Outcomes of Revisional Procedures for Insufficient Weight Loss or Weight Regain After Roux-En-Y Gastric Bypass

Background

The Roux-en-Y gastric bypass (RYGB) performed laparoscopically (LRYGB) is the most frequently performed bariatric procedure in Belgium. However, late results in terms of weight loss or weight regain are inconsistent and may warrant a second procedure. This retrospective study analyzes the laparoscopic options for revisional surgery after LRYGB.

Methods

Between January 1, 2001 and December 31, 2009, 70 patients underwent a new laparoscopic procedure for poor weight loss or weight regain after LRYGB. The revisional procedure was performed a median of 2.6?years after the initial bypass operation. Fifty-eight patients were available for follow-up (82.9?%); 19 underwent distalization; and 39 a new restrictive procedure.

Results

The mean mass index (BMI) before the revisional procedure was 39.1?+?11.3?kg/m² (30.8?C51.8), down from 42.7?+?19.7?kg/m² (33.0?C56.6) initially, which corresponded to a percentage of excess weight loss (EWL) of 12.4?+?9.3?% (?1.0?C29.1). After the corrective procedure, with a follow-up of approximately 4?years, mean BMI was 29.6?+?12.4?kg/m² (18.0?C45.5), for a significant additional percentage of EWL of 53.7?+?9.8?% (2.0?C65.8). The overall complication rate was 20.7?%, and the reoperation rate was 7.3?%. The overall leak rate was 12.1?%. Patients suffering from leaks could consistently be treated conservatively or by stent placement. Two patients needed reconversion after distal bypass. The satisfaction index was good in just over 50?% of the patients.

Conclusion

Revisional laparoscopic surgery after RYGB performed for weight issues provides good additional weight loss but carries significant morbidity. Leaks can usually be handled non-surgically. Patient satisfaction is only fair.     

Gastric Pouch Carcinoma after Gastric Bypass for Morbid Obesity

The relationship between bariatric surgery and gastric cancer is conjectural. We present a 52-year-old woman with BMI 45 operated initially by a Lap-Band procedure complicated by gastric wall erosion of the band 9 months later. She was re-operated and the band was removed. She subsequently underwent a Roux-en-Y gastric bypass. 5 years after, gastric carcinoma was discovered in the gastric pouch. Because of varied symptoms following bariatric surgery, patients may not present promptly with symptoms related to a gastric carcinoma.     

Comorbidities Remission After Roux-en-Y Gastric Bypass for Morbid Obesity is Sustained in a Long-Term Follow-up and Correlates with Weight Regain

Background

Obesity-related comorbidities are treated by Roux-en-Y gastric bypass (RYGB) due to weight loss and intestinal hormone changes. Few studies report the evolution of these comorbidities in a long-term follow-up, especially if weight regain is present. This study aims to analyze: (1) the resolution of obesity-related comorbidities after RYGB in a long-term follow-up and (2) its relationship to weight regain.

Methods

A retrospective study was conducted on 140 patients submitted to RYGB for morbid obesity for at least 5?years (mean follow-up 90?months). Mean body mass index (BMI) before operation was 52?kg/m², at nadir weight 29?kg/m², and at last follow-up 33?kg/m². The comorbidities diabetes, cardiovascular disease, arterial hypertension, dyslipidemia, sleep apnea, arthropathy, and infertility were classified as resolved, improved, unchanged, and worsened at nadir weight that happened between the first and second year and after five or more years of surgery. For each comorbidity, we compared the changes in the distribution of patients in the categories and the correlation of it with weight loss at the nadir and final weight.

Results

BMI was significantly different in the three periods. Comorbidities resolution was sustained in a long-term follow-up for diabetes, hypertension, cardiovascular disease, and infertility. Comorbidities status was directly related to the weight loss for all comorbidities except infertility.

Conclusions

Our results show that comorbidities remission after RYGB is sustained in a long-term follow-up. Weight regain is linked to worse results for all comorbidities except infertility.     

Revision Surgery for Treatment of Weight Regain After Roux-En-Y Gastric Bypass

Background

This study aims to evaluate results on revision surgery for weight regain after gastric bypass, based on surgical technique and follow-up.

Methods

This study is a retrospective analysis of 29 patients who presented weight regain on follow-up after more than 5 years, divided into four groups according to revision surgery type: group 1 (n?=?9) includes patients who underwent an increase in the length of the alimentary limb to 200 cm; group 2 (n?=?13) are patients who underwent an increase in the length of the alimentary limb and placing of a silicon ring; group 3 (n?=?2) are patients who underwent an increase in the length of the alimentary limb and gastric plication, and group 4 (n?=?5) are patients who underwent gastric plication and placing of a silicon ring.

Results

The average preoperative weight before revision surgery was 117.8 kg, and the average postoperative follow-up for revision surgery was 13.7 months. Weight loss after revision surgery was observed in all groups but was greater in patients with longer revisional postoperative follow-up. Patients who underwent placing of a silicon ring presented greater weight loss than those who had had such a band since the original gastric bypass operation.

Conclusions

Data suggest that revision surgery may be a useful tool in achieving weight loss in patients presenting weight regain following gastric bypass, obesity, bariatric surgery, gastric bypass, weight regain, and revision surgery.     

Revisional Surgery for Failed Gastric Restrictive Procedures for Morbid Obesity

As part of the Adelaide Obesity Surgery Study, we have reviewed all patients who have undergone revisional surgery. Of the 310 trial patients, 63 (20%) had revisions 1-69 (median 32) months following their original surgery--30% of all 105 gastrogastrostomy (GG) operations, 22% of 106 gastroplasty (GP) procedures, and 9% of 99 gastric bypasses (GB). Failure was due to stomal dilatation, 11% of all trial patients (71% of GG revisions), stomal stenosis, 6% (52% of GP revisions) and staple dehiscence, 4%. There was no mortality and a low hospital morbidity. Long-term success was only 23% (follow-up at least 3 years) and was achieved at considerable expense (3 reversals, 10 further revisions, 44 endoscopic procedures). Revisional surgery was successful in 45% of patients with stomal dilatation or dehiscence but in only 17% with stenosis. Overall, the most successful operation was revision of, or conversion to, gastric bypass (58% success rate), compared with gastroplasty (24%) and gastrogastrostomy (25%). Our long-term results following revisional surgery were disappointing, particularly for stenosis, and most failures followed revision to GG or GP. Roux-en-Y gastric bypass is the procedure of choice when considering revision.     

Pregnancy Following Gastric Bypass Surgery for Morbid Obesity: Maternal and Neonatal Outcomes

Background The purpose of this study was to compare obstetric and neonatal outcomes after Roux-en-Y gastric bypass (RYGB) to those in women without such surgery. Methods Women with RYGB (cases) were matched for maternal age and prior cesarean to the next two consecutive women delivering without prior bariatric surgery (controls). Pregnancy and newborn outcomes were compared by univariate analysis. Outcomes approaching or reaching statistical significance were evaluated by conditional logistic regression controlling for maternal body mass index (BMI). Results Despite gastric bypass, the 38 cases were heavier (BMI 33.4 ± 7.3 vs. 28.1 ± 6.7 kg/m², p < 0.001) and more often obese (BMI ≥ 30 kg/m², 26/38 (68.4%) vs. 20/76 (26.3%), p < 0.001) than controls. Variables evaluated by logistic regression adjusted for BMI did not differ in cases versus controls, including hypertension (odds ratio [OR] 2.62, 95% confidence interval [CI] 0.66–10.50), preterm premature rupture of membranes (OR 0.24, 95% CI 0.02–3.38), oligohydramnios (OR 2.39, 95% CI 0.66–8.61), and delivery ≥41 weeks (OR 0.57, 95% CI 0.11–2.97). Discussion Obstetric and neonatal outcomes after RYGB are similar to those of our general obstetric population. Reprints unavailable.     

Helicobacter pylori Infection in Patients Undergoing Gastric Bypass Surgery for Morbid Obesity

Background: Studies suggest that the incidence of Helicobacter pylori infection in obese patients, including those undergoing gastric reduction surgery, may be increased. Methods: We examined the histologic findings at the time of surgery in a series of patients who were undergoing Roux-en-Y gastric bypass (RYGBP) for morbid obesity and compared these results with patients in our institution undergoing endoscopy. Results: Of 60 patients undergoing RYGBP,material for histologic examination was available in 56 cases, and in 40 cases gastric fundic mucosa from the anastomotic site was sampled at the time of surgery. Active chronic gastritis was present in 6 (15%), and chronic gastritis was present in 27 (68%). H. pylori was present in all 6 cases of active chronic gastritis and in 9 cases of chronic gastritis (total 38%).This incidence of H. pylori infection was higher than that found in the series of gastric biopsies (107/500, 21%, p = 0.03) and fundic biopsies (10/80, 13%, p = 0.003), but was not different when compared with age-matched gastric biopsies (44/177, 25%, p = 0.12). Conclusions: The incidence of H. pylori in patients undergoing RYGBP was higher than that found in all patients undergoing endoscopy and biopsy and than those undergoing fundic biopsies, but not higher when age-matched controls were considered.     

Retrograde Intussusception After Roux-En-Y Gastric Bypass for Morbid Obesity

Intussusception after Roux-en-Y gastric bypass procedure (RYGBP) is a rare complication that typically presents late after open or laparoscopic procedures with intermittent partial or complete bowel obstruction. It may be antegrade (peristaltic) or retrograde (antiperistaltic) and usually the common channel is affected. We describe an unusual case of retrograde intussusception that occurred 2 years after a laparoscopic RYGBP in which the proximal common channel had invaginated into the distal anastomotic site and the distal Roux limb.     

Revisional Surgery for Severe Obesity with Fascia Banded Stoma Roux-en-Y Gastric Bypass

The fascia banded stoma Roux-en-Y gastric bypass (RYGBP) has been effective both as a primary and revision operation for severe obesity or failure of another operation. Since May 1984, 361 primary and 100 revisional fascia banded RYGBP operations have been reported. Weight loss achieved a mean body mass index of 30 for primary and 31 for revision patients at most recent follow-up of 3-6 years (mean 4.3 years) postoperatively. Mean overweight was 28% for primary, and 34% for revision patients. Eighty percent of primary and 79% of revision patients were within 50% of ideal weight. Revision rates for these patients were 0 for primary and 1% for revision patients. Operative mortality was 0 for primary and 1% for revision patients. Since morbidity and mortality, although low, are higher for revision than primary surgery, it is important to use an effective primary operation.     

Morbid Obesity and Gastric Bypass Surgery: Biochemical Profile

Background: Morbid obesity (MO) and the pathologies associated with it constitute an important public health problem, accounting for 7% of the health expenditure in industrialized countries. An important percentage of this expense is attributed to the different biochemical tests performed in these patients, who suffer from several metabolic derangements. We evaluated the basic biochemical abnormalities in MO patients and their reversibility by weight loss after gastric bypass, to standardize the surveillance of the different metabolic abnormalities in obese patients. Methods: By a retrospective analysis on 125 patients operated in our hospital, we evaluated anthropometric and biochemical data before and 1, 3, 6, 12 and 24 months after gastric bypass. Results: Preoperatively hyperinsulinemia, hyperglycemia, dyslipidemia and hypertensive disease were present, and began to improve 1 and 3 months after surgery (although not significantly) and significantly at 6, 12 and 24 months after it. We also observed deficient protein nutrition and a deficiency of micronutrients both before bypass and during the follow-up. Conclusion: After gastric bypass, a marked decrease in insulin occurred, with normalization of blood pressure and the biochemical parameters associated with the metabolic syndrome. We propose a biochemical follow-up protocol for MO patients.     

The Influence of Dumping on Weight Loss After Gastric Restrictive Surgery for Morbid Obesity

Background: The dumping syndrome that follows Roux-en-Y gastric bypass for morbid obesity is considered to be the primary mechanism of improved weight loss as compared with the purely restrictive vertical banded gastroplasty. To evaluate the influence of dumping on post-operative weight loss, severity of dumping was determined using Sigstad's clinical diagnostic index. Methods: One hundred and thirty seven gastric bypass and 19 gastroplasty patients were assessed 18-24 months following surgery. Sigstad's criteria for the dumping syndrome were met by 75.9% of gastric bypass and no gastroplasty patients. Among gastric bypass patients, no relationships were found between severity of dumping and weight loss, as measured by per cent of excess body weight loss or change in body mass index. Weight loss was significantly greater with gastric bypass than gastroplasty patients (72.5 compared to 47.9% of excess body weight loss). All gastroplasty and 24.1% of gastric bypass patients were classified as nondumpers. The difference in weight loss between surgical procedures was not related to dumping: gastric bypass non-dumpers lost significantly more weight (69.1% excess body weight loss) than gastroplasty patients. Conclusions: This study fails to demonstrate a significant relationship between dumping severity and weight loss. It is inferred that the superior weight loss of gastric bypass compared to gastroplasty has some other etiology.     

Bariatric Surgery for the Treatment of Morbid Obesity: A Meta-analysis of Weight Loss Outcomes for Laparoscopic Adjustable Gastric Banding and Laparoscopic Gastric Bypass

Bariatric surgery has emerged as an important tool in the fight against morbid obesity. However, reviewers have noted that there is a scarcity of long-term clinical surveillance data for bariatric surgery beyond 1-year follow-up and that a high percentage of patients are lost to follow-up, raising questions regarding the accuracy of current outcomes estimates. A meta-analysis of clinical reports providing bariatric surgery weight loss outcomes for morbidly obese patients was conducted over the period 2003–2007. Studies included were randomized controlled trials, nonrandomized controlled trials, and consecutive case series involving patients receiving either laparoscopic adjustable gastric banding (LAGB) or laparoscopic gastric bypass (LGB) surgery. Included studies involved n = 7,383 patients and were largely academic hospital-based (78.6%) and retrospective in design (71.4%). Weight loss outcome was defined by percent excess weight loss (%EWL). Composite estimates showed a significantly greater %EWL for LGB surgery (62.6%) compared to LAGB (49.4%). The superiority of LGB persisted at all three postsurgical time points examined (1, 2, and >3 years). Problems were identified regarding incomplete or suboptimal data reporting in many studies reviewed, and high patient attrition was evident at 2-year (49.8% LAGB, 75.2% LGB) and >3-year (82.6% LAGB, 89% LGB) end points. This meta-analysis confirms the superiority of LGB to LAGB in %EWL found in earlier studies. Although problems in study quality raised significant concerns regarding the validity of current weight loss estimates in this area, there was no evidence of publication bias.     

Anastomotic Leak following Antecolic versus Retrocolic Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Background Laparoscopic Roux-en-Y gastric bypass(LRYGBP) is the most commonly performed operation for the treatment of morbid obesity in the United States. Previous reports suggest that postoperative complications may be influenced by Roux limb orientation (antecolic versus retrocolic), although thisremains controversial. The aim of this study was toanalyze our experience with anastomotic leaks following LRYGBP with an antecolic- versus retrocolicrouted Roux limb. Methods During the 2-year period of June 2003 to June 2005, 353 patients underwent a LRYGBP. 135 were antecolic and 218 retrocolic. All cases were performedby one of three bariatric surgeons. The decisionto perform antecolic versus retrocolic LRYGBP was left to the surgeon’s preference. The primary outcome measure was anastomotic leak. Results Mean follow-up was 28 weeks. There wereno perioperative deaths. Overall complication rate was 16.9%. 17 gastrojejunal leaks (4.8%) were identified, consisting of 12 intraoperative leaks (3.4%) and 5 postoperative leaks (1.4%). Postoperative gastrojejunal leak rate was higher in the antecolic group (P = 0.04). Conclusion Mortality and complication rates were consistent with reported benchmarks on the efficacy and safety of LRYGBP. Our review suggests that anastomotic leak may be more common after antecolic than after retrocolic LRYGBP for morbid obesity. A prospective randomized study is needed to determine whether antecolically-routed Roux limb is an independent predictor for anastomotic leak following LRYGBP.     

Weight Regain After Gastric Bypass: Influence of Gut Hormones

Background

The Roux-en-Y gastric bypass (RYGB) is the gold standard bariatric operation. However, a major concern in late follow-up is the substantial weight regain. Understanding the role of gastrointestinal hormone secretion in this situation is relevant.

Methods

The aim of the present study was to evaluate the influence of gastrointestinal hormones comparing postprandial secretion of ghrelin, glucose-dependent insulinotropic polypeptide (GIP), glucagon-like peptide 1 (GLP-1), and leptin between patients with weight regain and those with favorable weight control. Twenty-four patients with follow-up from 27 to 59 months were divided into two groups according to sustained weight loss: group A (14 patients) had sustained weight losses, and group B (10 patients) had significant weight regain. Basal serum levels of ghrelin, GIP, GLP-1, and leptin after fasting and 30, 60, 90, and 120 min after a standard meal were measured.

Results

There was no difference in the ghrelin secretion. There was a difference in the GIP secretion, with a higher percentage increase in 30 min in group A (330 %?×?192.2 %; p?=?0.01). There were also differences in the GLP-1 secretion, with higher increases in absolute (p?=?0.03) and percentage values after 30 min in group A (124 %?×?46.5 %; p?=?0.01). There was also a difference between baseline leptin values, with higher levels in group B (p?=?0.02).

Conclusions

The secretion of gut hormones in patients with weight regain after RYGB is different from that in patients with satisfactory weight outcome. After meal stimulation, reduced levels of GIP and GLP-1 may indicate the influence of gut hormones in the process of weight regain.

     

Skin Vasodilator Function and Vasomotion in Patients with Morbid Obesity: Effects of Gastric Bypass Surgery

Obesity-associated microvascular dysfunction (MVD) involves different body tissues, including skin, and concurs to increased cardiovascular risk in obese patients (Ob-P). Generalized improvement of MVD is an important goal in obesity treatment. Since skin MVD mirrors generalized systemic MVD, skin microvascular investigation in prospective studies in Ob-P may surrogate microvascular investigation in organs more important for cardiovascular risk of the studied patients. In this prospective study, we measured forearm skin post-occlusive reactive hyperaemia (PORH), as percentage flow increase from baseline, and skin vasomotion in 37 Ob-P before Roux-en-Y gastric bypass (RYGB), and in 24 of them about 1 year after RYGB, using laser Doppler flowmetry (LDF). The spectral contribution of skin LDF signal oscillations in the frequency intervals of 0.01–0.02 Hz, 0.02–0.06 Hz, and 0.06–0.2 Hz—corresponding to endothelial-, sympathetic-, and myogenic-dependent vasomotion, respectively, was measured by means of spectral Fourier analysis. The same measurements were also performed in 28 healthy, lean subjects (HLS). Before RYGB, Ob-P had a significant reduction in PORH and in the all vasomotion parameters investigated, compared with HLS. After RYGB, Ob-P who completed the follow-up, had a significant weight loss (∼40 kg on average), together with a full normalisation in PORH and in vasomotion parameters, regardless of diabetes status. Surgically induced sustained weight loss resulted in full normalisation of skin microvascolar function in Ob-P about 1 year after RYGB. This result suggests a beneficial effect of sustained weight loss on generalized MVD of the studied Ob-P.     

Hepatic Histopathology of Patients with Morbid Obesity Submitted to Gastric Bypass

Background: The authors analyze and describe the hepatic histopathology of patients with morbid obesity submitted to gastric bypass. Methods: A liver biopsy was performed in 112 patients at the beginning of gastric bypass, and clinical data (gender, age, BMI and associated diseases) were obtained from the patient records. Results: Among the patients, 74.1% (n=83) were females and 25.9% (n=29) were males, age 39.59±10.12 years, with BMI 48.79±7.54. Regarding the diseases associated with morbid obesity, arterial hypertension was observed in 67.9% (n=76) of the patients, joint diseases in 55.4% (n=62), dyslipidemia in 40.2% (n=45), and diabetes type 2 in 27.7% (n=31). 111 patients (99.1%) showed different types of non-alcoholic fatty liver disease (NAFLD) (types 1, 2, 3 and 4), with types 3 and 4 accounting for 57.7% (n=64). A significant association was observed between NAFLD type 4 and diabetes type 2 (P=0.018). The presence of glycogen nuclei was significantly correlated with steatosis (P=0.000), lobular inflammation (P=0.019) and perisinusoidal fibrosis (P=0.000). Conclusion: 1) Liver biopsy taken at gastric bypass reveals different types of NAFLD; 2) Diabetes type 2 is associated with NAFLD type 4; 3) Glycogen nuclei are correlated with steatosis, lobular inflammation and perisinusoidal fibrosis; 4) Steatosis represents the basic injury in NAFLD and is associated with hepato-cellular ballooning. 5) In view of the frequency of hepatic alterations, a biopsy should be part of the surgical protocol of morbid obesity, this method being the only one able to determine the presence of lesions and to stage fibrosis.     

Laparoscopic Placement of Non-Adjustable Silicone Ring for Weight Regain After Roux-en-Y Gastric Bypass

Background  Roux-en-Y gastric bypass (RYGBP) is presently one of the most popular surgical procedures for obesity. One of the possible long-term problems is weight regain, usually after a period of successful weight loss. Weight regain after RYGBP can be due to new eating habits, like sweet-eating or grazing, or volume eating because of impaired restriction. This paper reports our experience in patients who presented weight regain after laparoscopic RYGBP, because of new appearance of volume eating or hyperphagia, treated by the laparoscopic placement of a non-adjustable silicone ring around the gastric pouch. Methods  From July 2004 to November 2007, six patients affected by weight regain due to hyperphagic behavior, benefited from revision of RYGBP consisting of the placement of a non-adjustable silicone ring loosely encircling the stomach part. Mean weight and body mass index (BMI) at the time of RYGBP were 105.0 kg ± 12.3 and 36.3 ± 3.0 kg/m², respectively, and all patients suffered from obesity-related co-morbidities. After a mean time from RYGBP of 26.0 ± 14.2 months, patients presented a weight regain of 4.7 ± 3.4 kg compared with their minimal weight, with a final mean weight, BMI, and percentage of excess weight loss (%EWL) at the time of the silicone ring of 86.0 ± 13.1 kg, 29.5 ± 3.9 kg/m², and 47.0 ± 24.7%, respectively. Preoperative evaluation for each patient included history and physical examination, nutritional and psychiatric evaluation, laboratory tests, and barium swallow check. Outcome measures included evaluation of the Roux-en-Y construction, operative time, postoperative morbidity and mortality, and weight loss in terms of absolute weight loss, BMI, and %EWL. Results  Any modification of the digestive circuit was evidenced. Mean operative time was 82.5 ± 18.3 min. No operative mortality and no conversion to open surgery were achieved. No postoperative complications were achieved. Mean hospital stay was 2.6 ± 1.5 days. After a mean follow-up of 14.0 ± 9.2 months, the six patients presented a mean weight loss of 9.1 ± 2.4 kg, with a final mean weight, BMI, and %EWL of 76.8 ± 13.7 kg, 26.4 ± 4.2 kg/m², and 70.4 ± 30.4%, respectively. Difference in term of %EWL before and after revision (23.4 ± 5.7) is statistically significant (p < 0.05). There have been no erosions or slippage of the ring during this follow-up. Conclusion  One of the possible causes of weight regain after RYGBP is the new eating behavior of the patient, one of which is hyperphagia. Treatment of this condition can be the placement of a non-adjustable silicone ring loosely fitted around the gastric pouch which contributes to improved weight loss. This paper was presented at the XIII World Congress of International Federation for the Surgery of Obesity and metabolic disorders, Buenos Aires, Argentina, September 24–27, 2008.     

Laparoscopic Gastric Bypass for Morbid Obesity with Linear Gastroenterostomy

Background: Laparoscopic gastric bypass (LGBP) is a well-established procedure for the surgical management of morbid obesity. Most surgeons create the gastroenteral anastomosis by using the circular EEA stapler. We describe an alternative laparoscopic anastomotic technique using the EndoGIA linear stapling device. Methods: The stomach was proximally transected with a linear stapler (45 mm, Endo-GIA) to create a 15 to 20 ml pouch. Next, an antecolic Roux-en-Y gastroenterostomy was performed, using the 45 mm Endo-GIA. The proximal loop of the intestine was then separated from the anastomotic site by the Endo-GIA. Finally, the Endo-GIA was used for the intraabdominal creation of a side-to-side enteroenterostomy. Results: Between June and August 2001, 5 patients with mean BMI 56.7 kg/m²±7.3 underwent LGBP. All patients were seen 6 months post-surgery. Operating time was 7.5 and 6.5 hours for the first 2 operations, but was under 4.5 h for the next 3 cases. 1 patient suffered from perioperative hypoxia leading to long-term artificial respiration. 6 weeks after surgery, 1 patient developed obstruction due to torsion of the enteroenterostomy and required open revision. The 3 remaining patients made an uneventful recovery. All patients lost considerable weight (mean 36.5 kg; [range 32 to 45] after 6 months). No stenosis or anastomotic leakage was noted. Conclusions: A linear stapled anastomosis is an alternative to the use of the circular stapler.     

Pouch Size After Gastric Bypass Does not Correlate with Weight Loss Outcome

A large gastric pouch is a classic explanation for weight loss problems after gastric bypass. However, several reports have emphasized the role of others, essentially behavorial, factors. We reviewed the outcomes of 151 patients who were operated on over a period of nearly 2 years. 132 patients who had not been reoperated on were assessed between June and September 2009. A barium swallow was available to assess the gastric pouch volume which was determined by the radiologist. %EWL was compared to the pouch volume using ANOVA test. Pouch volumes were compared using t test. The gastric pouch was dilated when >50 ml and failure to lose enough weight was defined by a %EWL<50%. 107 patients (81%) had a complete follow up of 35.7 ± 5.8 months. Mean pouch volume was 68 ± 4.5 ml with a %EWL of 68 ± 26.1%. 59 patients had a large pouch with a weight loss similar to those with a normally sized pouch (68 ± 3.6 vs 66 ± 3.6%EWL). 25 patients (23.3%) had weight loss failure with a similar pouch volume. No correlation was found between the %EWL and the pouch volume. Pouch size probably plays a role in the weight loss process of RYGB. However, 3 years later, pouch volume does not appear to be the most important factor. Behavorial factors such as recurrent eating disorders and failure to adapt to the changes induced by the surgery may explain at least in part weight loss failure.     

Endoscopic Dilation of Gastrojejunal Anastomotic Strictures After Laparoscopic Gastric Bypass. Predictors of Initial Failure

Background and aims  

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most frequent technique performed in bariatric surgery. Gastrojejunal anastomotic stricture is one of the most common postoperative complications. The aims of this study were to evaluate the efficacy and safety of endoscopic balloon dilation in the treatment of the gastrojejunal anastomotic strictures after LRYGB and to look for predicting factors that would indicate the need of repeated dilations.