Outcomes of laparoscopic adjustable gastric banding in patients with low body mass index

BackgroundThe current National Institutes of Health guidelines have recommended bariatric surgery for patients with a body mass index (BMI) >40 kg/m² or BMI >35 kg/m² with significant co-morbidities. However, some preliminary studies have shown that patients with a BMI that does not meet these criteria could also experience similar weight loss and the benefits associated with it.MethodsAn institutional review board-approved protocol was obtained to study the effectiveness of laparoscopic adjustable gastric banding in patients with a low BMI. A total of 66 patients with a BMI of 30–35 kg/m² and co-morbidities (n = 22) or a BMI of 35–40 kg/m² without co-morbidities (n = 44) underwent laparoscopic adjustable gastric banding. These patients were compared with 438 standard patients who had undergone laparoscopic adjustable gastric banding who met the National Institutes of Health criteria for bariatric surgery. The excess weight loss at 3, 6, 12, and 18 months and the status of their co-morbidities were compared between the 2 groups.ResultsThe average BMI for the study group was 36.1 ± 2.6 kg/m² compared with 46.0 ± 7.3 kg/m² for the control group. Both groups had significant co-morbidities, including hypertension, diabetes, hyperlipidemia, arthritis, gastroesophageal reflux disease, stress incontinence, and obstructive sleep apnea. The mean percentage of excess weight loss was 20.3% ± 9.0%, 28.5% ± 14.0%, 44.7% ± 19.3%, and 42.2% ± 33.7% at 3, 6, 12, and 18 months, respectively. This was not significantly different from the excess weight loss in the control group, except for at 12 months. Both groups showed similar improvement of most co-morbidities.ConclusionModerately obese patients whose BMI is less than the current guidelines for bariatric surgery will have similar weight loss and associated benefits. Laparoscopic adjustable gastric banding is a safe and effective treatment for patients with a BMI of 30–35 kg/m².     

Long-term follow-up in patients undergoing open gastric bypass as a revisional operation for previous failed restrictive procedures

BackgroundWe have previously described our early experience with Roux-en-Y gastric bypass (RYGB) as a revisional procedure. The favorable results have stimulated us to continue using RYGB as our standard operating procedure after failed bariatric surgery. Our objective was to evaluate the perioperative risks, weight result, and abdominal symptoms 5 years after revisional RYGB surgery at a university hospital in Sweden.MethodsWe studied 121 patients undergoing revisional open RYGB (age 42.0 yr, body mass index 37.7 kg/m², 101 women) 5 years after RYGB surgery. The patients underwent reoperation because of either intolerable side effects or inferior weight loss. The initial procedures were horizontal gastroplasty (n = 2), vertical banded gastroplasty (n = 34), gastric banding (n = 21), and silicone adjustable gastric banding (n = 64). The mean interval between the first surgery and revision was 5 years. The 5-year follow-up data were obtained annually using a questionnaire survey.ResultsThe average operating time was 162 minutes (range 75–355). In these 121 cases, 10 (8%) reoperations were performed in the first 30-day period (4 for leakage). No perioperative mortality occurred, and the 5-year follow-up rate was 91%. The mean body mass index was 30.7 kg/m². Seven patients (5.7%) had undergone subsequent surgery because of complications. At follow-up, 93% reported being very satisfied or satisfied with the revisional procedure. Disturbing abdominal symptoms after RYGB were rare.ConclusionThe perioperative risks of revisional RYGB are greater than those for primary RYGB. However, because the long-term weight results and patient satisfaction are very good, we believe that the 8% reoperative rate is acceptable. We consider RYGB to be a suitable procedure for patients in whom previous bariatric procedures have failed.     

Laparoscopic revisional surgery after Roux-en-Y gastric bypass and sleeve gastrectomy

BackgroundFailure of primary bariatric surgery is frequently due to weight recidivism, intractable gastric reflux, gastrojejunal strictures, fistulas, and malnutrition. Of these patients, 10–60% will undergo reoperative bariatric surgery, depending on the primary procedure performed. Open reoperative approaches for revision to Roux-en-Y gastric bypass (RYGB) have traditionally been advocated secondary to the perceived difficulty and safety with laparoscopic techniques. Few studies have addressed revisions after RYGB. The aim of the present study was to provide our experience regarding the safety, efficacy, and weight loss results of laparoscopic revisional surgery after previous RYGB and sleeve gastrectomy procedures.MethodsA retrospective analysis of patients who underwent laparoscopic revisional bariatric surgery for complications after previous RYGB and sleeve gastrectomy from November 2005 to May 2007 was performed. Technical revisions included isolation and transection of gastrogastric fistulas with partial gastrectomy, sleeve gastrectomy conversion to RYGB, and revision of RYGB. The data collected included the pre- and postoperative body mass index, operative time, blood loss, length of hospital stay, and intraoperative and postoperative complications.ResultsA total of 26 patients underwent laparoscopic revisional surgery. The primary operations had consisted of RYGB and sleeve gastrectomy. The complications from primary operations included gastrogastric fistulas, refractory gastroesophageal reflux disease, weight recidivism, and gastric outlet obstruction. The mean prerevision body mass index was 42 ± 10 kg/m². The average follow-up was 240 days (range 11–476). The average body mass index during follow-up was 37 ± 8 kg/m². Laparoscopic revision was successful in all but 1 patient, who required conversion to laparotomy for staple line leak. The average operating room time and estimated blood loss was 131 ± 66 minutes and 70 mL, respectively. The average hospital stay was 6 days. Three patients required surgical exploration for hemorrhage, staple line leak, and an incarcerated hernia. The overall complication rate was 23%, with a major complication rate of 11.5%. No patients died.ConclusionLaparoscopic revisional bariatric surgery after previous RYGB and sleeve gastrectomy is technically challenging but compared well in safety and efficacy with the results from open revisional procedures. Intraoperative endoscopy is a key component in performing these procedures.     

Changes in brain activation to food pictures after adjustable gastric banding

BackgroundAdjustable gastric banding is an effective weight-loss treatment, but little is known about the neural mechanisms underlying weight loss. The purpose of the present study was to determine whether gastric banding affects brain function in regions previously implicated in food motivation, reward, and cognitive control. The setting for the study was the University of Missouri-Kansas City, Department of Psychology; Hoglund Brain Imaging Center, University of Kansas Medical Center; and private practice in the United States.MethodsTen obese participants were recruited before adjustable gastric banding surgery (mean body mass index before surgery 40.6 ± 1.96 kg/m²). Their mean body mass index at 12 weeks after surgery was 36.1 ± 2.32 kg/m², with a mean percentage of excess weight loss of 25.21% ± 8.41%. Functional magnetic resonance imaging scans were conducted before and 12 weeks after adjustable gastric banding surgery. At each assessment point, the participants completed questionnaires assessing food motivation and were scanned while hungry (before eating) and immediately after a standardized meal (after eating). During the functional magnetic resonance imaging scans, the participants viewed food pictures, nonfood pictures (animals), and blurred baseline control pictures. The functional magnetic resonance imaging data were analyzed using BrainVoyager QX.ResultsAfter surgery, the participants reported significantly less food motivation and more cognitive restraint. The participants also showed decreased brain activation to food versus nonfood pictures in regions implicated in food motivation and reward, including the parahippocampus, medial prefrontal cortex, insula, and inferior frontal gyrus. In contrast, they demonstrated increased activation to food versus nonfood pictures in anterior prefrontal cortex, a region implicated in cognitive control and inhibition.ConclusionThis is the first study to examine the functional brain changes after gastric banding surgery and 1 of the first studies to longitudinally examine neural changes associated with weight loss. These results have provided preliminary evidence that adjustable gastric banding alters brain function in regions known to regulate reward and cognitive control.     

Adjustable gastric band placed around gastric bypass pouch as revision operation for failed gastric bypass

BackgroundThe failure rate after gastric bypass surgery for weight loss has been reported at 10–20%. To date, no reliably safe and effective salvage operation is available. This pilot study was conducted to determine whether restriction of the Roux-en-Y gastric bypass (RYGB) pouch using the adjustable gastric band (AGB) is an effective revision operation.MethodsA prospectively accrued group of patients who underwent revisional surgery using the AGB placed around the RYGB pouch by our bariatric surgical group from October 2004 to October 2006 was analyzed.ResultsOf the 10 patients accrued during this period, 2 were lost to follow-up, leaving 8 patients for analysis. Of the 8 patients, 1 was a man and 7 were women. The mean prerevision weight was 135.75 kg (range 105–165), and the body mass index was 48.42 kg/m² (range 38.92–55). The mean weight loss at 1 year of follow-up was 17.03 kg (range 0.2–42), with a mean percentage of excess weight loss of 24.29% (range 0.2–49.2%). The mean weight loss of the 5 patients with 2 years of follow-up was 36.4 kg (range 20–58), with a mean percentage of excess weight loss of 48.7% (range 21.8–98.1%). One patient with 3 years of follow-up had a weight loss of 56 kg and a percentage of excess weight loss of 66.2%. Three minor complications developed: 2 AGB port-related complications requiring port revision and 1 postoperative wound hematoma requiring evacuation. No band erosions or band slippages occurred, and no major complications developed.ConclusionIn our study, an AGB placed around the RYGB pouch was a safe and effective revision operation for a failed RYGB operation.     

Roux-en-Y gastric bypass after previous unsuccessful gastric restrictive surgery

In the treatment of morbid obesity, simple gastric restrictive methods such as silicone adjustable gastric banding, vertical banded gastroplasty, and nonadjustable gastric banding often fail to control weight in the long run or give rise to intolerable side effects. Here we review our results from conversion of such failures to Roux-en-Y gastric bypass. The study comprised 44 patients (median age 42 years, range 24 to 60 years) who underwent revision surgery in 1996 and 1997. Body mass index at revision was 35 kg/m² (range 21 to 49 kg/m²). Previous bariatric procedures included silicone adjustable gastric banding (n = 26), vertical banded gastroplasty (n = 13), and gastric banding (n = 5). The most common reasons for conversion after silicone adjustable gastric banding and nonadjustable gastric banding were band erosion (n = 12) and esophagitis (n = 11). Staple line disruption (n = 12) with subsequent weight loss failure was the primary cause after vertical banded gastroplasty. There were no postoperative deaths or anastomotic leaks. One patient underwent reexploration because of an infected hematoma. Reflux symptoms and vomiting resolved promptly. At global assessment 2 years later, 70% of the patients were very satisfied. Median body mass index had decreased to 28 kg/m² (range 18 to 42 kg/m²). No patient was lost to followup. As reported previously, failure after vertical gastric banding can be treated by conversion to Roux-en-Y gastric bypass with good results. In this study we found that failure after silicone adjustable gastric banding can be treated successfully with Roux-en-Y gastric bypass as well. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 17–20, 1998 (poster presentation).     

Biliopancreatic diversion with duodenal switch or gastric bypass for failed gastric banding: retrospective study from two institutions with preliminary results.

BACKGROUND: Of patients who have undergone gastric banding, 11-25% will require a major reoperation with band removal and conversion to another bariatric procedure after they have failed to lose sufficient weight or have developed dysphagia or reflux. The aim of this study was to evaluate the respective benefits of Roux-en-Y gastric band (RYGB) or biliopancreatic diversion with duodenal switch (BPD-DS) after failed gastric banding and whether 1 of the 2 procedures might be a better procedure for such cases. METHODS: RYGB or BPD-DS was performed according to the institutional protocols with synchronous band removal, irrespective of the reason for failure. RESULTS: Of the 53 patients, 32 underwent laparoscopic RYGB for a body mass index (BMI) of 43.1 +/- 6.4 kg/m(2) (BMI 45.8 +/- 6.4 kg/m(2) before laparoscopic adjustable gastric banding) and 21 underwent BPD-DS for a BMI of 46.0 +/- 5.5 kg/m(2) (BMI 49.6 +/- 5.2 kg/m(2) before laparoscopic adjustable gastric banding). BPD-DS required significantly longer operative times (239.7 +/- 55.8 versus 135 +/- 26.7 minutes) and resulted in more complications (62% versus 12.5%; P <.002). No patients died postoperatively. The 2 groups of patients had a similar BMI at 12 and 18 months after revision (BMI 33.4 +/- 5.6 kg/m(2) and 31.4 +/- 3.5 kg/m(2)). The weight loss was greater after BPD-DS than after RYGB compared with the prerevision weight loss (66.2% versus 58.8% excess weight loss) or initial weight (73% versus 61.8%), although this was not significant. CONCLUSION: Despite an excessive rate of complications that were, in part, related to the learning curve in this series, BPD-DS resulted in greater weight loss compared with RYGB. However, both procedures were successful after failed gastric banding. A more accurate definition of failure could help to determine the respective indications for revisional surgery.     

Long-term follow-up evaluation of revisional gastric bypass after failed adjustable gastric banding

Background

Disappointing long-term results, frequent band failure, and high rates of band-related complications increasingly necessitate revisional surgery after adjustable gastric banding. Laparoscopic conversion to gastric bypass has been recommended as the procedure of choice. This single-center retrospective study aimed to evaluate the long-term results of revisional gastric bypass after failed adjustable gastric banding.

Methods

The study included 108 consecutive patients who underwent laparoscopic conversion of gastric banding to gastric bypass from 2002 to 2012. Indications for surgery, operative data, weight development, morbidity, and mortality were analyzed. The median follow-up period was 3.4 years (maximum, 10 years).

Results

The most common indications for band removal were band migration, insufficient weight loss, and pouch dilation. The median interval between gastric banding and gastric bypass was 6.6 years. In 52 % of the cases, band removal and gastric bypass surgery were performed simultaneously as a single-stage laparoscopic procedure. The early postoperative morbidity rate was 10.2 %. The body mass index before gastric banding (43.3 kg/m²) decreased significantly to 37.9 kg/m² before gastric bypass and to 28.8 kg/m² 5 years after gastric bypass.

Conclusions

This is the first report on the long-term outcome after conversion of failed adjustable gastric banding to gastric bypass. Findings have shown revisional gastric bypass to be a feasible bariatric procedure particularly for patients with insufficient weight loss that guarantees a constant and long-lasting weight loss.     

Sleeve gastrectomy as revisional procedure for failed gastric banding or gastroplasty

BackgroundLaparoscopic sleeve gastrectomy (LSG) is considered an effective multipurpose operation for morbid obesity, although long-term results are still lacking. Also, the best procedure to be offered in the case of failed restrictive procedures is still debated. We here reported our results of LSG as a revisional procedure for inadequate weight loss and/or complications after adjustable gastric banding or gastroplasty.MethodsSince April 2005, 57 patients (20 men and 37 women), with a mean age of 49.9 ± 11.9 years, underwent revisional LSG, 52 after laparoscopic adjustable gastric banding/adjustable gastric banding and 5 after vertical banded gastroplasty at our institution. The mean interval from the primary procedure to LSG was 7.54 ± 4.8 years. The LSG was created using a 34F bougie with an endostapler, after removing the laparoscopic adjustable gastric band or the anterior portion of the band in those who had undergone vertical banded gastroplasty. An upper gastrointestinal contrast study was performed within 3 days after surgery and, if the findings were negative, a soft diet was promptly started.ResultsA total of 41 patients had undergone concurrent band removal and LSG and 16 had undergone band removal followed by an interval LSG. Three cases required conversion to open surgery because of a large incisional hernia. The mean operative time was 120 minutes (range 90–180). One patient died of multiple organ failure from septic shock. Three patients (5.7%) developed a perigastric hematoma, 3 (5.7%) had leaks, and 1 had mid-gastric short stenosis. The median hospital stay was 5 days. The mean body mass index at revisional LSG was 45.7 ± 10.8 kg/m² and had decreased to 39 ± 8.5 kg/m² after 2 years, with a mean percentage of the estimated excess body mass index lost of 41.6% ± 24.4%. Two patients required a duodenal switch for insufficient weight loss.ConclusionLSG seems to be effective as revisional procedure for failed LAGB/vertical banded gastroplasty, although with greater complication rates than the primary procedures. Larger series and longer follow-up are needed to confirm these promising results.     

Salvage banding for failed Roux-en-Y gastric bypass

BackgroundAfter Roux-en-Y gastric bypass (RYGB), a substantial number of patients do not achieve successful long-term weight loss. In cases of loss of restriction, the application of an adjustable gastric band (“salvage banding”) over the gastric pouch, or gastrojejunostomy, could prevent weight regain or increase weight loss. The objective of this literature review is to provide an overview of the studies that report the effect of salvage banding after failed RYGB.MethodsA systemic literature search was conducted in PubMed, Google Scholar, Medline, the Cochrane Library, and the online websites of specific bariatric surgery journals to identify all relevant studies describing salvage banding after failed RYGB.ResultsSeven studies, with a total of 94 patients, were included for a systemic literature review. Inclusion criteria for salvage banding varied from unsuccessful weight loss to technical pouch failure. After salvage banding, all studies reported further weight loss, varying from 55.9%–94.2% excess body mass index loss (EBMIL) after 12–42 months of follow-up. In the included study group, 18% (17/94) of the patients developed long-term complications requiring a re-revision in 17% (16/94) of the cases.ConclusionThe results of all 9 studies that were included in this review report a further increase in weight loss after salvage banding for failed RYGB. In case of insufficient weight loss or technical pouch failure after RYGB, all reports suggest that salvage banding is a safe and feasible revisional procedure. Prospective studies are necessary to determine to the success of direct application of an adjustable gastric band in primary RYGB.     

Weight loss and effect on co-morbidities in the long-term after duodenal switch and gastric bypass: a population-based cohort study

BackgroundUnsatisfactory weight loss is common after bariatric surgery in patients with super obesity (body mass index [BMI] ≥50 kg/m²). Unfortunately, this group of patients is increasing worldwide.ObjectiveThe aim of this study was to compare long-term weight loss and effect on co-morbidities after duodenal switch (DS) and gastric bypass (RYGB) in super-obese patients.SettingUniversity hospital, Sweden, national cohort.MethodsThis observational population-based cohort-study of primary DS and RYGB (BMI ≥48 kg/m²) in Sweden from 2007 to 2017 used data from 4 national registers. Baseline characteristics were used for propensity score matching (1 DS:4 RYGB). Weight loss was analyzed up until 5 years after surgery. Medication for diabetes, hypertension, dyslipidemia, depression, and pain were analyzed up until 10 years after surgery.ResultsThe study population consisted of 333 DS and 1332 RYGB, with 60.7% females averaging 38.5 years old and BMI 55.0 kg/m² at baseline. DS resulted in a lower BMI at 5 years compared with RYGB, 32.2 ± 5.5 and 37.8 ± 7.3, respectively, (P < .01). DS reduced prevalence of diabetes and hypertension more than RYGB, while reduction in dyslipidemia was similar for both groups, during the 10-year follow-up. Both groups increased their use of antidepressants and a maintained a high use of opioids.ConclusionThis study indicates that super-obese patients have more favorable outcomes regarding weight loss and effect on diabetes and hypertension, after DS compared with RYGB.     

Long-term results for gastric banding as salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass

Background

Studies reporting revisionary options for weight loss failure after Roux-en-Y gastric bypass (RYGB) have been underpowered and lacking long-term data. We have previously shown that short-term (12 mo) and midterm (24 mo) weight loss is achievable with laparoscopic adjustable gastric banding (LAGB) for failed RYGB. The present study represents the largest published series with longest postoperative follow-up of patients receiving salvage LAGB after RYGB failure.

Outcomes of bariatric surgery in extreme obesity: results from the United Kingdom National Bariatric Surgery Registry for patients with a body mass index >70 kg/m2

BackgroundBariatric and metabolic surgery (BMS) is an established safe, effective, and durable treatment for obesity and its complications. However, there is still a paucity of evidence on surgery outcomes in patients suffering from extreme obesity.ObjectivesThis study aimed to evaluate outcomes of BMS in weight loss and the resolution of co-morbidities in patients with a body mass index (BMI) ≥70kg/m².SettingNational Health Service and private hospitals in the United Kingdom.MethodsThis cohort study analyzed prospectively collected records from the UK National Bariatric Surgery Registry of patients with a BMI ≥70 kg/m² undergoing Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), or adjustable gastric band (AGB) between January 2009 and June 2014.ResultsThere were 230 patients (64% female) eligible for inclusion in the study: 22 underwent AGB; 102 underwent SG, and 106 underwent RYGB. Preoperative weight and BMI values were comparable (76 ± 7 kg/m² for AGB; 75 ± 5 kg/m² for SG; 74 ± 5 kg/m² for RYGB). The median postoperative follow-up was 13 months for AGB (10–22 mo), 18 for SG (6–28 mo), and 15 for RYGB (6–24 mo). Patients undergoing RYGB and SG exhibited the greatest postoperative total body weight loss (35 ± 13% and 31 ± 15%, respectively; P = .14), which led to postoperative BMIs of 48 ± 10 kg/m² and 51 ± 11 kg/m², respectively (P = .14). All procedures conferred a reduction in the incidence of co-morbidities, including type 2 diabetes, and led to improved functional statuses. The overall complication rate was 7%, with 3 deaths (1%) within 30 days of surgery.ConclusionThis study found that primary BMS in patients with a BMI >70kg/m² has an acceptable safety profile and is associated with good medium-term clinical outcomes. RYGB and SG are associated with better weight loss and great improvements in co-morbidities than AGB. Given the noninferiority of SG outcomes and SG’s potential for further conversion to other BMS procedures if required, SG may be the best choice for primary BMS in patients with extreme obesity.     

Early complications,long-term adverse events,and quality of life after duodenal switch and gastric bypass in a matched national cohort

BackgroundInsufficient weight loss is common in super-obese patients (body mass index >50) after Roux-en-Y gastric bypass (RYGB). Duodenal switch (DS) is more effective; however, it is considered to have an increased complication rate.ObjectivesTo compare early complications (≤30 d), long-term adverse events, and quality of life (QoL) between primary DS and RYGB.SettingSweden.MethodsNational cohort-study of super-obese patients after primary DS or RYGB in Sweden 2007 to 2017. Propensity-score matching was used to reduce confounders. Five national registers were cross-matched.ResultsThe study population consisted of 333 DS and 1332 RYGB (body mass index 55 ± 5 kg/m², 38.5 ± 11 yr, and 60.7% females). Laparoscopic approach was used in 25% of DS and 91% of RYGB. Early complications were more common after DS (15.3% versus 8.1%, P < .01), mainly because of more open surgery and related surgical site infections. During 4.6 ± 2.3 years mean follow-up, hospital admission rate was 1.4 ± 2.3 versus 1.1 ± 3.3 (P = .18), with 6.7 ± 18.3 versus 7.0 ± 43.0 in-hospital days, for DS and RYGB, respectively. An increased risk of malnutrition/malabsorption requiring inpatient care (2.8% versus .2%, odds ratio 12.3 [3.3–45.7]) and greater need for additional abdominal surgery (25.8% versus 15.3%, odds ratio 2.0 [1.5–2.7]) was observed for DS. However, QoL was more improved after DS.ConclusionDS was associated with more early complications because of more open surgery, but long-term requirement of inpatient care was similar to RYGB. The increased risk of malnutrition/malabsorption and need for additional abdominal surgeries was contrasted with a greater improvement in QoL for DS.     

Roux-en-Y gastric bypass after successful weight loss with a laparoscopic adjustable gastric band: rationales and early outcomes in patients of body mass index<35 kg/m2

BackgroundLaparoscopic adjustable gastric banding (LAGB) has a number of well-established acute and chronic issues that can require revisional surgical procedures. There is no existing data to evaluate conversion of band patients with body mass index (BMI)<35 kg/m² from LAGB to a Roux-en-Y gastric bypass (RYGB). This study aims to report on the indications for and the safety profile of conversion of the LAGB to RYGB in patients with BMI<35 kg/m².MethodsA review of data from 200 consecutive conversions of LAGB to RYGB was conducted. Fifty-two patients whose BMI was<35 kg/m² were included in this analysis. Indications for conversion, technical details, early morbidity, length of hospital stay, and weight loss data were assessed.ResultsLaparoscopic conversion to RYGB was performed in 100% of patients. The median BMI pre-RYGB was 32.8 kg/m². The most common indication for surgery was weight regain after removal of LAGB (28.8%). There was no mortality. Early morbidity was seen in 25% of patients; the most common complication was stricture of the gastrojejunal anastomosis (9 patients).ConclusionMorbidity resulting from conversion of LAGB to RYGB in patients with BMI <35 kg/m² is similar to that seen in the BMI>35 kg/m² population. The procedure is technically challenging and morbidity rates are higher than those reported for surgically ‘naïve’ patients. It is recommended that this procedure be undertaken by appropriately trained surgeons in high-volume bariatric centers to optimize safety and outcomes.     

Weight loss is more sustained after biliopancreatic diversion with duodenal switch than Roux-en-Y gastric bypass in superobese patients

BackgroundAlthough biliopancreatic diversion with duodenal switch (BPD-DS) is not the most performed procedure, Roux-en-Y gastric bypass (RYGB) is challenged by weight regain and insufficient weight loss, especially in patients with a body mass index >50 kg/m². The aim of our retrospective study was to compare the weight loss after 2 types of primary bariatric surgery. A total of 83 BPD-DS and 97 RYGB procedures were performed from March 2002 to October 2009 for an initial mean body mass index of 55 kg/m².MethodsAll RYGB patients underwent surgery at a private practice hospital and BPD-DS patients underwent surgery at a university hospital before February 2007 and at the same private hospital thereafter. The patients were seen in follow-up every 4 months the first year, every 6 months the second, and yearly thereafter. The maximum weight loss was assessed, as well as the weight regain beyond the first postoperative year. Weight loss success was defined as a percentage of excess weight loss (%EWL) of ≥50%.ResultsThe patients did not differ by age, gender, or length of follow-up (mean 46 mo, range .5–102 for RYGB and 44.3 mo, range 9–111 for BPD-DS). Of the patients, 17 RYGB and 7 BPD-DS patients were lost to follow-up within 3 years postoperatively. At 3 years of follow-up, the mean %EWL was 63.7% ± 17.0% after RYGB and 84.0% ± 14.5% after BPD-DS (P < .0001). Weight loss success was achieved by 83.5% of the RYGB and 98.7% of the BPD-DS patients (P = .0005).ConclusionAfter 12 months postoperatively, the number of patients regaining 10% of the weight lost during the first postoperative year was significantly greater after RYGB than after BPD-DS.     

Bariatric revisional surgery for gastrogastric fistula following Roux-en-Y gastric bypass positively impacts weight loss

BackgroundGastrogastric fistula (GGF) is a rare complication from Roux-en-Y gastric bypass (RYGB). It is a known risk factor associated with weight recidivism and an indication for Bariatric Revisional Surgery (BRS).ObjectivesThe primary outcome of this study is to evaluate perioperative outcomes and the long-term total body weight loss (TBWL) outcomes following revision.SettingSingle Academic Institution, Center of Bariatric Excellence.MethodsWe selected patients who had primary bariatric surgery and BRS from 2003 to 2020, followed by BRS for GGF. Patients’ demographics, perioperative outcomes, and TBWL were analyzed.ResultsOne hundred five patients underwent BRS for GGF. Mean body mass index (BMI) at index operation and revision was 51.6 ± 10.1, and 42.4 ± 11.2 respectively. Ninety percent of patients had open primary RYGB, and 69% had open revisional surgery. The median length of stay after BRS was 3 days. The 30-day reintervention rate was 19%. The 30-day readmission rate was 34%. Of the 77 patients included for weight loss analysis, the mean %TBWL after primary RYGB was 34% ± 14. The total mean %TBWL at the time of revision was 18.8%, translating into a weight regain of 13.6% ± 9.5. The total mean %TBWL after revision was 37.6% ± 11.4, translating into TBWL of 18.8% ± 9.4 after revision when compared to TBWL at revision time.ConclusionsOur results demonstrate that revision for GGF can be safely performed, however is associated with higher morbidity than primary bariatric surgery. Revision for GGF results in significant long-term weight loss.     

Conversion of failed gastric banding into four different bariatric procedures

BackgroundThe most common bariatric operation in Europe, laparoscopic adjustable gastric banding (LAGB), is reported to have a high incidence of long-term complications. Also, insufficient weight loss is reported. The optimal conversion technique is unknown. Our objective was to report our experience in the conversions of failed laparoscopic gastric banding procedures to 4 different bariatric procedures at a university hospital.MethodsFrom March 2006 to December 2010, 630 bariatric operations were performed. Of these patients, 45 underwent conversion of failed LAGB (n = 38) and nonadjustable gastric banding (n = 7). Using a prospectively collected database, we analyzed these procedures.ResultsThe 45 patients underwent laparoscopic conversion of failed LAGB (n = 38) and nonadjustable gastric banding (n = 7) to 4 different procedures. Of the 45 patients, 18 underwent conversion to laparoscopic sleeve gastrectomy, 18 to laparoscopic Roux-en-Y gastric bypass, 7 to laparoscopic biliopancreatic diversion with duodenal switch, and 2 to laparoscopic biliopancreatic diversion. All conversions but 1 were completed laparoscopically. The mean operating time and hospital stay for laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, laparoscopic biliopancreatic diversion with duodenal switch, and biliopancreatic diversion was 111 ± 28 minutes and 4.3 ± 1.4 days, 195 ± 59 minutes and 3.9 ± 1.5 days, 248 ± 113 minutes, and 5.9 ± 2.6 days, and 203 minutes and 6.5 days, respectively. No patient died. Perioperative complications occurred in 4 patients (9.8%). The mean body mass index decreased from 41.5 ± 8 kg/m² to 31.3 ± 6.8 kg/m² during a mean follow-up period of 13.7 ± 9.6 months. Although laparoscopic biliopancreatic diversion with and without duodenal switch had the greatest preoperative body mass index, they achieved the greatest excess weight loss.ConclusionConversion of LAGB or nonadjustable gastric banding to laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic biliopancreatic diversion with or without duodenal switch is feasible and effective to treat the complications of LAGB and to further reduce the weight of morbidly obese patients.     

Conversion from laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) to one anastomosis gastric bypass (OAGB): preliminary data from a multicenter retrospective study

BackgroundLaparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure, while laparoscopic adjustable gastric banding (LAGB) has been for a decade one of the most popular interventions for weight loss. After LSG and LAGB, some patients may require a second surgery due to weight regain or late complications. One anastomosis gastric bypass (OAGB) is a promising bariatric procedure, which provides effective long-term weight loss and has a favorable effect on type 2 diabetes.ObjectivesTo retrospectively analyze data from 10 Italian centers on conversion from LAGB and LSG to OAGB.SettingHigh-volume centers for bariatric surgery.MethodsProspectively collected data from 10 high-volume centers were retrospectively reviewed. Body mass index (BMI), percentage of excess BMI loss, reasons for redo, remission from co-morbidities (hypertension, diabetes, gastroesophageal reflux, and dyslipidemia), and major complications were recorded.ResultsThree hundred patients were included in the study; 196 patients underwent conversion from LAGB to OAGB and 104 were converted from LSG. BMI was 45.1 ± 7 kg/m² at the time of first intervention, 41.8 ± 6.3 kg/m² at redo time, and 30.5 ± 5.5 kg/m² at last follow-up appointment. Mean percentage of excess BMI loss was 13.2 ± 28.2 at conversion and 73.4 ± 27.5 after OAGB. Remission rates from hypertension, diabetes, gastroesophageal reflux, and dyslipidemia were 40%, 62.5%, 58.7% and 52%, respectively. Mean follow-up was 20.8 (range, 6–156) months and overall complications rate was 8.6%.ConclusionOur data show that OAGB is a safe and effective revisional procedure after failed restrictive bariatric surgery.     

Diabetes remission and reduced cardiovascular risk after gastric bypass in Asian Indians with body mass index <35 kg/m2

BackgroundRoux-en-Y gastric bypass (RYGB) benefits patients with type 2 diabetes mellitus (T2DM) and a body mass index (BMI) >35 kg/m²; however, its effectiveness in patients with T2DM and a BMI <35 kg/m² is unclear. Asian Indians have a high risk of T2DM and cardiovascular disease at relatively low BMI levels. We examined the safety and efficacy of RYGB in Asian Indian patients with T2DM and a BMI of 22–35 kg/m² in a tertiary care medical center.MethodsA total of 15 consecutive patients with T2DM and a BMI of 22–35 kg/m² underwent RYGB. The data were prospectively collected before surgery and at 1, 3, 6, and 9 months postoperatively.ResultsOf the 15 patients, 8 were men and 7 were women (age 45.6 ± 12 years). Their preoperative characteristics were BMI 28.9 ± 4.0 kg/m², body weight 78.7 ± 12.5 kg, waist circumference 100.2 ± 6.8 cm, and duration of T2DM 8.7 ± 5.3 years. At baseline, 80% of subjects required insulin, and 20% controlled their T2DM with oral hypoglycemic medication. The BMI decreased postoperatively by 20%, from 28.9 ± 4.0 kg/m² to 23.0 ± 3.6 kg/m² (P <.001). All antidiabetic medications were discontinued by 1 month after surgery in 80% of the subjects. At 3 months and thereafter, 100% were euglycemic and no longer required diabetes medication. The fasting blood glucose level decreased from 233 ± 87 mg/dL to 89 ± 12 mg/dL (P <.001), and the hemoglobin A1c decreased from 10.1% ± 2.0% to 6.1% ± 0.6% (P <.001). Their waist circumference, presence of dyslipidemia, and hypertension improved significantly. The predicted 10-year cardiovascular disease risk (calculated using the United Kingdom Prospective Diabetes Study equations) decreased substantially for fatal and nonfatal coronary heart disease and stroke. No mortality, major surgical morbidity, or excessive weight loss occurred.ConclusionRYGB safely and effectively eliminated T2DM in Asian Indians with a BMI <35 kg/m². Larger, longer term studies are needed to confirm this benefit.