the EWL% of LRYGB and LRSG for failed primary LSG was not significant (p value 0.097).
Conclusion:
Following our algorithm, revising an LSG with an LRSG or LRYGB for poor weight loss is feasible with good outcomes. Larger and longer follow-up studies are needed to verify our results.
Background:
Laparoscopic sleeve gastrectomy (LSG) has rapidly become increasingly popular in bariatric surgery. However, in the long-term follow-up, weight loss failure and intractable severe reflux after primary LSG can necessitate further surgical interventions.
Objectives:
To evaluate the safety and the efficiency of revisional sleeve gastrectomy (ReSG).
Setting:
Private hospital.
Methods:
From October 2008 to October 2014, 61 patients underwent ReSG. All patients with failure after primary LSG underwent radiologic evaluation, and an algorithm of treatment was proposed.
Results:
Sixty-one patients (54 women, 7 men; mean age 40.8 yr) with a body mass index (BMI) of 39.4 kg/m² underwent ReSG. The primary LSG was performed for mean BMI of 46.2 kg/m² (range 35.4-77.9). The mean interval time from the primary LSG to ReSG was of 37.5 months (9-80 mo). The indication for ReSG was insufficient weight loss in 28 patients (45.9%), weight regain in 29 patients (47.5%), and gastroesophageal reflux disease (GERD) in 4 patients. In 42 patients the gastrografin swallow results were interpreted as primary dilation and in the remaining 19 cases as secondary dilation. The computed tomography (CT) scan volumetry was obtained in 38 patients with mean gastric volume of 436.3 cc (275-1056 cc). All cases were completed by laparoscopy with no intraoperative incidents. The mean operative time was 39 minutes (range 29-70 min) and the mean hospital stay was 3.5 days (range 3-16 d). One perigastric hematoma and 2 cases of gastric stenosis were recorded. The mean BMI decreased to 29.2 kg/m(2) (range 20.2-37.5); the mean percentage of excess weight loss (%EWL) was 58.5% (±25.3) (P<.0004) for a mean follow-up of 20 months (range 6-56 mo).
Conclusion:
The ReSG may be a valid option for failure of primary LSG. Further prospective clinical trials are required to compare the outcomes of ReSG with those of laparoscopic Roux-en-Y gastric bypass or duodenal switch for weight loss failure after LSG.
Longitudinal sleeve gastrectomy (LSG) has been validated for the treatment of morbid obesity. However, treatment failures can appear several months after SG. Ad-ditional malabsorptive surgery is generally recommended in such cases. The objective of the present study was to eval-uate the outcomes of repeat SG (re-SG) relative to first-line SG. This was a retrospective study included 15 patients underwent re-SG after failure of first-line SG (i.e. University Hospital, France; Public Practice). These patients were matched (for age, gender, body mass index and comorbid-ities) 1:2 with 30 patients having undergone first-line SG. The efficacy criteria comprised intra-operative data and postoperative data. The overall study population comprised 45 patients. The re-SG and first-line SG groups did not differ significantly in terms of median age (p0NS). The median BMI was similar in the two groups (43 kg/m 2 vs. 42.3 kg/m 2 , p0NS). The two groups were similar in terms of the prevalence of comorbidities. The mean operating time was longer in the re-SG group (116 vs. 86 min; p≤0.01). The postoperative complication rate was twice as high in the re-SG group (p00.31). Two patients in the re-SG group developed a gastric fistula (p00.25) and one of the latter died. At 12 months, the Excess Weight Loss was 66 % (re-SG group) and 77 % (first-line SG group) (p00.05). Re-SG is feasible but appears to be associated with a greater risk of complications. Nevertheless, re-SG can produce results (in terms of weight loss), equivalent to those obtained after first-line SG.
This retrospective study evaluated long-term weight loss, resolution of comorbidities, quality of life (QoL), and food tolerance after laparoscopic sleeve gastrectomy (LSG).
Between January 2003 and July 2008, 102 patients underwent LSG as a sole bariatric operation. A retrospective review of a prospectively collected database was performed. Demographics, complications, and percentage of excess weight loss (%EWL) were determined. Quality of life was measured using Medical Outcomes Survey Short Form 36 (SF-36) and Bariatric Analysis and Reporting Outcome System (BAROS) questionnaires, which were sent to all patients. The food tolerance score (FTS) was determined and compared with that of nonobese subjects.
A total of 83 patients (81.4%) were eligible for follow-up evaluation. Their mean initial body mass index (BMI) was 39.3 kg/m(2). No major complications occurred. At a median follow-up point of 49 months (range, 17-80 months), the mean %EWL was 72.3% ± 29.3%. For the 23 patients who reached the 6-year follow-up point, the mean %EWL was 55.9% ± 25.55%. The mean BAROS score was 6.5 ± 2.1, and a "good" to "excellent" score was observed for 75 patients (90.4%). In the comparison of patients with a %EWL greater than 50% and those with a %EWL of 50% or less, the SF-36 scores were statistically different only for "physical functioning" and "general health perception." The mean FTS was 23.8, and 95.2% of the patients described their food tolerance as acceptable to excellent.
Laparoscopic sleeve gastrectomy is a safe and effective bariatric procedure, although a tendency for weight regain is noted after 5 years of follow-up evaluation. Resolution of comorbidity is comparable with that reported in the literature. The LSG procedure results in good to excellent health-related QoL. Food tolerance is lower for patients after LSG than for nonobese patients who had no surgery, but 95.2% described food tolerance as acceptable to excellent.
Introduction:
Sleeve gastrectomy (SG) can be associated with inadequate weight loss, insufficient resolution of co-morbidities and severe reflux. Conversion to Roux-en-Y Gastric Bypass (RYGB) is a potential solution. The aim of this study was to determine the common indications for conversion from SG to RYGB at our centre, and evaluate patient outcomes with respect to weight loss and co-morbidity resolution.
Methods:
A retrospective review of patients who underwent conversion from SG to RYGB between 2008 and 2015.
Results:
273 SGs were performed of which 6.6% (n = 18) were converted to RYGB most commonly due to inadequate weight loss (65.3%) and severe reflux (26.1%). Two patients were converted as a planned two-stage approach to RYGB. Patients went from a mean preoperative BMI of 50.5 to a mean BMI of 40.5 post-SG on average by 20.9 months. The mean time to conversion was 41.8 months. There was a positive correlation between pre-SG BMI and time to conversion (p = 0.040). The mean BMI after conversion was 36.4, but this additional weight loss was not significant (p = 0.057). After conversion, four of the five diabetic patients are now medication free and 75% of patients no longer have reflux symptoms. All patients had complete resolution of their hypertension and obstructive sleep apnea. Revision perioperative complication rates were comparable to primary RYGB. Two patients developed new onset iron deficiency anemia.
Conclusion:
Revision to RYGB is a safe option for SG failure and resulted in significant benefits from co-morbidity resolution.
Background:
Laparoscopic sleeve gastrectomy (SG) has become an accepted primary bariatric operation. Like other bariatric operations, inadequate weight loss and complications have been reported.
Objectives:
The aim of this study was to assess the indications and outcomes of revision of SG to laparoscopic Roux-en-Y gastric bypass (RYGB) at a single community hospital.
Setting:
Community hospital, United States.
Methods:
Retrospective review of a prospectively collected database identifying SG operations done from February 2009 to June 2014. All patients who underwent revision from SG to RYGB were studied.
Results:
Forty-eight patients underwent revision of SG to RYGB. Mean time to revision was 26 months (range, 2-60 mo) and mean follow up after RYGB was 20 months (range, 4-48 mo). Indications for revision were reflux (n = 14), inadequate weight loss (n = 11), reflux and inadequate weight loss (n = 16), stricture (n = 4), chronic leak (n = 1), and recurrent diabetes and reflux (n = 2). Reflux symptoms resolved in 96% of patients after revision, and hiatal hernias were repaired in 50% of patients. Percentage total weight loss at 3, 6, 12, 24, and 36 months was 9.0%, 12.9%, 15.7%, 13.3%, and 6.5%, respectively. The overall rate of complication was 31%. There were no mortalities.
Conclusions:
Revision of SG to RYGB is a potentially effective means of treating SG complications, particularly reflux. Reflux was the most common indication for revision and was often associated with a hiatal hernia. Further studies will be necessary to evaluate the long-term maintenance of additional weight loss after revision of SG to RYGB.
Background:
Sleeve gastrectomy (SG) is currently one of the most frequently performed bariatric interventions worldwide due to its simplicity and good weight loss results. Nevertheless, SG failure and complications are increasingly being observed as the number of procedures increases.
Objectives:
To report our results in converting SG to revisional laparoscopic Roux-en-Y gastric bypass (R-LRYGB).
Setting:
University Hospital, Chile.
Methods:
Retrospective analysis of our bariatric surgery database. Patients who underwent R-LRYGB after SG between June 2005 and April 2015 were identified. Demographic characteristics, anthropometrics, preoperative workup, and perioperative data were retrieved. Total weight loss (TWL), excess weight loss (EWL), and clinical progression over 3 years were registered.
Results:
Fifty patients were identified, mean age 39±8.4 years, 42 (84%) women; median body mass index previous to R-LRYGB was 33.8 (31-36) kg/m(2). Indications for revision were weight regain (n = 28, 56%), gastroesophageal reflux disease (n = 16, 32%), and gastric stenosis (n = 6, 12%). In weight-regain patients, mean follow-up at 3 years was 72.2% and median percentage of total weight loss at 12 and 36 months was 18.5 (12-24) and 19.3 (8-23), respectively; percentage of excess weight loss at 12 and 36 months was 60.7 (37-82) and 66.9 (26-90), respectively. Over 90% of gastroesophageal reflux disease patients resolved or improved symptoms. All patients with gastric stenosis resolved symptoms after conversion. There were no major complications.
Conclusion:
R-LRYGB is a feasible, effective, and well-tolerated alternative in selected patients with failed SG in which other therapies have been insufficient to either maintain weight loss or resolve complications. However, long-term follow-up is still needed.
Background:
With promising short-term results, laparoscopic sleeve gastrectomy (SG) has become the second most frequently performed bariatric procedure worldwide. Aside from a growing number of reports covering up to 10 years of follow-up, only limited data have been published so far on long-term results.
Objectives:
The aim of the study was to present a 10-year follow-up for SG.
Setting:
University hospital setting, Austria.
Methods:
We present the first complete 10-year follow-up of 53 consecutive patients who underwent SG before 2006. In this multicenter study, weight loss success, weight regain, and revisional surgery were analyzed beside Bariatric Analysis and Reporting Outcome System (BAROS) scores.
Results:
A mean maximum percent excess weight loss of 71±25% (percent total weight loss: 28±15%) was reached at a median of 12 (range 12-120) months after SG. At 10 years, a mean percent excess weight loss of 53±25% was achieved by 32 patients, corresponding to a percent total weight loss of 26.3±13.4%. Nineteen of the 53 patients (36%) were converted to Roux-en-Y gastric bypass (n = 18) or duodenal switch (n = 1) due to significant weight regain (n = 11), reflux (n = 6), or acute revision (n = 2) at a median of 36 months. Two patients died at 3 and 101 months postoperatively, unrelated to SG. A total of 31 patients (59%) suffered from weight regain of 10 kg or more, among them 24 patients (45%) with 15 kg or more, 16 patients (30%) with 20 kg or more, and 7 patients (13%) with 25 kg or more weight regain from nadir. Mean BAROS score was 2.4±2.2 at 10 years follow-up, classifying SG as "fairly efficient."
Conclusion:
Within a long-term follow-up of 10 years or more after SG, a high incidence of both significant weight regain and intractable reflux was observed, leading to conversion, most commonly to Roux-en-Y gastric bypass.
Background:
More than 10 years of outcomes for sleeve gastrectomy (LSG) have not yet been documented.
Objectives:
Analysis of>11 years of outcomes of isolated LSG in terms of progression of weight, patient satisfaction, and evolution of co-morbidities and gastroesophageal reflux disease (GERD) treatment.
Setting:
Two European private hospitals.
Methods:
Chart review and personal interview in consecutive patients who underwent primary isolated LSG (2001-2003).
Results:
Of the 110 consecutive patients, complete follow-up data was available in 65 (59.1%). Mean follow-up was 11.7±.4 years. Two patients had died of non-procedure-related causes. Twenty (31.7%) patients required 21 reoperations: 14 conversions (10 duodenal switch (DS), 4 Roux-en-Y gastric bypass (RYGB), and 3 resleeve procedures) for weight issues and 2 conversions (RYGB), and 2 hiatoplasties for gastroesophageal reflux disease (GERD). For the 47 (74.6%) individuals who thus kept the simple sleeve construction, percentage of excess body mass index loss (%EBMIL) at 11+years was 62.5%, versus 81.7% (P = .015) for the 16 patients who underwent conversion to another construction. Mean %EBMIL for the entire cohort was 67.4%. At 11+years postoperatively, 30 patients versus 28 preoperatively required treatment for co-morbidities. None of the 7 patients preoperatively suffering from GERD were cured by the LSG procedure. Nine additional patients developed de novo GERD. Overall satisfaction rate was 8 (interquartile range 2) on a scale of 0-10.
Conclusion:
Isolated LSG provides a long-term %EBMIL of 62.5%. Conversion to another construction, required in 25% of the cases, provides a %EBMIL of 81.7% (P = .015). Patient satisfaction score remains good despite unfavorable GERD outcomes.
Laparoscopic sleeve gastrectomy (LSG) has gained popularity as a stand-alone procedure with good short-term results for weight loss. However, in the long-term, weight regain and other complications are reported. Demand for secondary surgery is rising, partly for these reasons.
To review the indications and effects of secondary surgery, biliopancreatic diversion with duodenal switch (BPD/DS) versus laparoscopic Roux-en-Y gastric bypass (LRYGB), after LSG.
Data from all patients who underwent revision of LSG was retrospectively analyzed, concerning data on indications for secondary surgery, weight loss, and complications.
43 Patients underwent secondary surgery after LSG; 25 BPD/DS and 18 LRYGB, respectively. Main indications for secondary surgery were inadequate weight loss (n = 17 [40%]) and weight regain (n = 8 [19%]). For these indications, the median excess weight loss was greater for BPD/DS (59% [range 15-113]) compared to LRYGB (23% [range -49-84]) (P = .008) after 34 months (range 14-79). In case of dysphagia or gastroesophageal reflux disease the complaints resolved after converting to LRYGB. BPD/DS patients were more likely to develop a short-term complication and vitamin deficiencies compared to LRYGB.
Secondary surgery of LSG to BPD/DS or LRYGB is feasible with slightly more complications after BPD/DS. Conversion to LRYGB is preferred in cases of dysphagia or gastroesophageal reflux disease. In cases of weight regain or insufficient weight loss after LSG, patients had better weight loss with a BPD/DS; however, this procedure has the risk of complications, such as severe vitamin deficiencies.
Copyright © 2014 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.
Background:
Whilst the early to mid-term efficacy of laparoscopic sleeve gastrectomy (SG) is well established, there is comparatively less detailing of long-term efficacy. The objectives of this study were to evaluate the long-term outcomes of patients undergoing SG at the authors' institution.
Methods:
All patients undergoing SG during the past 5 or more years were eligible. Outcomes included baseline demographic data, preoperative characteristics, percentage excess weight loss (%EWL), co-morbidity improvement and resolution, serum hemoglobin A(1c) (HbA(1c)), serum lipid profile, and the Bariatric Analysis Reporting Outcome System (BAROS) questionnaire. A subset analysis was also performed with patients stratified in to super obese (body mass index ≥ 50 kg/m(2)).
Results:
There were 96 patients who underwent surgery between March 2007 and July 2008. Of these, 10 declined to participate, 28 were unable to be contacted, and 3 were deceased; therefore, 55 patients were included in the analysis. The mean yearly %EWL to postoperative year 5 was 56% (year 1), 55% (year 2), 46% (year 3), 43% (year 4), and 40% (year 5). Combined improvement and resolution rates at 5 years were 79%, 61%, and 73% for type 2 diabetes, hypertension, and obstructive sleep apnea, respectively. The HbA(1c) was significantly reduced at long-term follow-up. The mean BAROS score was 3.13 (95% CI: 2.4, 3.9). Weight loss outcomes were less favorable in super obese patients.
Conclusion:
Weight loss outcomes at 5 year follow-up were modest after SG though improvement in co-morbidity status was maintained.
Background:
After sleeve gastrectomy, many surgical options are available in patients with insufficient weight loss. Duodenal switch is typically considered the operation that results in higher weight loss, although it is, perhaps unjustly, considered technically difficult and may be accompanied by severe side effects. Single-anastomosis duodenoileal bypass with sleeve gastrectomy is a simplification of the duodenal switch that may behave as a standard biliopancreatic diversion but is easier and quicker to perform. Given its effectiveness as a primary surgery we hypothesized that it would be successful as a second-step operation. The objective of this study was to analyze the weight loss and co-morbidities resolution after a single-anastomosis duodenoileal bypass (SADI) performed as a second step after sleeve gastrectomy.
Methods:
Sixteen patients with an initial body mass index of 56.4 kg/m(2) and a mean excess weight loss of 39.5% after a sleeve gastrectomy were submitted to a single-anastomosis duodenoileal bypass with a 250-cm common channel.
Results:
There were no postoperative complications. The mean excess weight loss was 72% 2 years after the second-step surgery. The complete remission rate was 88% for diabetes, 60% for hypertension, and 40% for dyslipidemia. The mean number of daily bowel movements was 2.1. One patient suffered an isolated episode of clinical hypoalbuminemia.
Conclusion:
SADI is a safe operation that offers a satisfactory weight loss for patients subjected to a previous sleeve gastrectomy. The side effects are well tolerated, and complications are minimal.
Background
Failed sleeve gastrectomy (SG), defined by inadequate weight loss or weight regain, can be treated by a laparoscopic conversion to a biliopancreatic diversion with duodenal switch (DS) or a Roux-en-Y gastric bypass (RYGB). We report the outcomes of these procedures after SG failure.
Methods
All patients who underwent DS (n=9) or RYGB (n=10) due to inadequate weight loss or weight regain between 12/2006-11/2012 after a failed SG were enrolled.
Results
The mean pre-SG weight and body mass index (BMI) for the DS and RYGB patients were 143±36 kg and 51.5±11 kg/m2 and 120±26 kg and 44.5±5 kg/m2, respectively. The interval between the SG and the conversion to DS and to RYGB was 27±18 months and 36±17 months, respectively. The operation time and hospital stay were 191±64 minutes and 4.3±2.4 days for DS, and 111±37 minutes and 3.1±1.1days for RYGB. At re-operation, the weight, BMI and percentage of excess weight loss (%EWL) were 113±22 kg, 43±6 kg/m2 and 28±16.5% and 107±27.5 kg, 40±5.7 kg/m2 and 25±12.7% (all P>.05), for the DS and RYGB, respectively. None of the patients were lost to follow-up. The post-DS weight, BMI and %EWL were 84±19 kg, 30.7±7.4 kg/m2 and 80±40%. The post-RYGB weight, BMI and %EWL were 81±21 kg, 30.2±4.8 kg/m2 and 65.5±34% (all P>.05).
Conclusions
DS and RYGB are feasible and effective operations after a failed SG. The DS yields a greater weight loss. The mechanism of failure should guide selection of the second procedure.
Background:
Laparoscopic sleeve gastrectomy (LSG) has been established as a reliable bariatric procedure, but questions have emerged regarding its long-term results. Our aim is to report the long-term outcomes of LSG as a primary bariatric procedure.
Methods:
Retrospective analysis of patients submitted to LSG between 2005 and 2007 in our institution. Long-term outcomes at 5 years were analyzed in terms of body mass index (BMI), excess weight loss (EWL) and co-morbidities resolution. Surgical success was defined as %EWL>50%. Also, we compared long-term results according to preoperative BMI, using Mann-Whitney test.
Results:
A total of 161 LSG were analyzed, and 114 patients (70.8%) were women. The median age was 36 years old (range 16-65), median preoperative BMI was 34.9 kg/m(2) (interquartile range [IQR], 33.3-37.5). A total of 112 patients (70%) completed 5 years of follow-up. At the fifth year, median BMI and %EWL was 28.5 kg/m(2) (IQR: 25.8-31.9) and 62.9% (IQR: 45.3-89.6), respectively, with a surgical success of 73.2% of followed patients. According to preoperative BMI, surgical success was achieved in 80% of patients with BMI<35 kg/m(2), 75% of BMI 35-40 kg/m(2), and 52.6% of BMI>40 kg/m(2), with significant lower %EWL in patients with BMI>40 kg/m(2) (P = .001 and .004). Dyslipidemia and insulin resistance resolution was 80.7% and 84.7%, respectively. A total of 26.7% of patients reported new-onset gastroesophageal reflux symptoms at 5 years.
Conclusion:
LSG as a primary procedure is a reliable surgery. We observed positive long-term outcomes of %EWL and co-morbidities resolution. In our series, best results are seen in patients with preoperative BMI<40 kg/m(2).
Bariatric surgery underwent a dramatic change in the past decade in France. The objective of this study was to examine elective bariatric surgical procedures from 2005 to 2011 in France and to determine trends in the use of the procedure.
Data were extracted from the National Hospital Database. All admissions involving a bariatric surgery procedure were included. Procedures authorized by the Public Health Authority for the treatment of morbid obesity, including the adjustable gastric banding (AGB), vertical banded gastroplasty (VBG), gastric bypass (GB), sleeve gastrectomy (SG), and biliopancreatic diversion (BPD), either by laparotomic or laparoscopic approach, were retrieved. Revisional procedures, such as band removal or repositioning, band changing, and access device revisions, were also evaluated.
We observed a 2.5-fold increase in bariatric procedures, from 12,800 in 2005 to 31,000 in 2011. Sleeve gastrectomy and gastric bypass became the most common bariatric procedures in France in 2011, whereas adjustable gastric banding has been decreasing since 2007. During the analysis period, about 50,000 revisional procedures were performed. The number of hospitals (private or public) providing bariatric surgery has considerably increased. However, most of the activity remains confined to a small number of centers, as 50% of all bariatric surgeries are carried out in 12% of hospitals. Bariatric procedures are predominantly performed in private hospitals.
In France the number of bariatric procedures increased considerably between 2005 and 2011. The type of procedures changed, with a constant decrease of AGB and an important increase of SG and GB. Most bariatric procedures are still performed in low volume activity hospitals and in private hospitals.
Laparoscopic sleeve gastrectomy (LSG) is gaining popularity, but studies reporting long-term results are still rare. The objective of this study was to present the 5-year outcome concerning weight loss, modification of co-morbidities, and late complications.
This is a retrospective analysis of a prospective cohort with a minimal follow-up of 5 years. A total of 68 patients underwent LSG either as primary bariatric procedure (n = 41) or as redo operation after failed laparoscopic gastric banding (n = 27) between August 2004 and December 2007. At the time of LSG, the mean body mass index (BMI) was 43.0±8.0 kg/m(2), the mean age 43.1±10.1 years, and 78% were female. The follow-up rate was 100% at 1 year postoperatively, 97% after 2 years, and 91% after 5 years; the mean follow-up time was 5.9±0.8 years.
The average excessive BMI loss was 61.5%±23.4% after 1 year, 61.1%±23.4% after 2 years, and 57.4%±24.7% after 5 years. Co-morbidities improved considerably; a remission of type 2 diabetes could be reached at 85%. The following complications were observed: 1 leak (1.5%), 2 incisional hernias (2.9%), and new-onset gastroesophageal reflux in 11 patients (16.2%). Reoperation due to insufficient weight loss was necessary in 8 patients (11.8%).
LSG was effective 5.9 years postoperatively with an excessive BMI loss of almost 60% and a considerable improvement or even remission of co-morbidities.
Obesity is considered a worldwide health problem of epidemic proportions. Bariatric surgery remains the most effective treatment for patients with severe obesity, resulting in improved obesity-related co-morbidities and increased overall life expectancy. However, weight recidivism has been observed in a subset of patients post-bariatric surgery. Weight recidivism has significant medical, societal and economic ramifications. Unfortunately, there is a very limited understanding of how to predict which bariatric surgical patients are more likely to regain weight following surgery and how to appropriately treat patients who have regained weight. The objective of this paper is to systematically review the existing literature to assess the incidence and causative factors associated with weight regain following bariatric surgery. An electronic literature search was performed of the Medline, Embase and Cochrane library databases along with the PubMed US national library from January 1950 to December 2012 to identify relevant articles. Following an initial screen of 2,204 titles, 1,437 abstracts were reviewed and 1,421 met exclusion criteria. Sixteen studies were included in this analysis: seven case series, five surveys and four non-randomized controlled trials, with a total of 4,864 patients for analysis. Weight regain in these patients appeared to be multi-factorial and overlapping. Aetiologies were categorized as patient specific (psychiatric, physical inactivity, endocrinopathies/metabolic and dietary non-compliance) and operation specific. Weight regain following bariatric surgery varies according to duration of follow-up and the bariatric surgical procedure performed. The underlying causes leading to weight regain are multi-factorial and related to patient- and procedure-specific factors. Addressing post-surgical weight regain requires a systematic approach to patient assessment focusing on contributory dietary, psychologic, medical and surgical factors.
Background:
Causes of failure after laparoscopic sleeve gastrectomy (LSG) are not known but may include a high residual gastric volume (RGV). The aim of this study was to use gastric computed tomography volumetry (GCTV) to investigate the RGV and relate the latter parameter to the outcome of LSG.
Methods:
A single-center, prospective study included patients with>24 months of follow-up after LSG. The RGV was measured with a unique GCTV technique. We determined the LSG outcomes according to a variety of criteria and examined potential relationships with the RGV. When the RGV was>250 cc, we offered a repeat LSG (RLSG).
Results:
Seventy-six patients were included. The mean RGV was 255 cc but differed significantly when comparing "failure" and "success" subgroups, regardless of whether the latter were defined by a percentage of excess weight loss>50 (309 cc versus 225 cc, respectively; P = .0003), a BAROS score>3 (312 cc versus 234 cc; P = .005), the Reinhold criteria (290 cc versus 235 cc; P = .019), or the Biron criteria (308 cc versus 237 cc; P = .008). The RGV threshold (corresponding to the volume above which the probability of failure after LSG is high) was 225 cc. Fifteen RLSGs were performed during the inclusion period.
Conclusion:
A high RGV 34 months after LSG is a risk factor for failure. Knowledge of the RGV can be of value in the management of failure after LSG.
Background:
Laparoscopic sleeve gastrectomy (SG) is the most recent bariatric surgical procedure to gain universal acceptance by providers and payers. Long-term clinical data on outcomes is limited at this time.
Methods:
We retrospectively examined 5-year outcomes (weight loss, complications, and resolution of co-morbid conditions) of patients undergoing SG at our institution.
Results:
Our initial SG was performed in 2005, and we operated on 55 consecutive patients who are 5 years out from surgery. Six patients were excluded from the long-term results. Four patients underwent conversion to a duodenal switch, and 2 patients died in the first year outside the perioperative period. Average starting body mass index was 65 kg/m(2). Five-year average percent excess weight loss was 86% (range 50%-103%). Percentage of co-morbidities resolved: hypertension (95%), type 2 diabetes mellitus (100%), hyperlipidemia (100%), and obstructive sleep apnea (100%). Gastroesophageal reflux disease (GERD) was resolved in 53%, and new GERD symptoms developed in 11% of patients. There was 1 staple line leak (1.9%), no strictures, no gastrointestinal bleeding, and no perioperative deaths.
Conclusion:
In this study, SG is a well-tolerated and effective bariatric surgical procedure with good long-term weight loss and resolution of co-morbid medical conditions.
Repeat sleeve gastrectomy (re-SG) and the addition of the duodenal switch (DS) are possible options to increase weight loss after isolated SG (ISG). We report the feasibility, safety, and outcomes of laparoscopic re-SG versus DS in patients presenting with insufficient weight loss or weight regain after ISG.
From November 2003 to December 2009, 7 and 19 patients underwent laparoscopic re-SG and DS, respectively, mainly because of the patients' dietary habits: volume eating (hyperphagia) was treated by re-SG and eating meals too frequently (polyphagia) by DS.
At ISG, the mean weight and BMI was 127.7 ± 31.4 kg, and 45.1 ± 11.8 kg/m(2) for the re-SG group and 119.8 ± 20.9 kg and 41.2 ± 5.5 kg/m(2) for the DS group, respectively. The mean interval between ISG and reoperation was 37.1 ± 20.3 months for the re-SG group and 29.8 ± 24.9 months for the DS group. At reoperation, the mean weight, BMI, and percentage of excess weight loss (%EWL) was 109.7 ± 21 kg, 38.9 ± 8.7 kg/m(2), 24.3 ± 16.6% for the re-SG group and 107.6 ± 19.6 kg, 36.9 ± 4.2 kg/m(2), and 19.5 ± 19.9% for the DS group, respectively. The mean operative time was 137.5 ± 75.5 minutes for the re-SG group and 152.6 ± 54.3 minutes for the DS group. No conversion to open surgery was required, and no mortality occurred. One patient in the re-SG group developed a leak at the angle of His. In the DS group, 1 patient presented with bleeding, 1 patient with a duodenoileostomy leak, and 1 patient with a duodenoileostomy stenosis. The mean hospital stay was 11.5 ± 20.5 days for the re-SG group and 4.7 ± 2.7 days for the DS group. The mean follow-up was 23.2 ± 11.1 months for the re-SG group and 24.9 ± 20.1 months for the DS group. The mean weight, BMI, and %EWL was 100 ± 21.1 kg, 35.3 ± 8.3 kg/m(2), 43.7 ± 24.9% for the re-SG group and 80.7 ± 22.5 kg, 27.3 ± 5.2 kg/m(2), 73.7 ± 27.7% for the DS group, respectively. During follow-up, 3 patients in the DS group required corrective surgery for late complications.
The results of the present study have shown that laparoscopic re-SG is feasible but carries the risk of fistula development, which is difficult to treat. Laparoscopic DS was also shown to be feasible at a cost of not negligible complications, which are easier to manage than with re-SG. The efficacy seemed greater after DS than after re-SG.
Surgical management of the supersuper obese patient (BMI >60 kg/m2) has been a challenging problem associated with higher morbidity, mortality, and long-term weight loss failure. Current limited experience exists with a two-stage biliopancreatic diversion and duodenal switch in the supersuper obese patient, and we now present our early experience with a two-stage gastric bypass for these patients.
We completed a retrospective bariatric database and chart review of super-super obese patients who underwent laparoscopic sleeve gastrectomy as a first-stage procedure followed by laparoscopic Roux-en-Y gastric bypass as a second-stage for more definitive treatment of obesity.
During a two-year period, 7 patients with BMI 58-71 kg/m2 underwent a two-stage laparoscopic Roux-en-Y gastric bypass by two surgeons at the Mount Sinai Medical Center. 3 patients were female, 4 patients were male, and the average age was 43. Prior to the sleeve gastrectomy, the mean weight was 181 kg with a BMI of 63. Average time between procedures was 11 months. Prior to the second-stage procedure, the mean weight was 145 kg with a BMI of 50 and average excess weight loss of 37 kg (33% EWL). Six patients have had follow-up after the second-stage procedure with an average of 2.5 months. At follow-up the mean weight was 126 kg with a BMI of 44 and average excess weight loss of 51 kg (46% EWL). The mean operative times for the two procedures were 124 and 158 minutes respectively. The average length of stay for all procedures was 2.7 days. 4 patients had 5 complications, which included splenic injury, proximal anastomotic stricture, left arm nerve praxia, trocar site hernia, and urinary tract infection. There were no mortalities in the series.
Laparoscopic sleeve gastrectomy with second-stage Roux-en-Y gastric bypass are feasible and effective procedures based on short-term results. This two-stage approach is a reasonable alternative for surgical treatment of the high-risk supersuper obese patient.
Circulating ghrelin, produced primarily in the stomach, is a powerful orexigen. Ghrelin levels are elevated in states of hunger, but rapidly decline postprandially. Early alterations in ghrelin levels in morbidly obese patients undergoing weight reduction surgery may be attributed to gastric partitioning.
Thirty-four patients underwent Roux-en-Y gastric bypass with a completely divided gastroplasty to create a 15-mL vertically oriented gastric pouch. Eight other patients underwent other gastric procedures that did not involve complete division of the stomach, including 4 vertical banded gastroplasties and 4 antireflux surgical procedures. Six additional patients undergoing antireflux surgery served as lean control subjects. Plasma samples were obtained before surgery and immediately after surgery. In a substudy, plasma was collected after Roux-en-Y limb formation and after dividing the stomach to identify any changes in plasma ghrelin levels.
Tertiary university medical center.
Ghrelin levels at different stages of surgical intervention.
Mean +/- SEM preoperative and postoperative ghrelin levels in the gastric bypass group were 355 +/- 20 and 246 +/- 13 pg/mL, respectively (P<.001). In the vertical banded gastroplasty group and in all patients undergoing antireflux surgery, ghrelin levels were not significantly changed.
Compared with morbidly obese humans, lean controls had significantly higher plasma ghrelin levels at baseline. A divided gastroplasty creating a small proximal gastric pouch results in significant early declines in circulating ghrelin levels that are not observed with other gastric procedures. This may explain, in part, the loss of hunger sensation and rapid weight loss observed following gastric bypass surgery.
The revisional surgery for patients with inadequate weight loss after biliopancreatic diversion with duodenal switch (BPD/DS) is controversial. It has not yet been determined whether a common channel should be shortened or gastric pouch volume reduced. Since the revision of the distal anastomosis remains technically difficult and associated with possible complications, we turned our attention to the reduction of gastric sleeve volume. This operation is more feasible and potential complications are less probable. Patient and Method: We present the case of a 47-year-old women with a life-long history of morbid obesity. She was operated on in January 2000 with a laparoscopic BPD/DS with 100 ml gastric pouch, 150 cm of alimentary limb and 100 cm of common channel. Before this operation, her weight was 170 kg, with BMI 64 kg/m(2). She lost most of her excess weight within 17 months after surgery and was regaining weight at 77 kg and BMI 29 kg/m(2). Upper GI series showed a markedly dilated gastric pouch. Her second surgery consisted of a laparoscopic sleeve partial gastrectomy along the greater curvature using endo GIA staplers with bovine pericardium for reinforcement of the stapler line.
No postoperative complications occurred. The patient was discharged on the first postoperative day. Significant further weight reduction was noted, and at 10 months after surgery, her weight is 61 kg with BMI 22.
A repeat laparoscopic gastric sleeve resection was performed for inadequate weight loss after BPD/DS, and resulted in further weight reduction.
Background:
Although the efficacy of laparoscopic sleeve gastrectomy (LSG) for morbidly obese patients with a BMI of <50 kg/m2, the incidence of weight gain by change of eating behaviors, and gastric dilatation following LSG have not been investigated thus far, LSG is becoming more common as a single-stage operation for the treatment morbid obesity.
Methods:
This is a prospective study of the initial 120 patients who underwent isolated LSG. Initially, the LSG was performed without a calibration tube and resulted in high sleeve volumes (group 1: n=25). In group 2 (n=32), a calibration tube of 44 Fr and in group 3 (n=63) a calibration tube of 32 Fr were used. The study group consists of 101 patients with high BMI who were scheduled for a two-step LBPD-DS, but rejected the second step after 1 year. Study endpoints include estimated sleeve volume, volume of removed stomach, operative time, complication rates, length of hospital stay, changes in co-morbidity, percentage of excess BMI loss (%EBL) and changes in BMI (kg/m2).
Results:
All 3 groups were comparable regarding age, gender, and co-morbidities. There was no hospital mortality, but there was one case of late mortality (0.8%). 2 early leaks (1.7%) were seen. % excess BMI loss was significantly higher for patients who underwent LSG with tube calibrations. LSG with large sleeve volume showed a slight weight gain during 5 years of observation. A total of 16 patients (13.3%) underwent a second stage procedure within a period of 5 years (2 redo-sleeves, 7 LBPD-DS, 3 LRYGBP).
Conclusion:
Early weight loss results were not different between the groups, but after 2 years the more restrictive LSG (groups 2, 3) results were significantly better than in patients without calibration. A removed gastric volume of <500 cc seems to be a predictor of failure in treatment or early weight regain. A statistically significant improved health status and quality of life were registered for all groups. The general introduction of LSG as a one-stage restrictive procedure in the bariatric field can be considered only if the procedure is standardized and long-term results are available.
Revision of primary sleeve gastrectomy to Roux-en-Y gastric bypass: indications and outcomes from a high-volume center
- R A Casillas
- S S Um
- Zelada Getty
- J L Sachs
- S Kim
Casillas RA, Um SS, Zelada Getty JL, Sachs S, Kim BB. Revision of
primary sleeve gastrectomy to Roux-en-Y gastric bypass: indications
and outcomes from a high-volume center. Surg Obes Relat Dis
2016;12(10):1817-25.