Long-term results of a randomized trial comparing banded versus standard laparoscopic Roux-en–Y gastric bypass

BackgroundBanded Roux-en-Y gastric bypass was designed to avoid or diminish weight regain in the long term. In 2008, we published the initial results of a pilot study design to comparatively evaluate surgical morbidity, mortality, and maximum weight loss in patients undergoing banded and unbanded laparoscopic Roux-en-Y gastric bypass (LRYGB). The present study analyzes the 5-year results.MethodsA randomized, controlled trial was carried out in 60 morbidly obese patients who underwent LRYGB. Patients were divided in 2 groups. Half of the patients underwent the banded version of the LRYGB, and half underwent the unbanded version. The 5-year excess weight loss (EWL) and loss of body mass index (BMI) were comparatively analyzed.ResultsThere were 58 females and 2 males with a mean preoperative BMI of 47±4.9 kg/m². A total of 21 patients with banded LRYGB and 22 with unbanded LRYGB completed 5-year follow-up. One patient died 3 years after surgery from metastatic melanoma. EWL at 5 years was 61.6%±19.6% versus 59.8%±15.9% (P = ns), and loss of BMI was 32.9%±5.2% versus 32.8%±4.3% (P = ns), respectively, for the banded and unbanded group.ConclusionsIn this small study, there were no statistical differences in the EWL and the BMI lost at 5 years between the group of patients who underwent banded and unbanded LRYGB.     

Long-term results of laparoscopic Roux-en-Y gastric bypass for morbid obesity: 105 patients with minimum follow-up of 15 years

BackgroundLaparoscopic Roux-en-Y gastric bypass (LRYGB) is the second most frequently performed bariatric procedure worldwide; however, long-term results are not frequently reported.ObjectivesTo evaluate the outcomes of LRYGB on weight loss and co-morbidities in a single center 15 years after the operation.SettingTertiary-care referral hospital.MethodsFrom February 2000 to December 2003, 105 patients (86 women; mean age 39.9 ± 17.4; mean body mass index [BMI] 47.2 ± 6.4 kg/m²; 78 with BMI < 50 kg/m² and 27 with BMI ≥ 50 kg/m²) underwent LRYGB. Retrospective analyses of a prospectively maintained database were carried out to evaluate weight loss; resolution of co-morbidities, including type 2 diabetes mellitus (T2D), hypertension (HTN), and dyslipidemia; complications; and nutritional status.ResultsThe follow-up rate at 15 years was 87.6%. Mean excess weight loss was 58.6 ± 27%, with 74.1% of patients achieving a total weight loss ≥ 20%. According to the Biron et al. criteria, an inadequate outcome was found in 11/21 (52.4%) of patients with an initial BMI ≥ 50 kg/m² versus 21/64 (32.8%) of patients with a preoperative BMI < 50 kg/m² (P = .001). Both groups experienced gradual weight regain (WR); specifically, 34.1% of patients regained more than 15% of their lowest postoperative weight. The rates of reoperations due to early and late surgical complications were 3.8% and 9.5%, respectively. T2D was resolved in 50% of patients, HTN in 61.1%, and dyslipidemia in 58.3%. Iron deficiency anemia (53%) was the most common postoperative nutritional finding.ConclusionLRYGB provides satisfactory weight loss and resolution of co-morbidities up to 15 years. WR was a common finding. A significant proportion of patients with a preoperative BMI ≥ 50 kg/m² did not achieve a favorable weight loss outcome. Indications to perform LRYGB in this group of patients should be definitively reconsidered.     

Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a prospective randomized trial

BackgroundTo perform a prospective, randomized comparison of laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB).MethodsLAGB, using the pars flaccida technique, and standard LRYGB were performed. From January 2000 to November 2000, 51 patients (mean age 34.0 ± 8.9 years, range 20–49) were randomly allocated to undergo either LAGB (n = 27, 5 men and 22 women, mean age 33.3 years, mean weight 120 kg, mean body mass index [BMI] 43.4 kg/m²; percentage of excess weight loss 83.8%) or LRYGB (n = 24, 4 men and 20 women, mean age 34.7, mean weight 120 kg, mean BMI 43.8 kg/m², percentage of excess weight loss 83.3). Data on the operative time, complications, reoperations with hospital stay, weight, BMI, percentage of excess weight loss, and co-morbidities were collected yearly. Failure was considered a BMI of >35 at 5 years postoperatively. The data were analyzed using Student’s t test and Fisher’s exact test, with P <.05 considered significant.ResultsThe mean operative time was 60 ± 20 minutes for the LAGB group and 220 ± 100 minutes for the LRYGB group (P <.001). One patient in the LAGB group was lost to follow-up. No patient died. Conversion to laparotomy was performed in 1 (4.2%) of 24 LRYGB patients because of a posterior leak of the gastrojejunal anastomosis. Reoperations were required in 4 (15.2%) of 26 LAGB patients, 2 because of gastric pouch dilation and 2 because of unsatisfactory weight loss. One of these patients required conversion to biliopancreatic diversion; the remaining 3 patients were on the waiting list for LRYGB. Reoperations were required in 3 (12.5%) of the 24 LRYGB patients, and each was because of a potentially lethal complication. No LAGB patient required reoperation because of an early complication. Of the 27 LAGB patients, 3 had hypertension and 1 had sleep apnea. Of the 24 LRYGB patients, 2 had hyperlipemia, 1 had hypertension, and 1 had type 2 diabetes. Five years after surgery, the diabetes, sleep apnea, and hyperlipemia had resolved. At the 5-year (range 60–66 months) follow-up visit, the LRYGB patients had significantly lower weight and BMI and a greater percentage of excess weight loss than did the LAGB patients. Weight loss failure (BMI >35 kg/m² at 5 yr) was observed in 9 (34.6%) of 26 LAGB patients and in 1 (4.2%) of 24 LRYGB patients (P <.001). Of the 26 patients in the LAGB group and 24 in the LRYGB group, 3 (11.5%) and 15 (62.5%) had a BMI of <30 kg/m², respectively (P <.001).ConclusionThe results of our study have shown that LRYGB results in better weight loss and a reduced number of failures compared with LAGB, despite the significantly longer operative time and life-threatening complications.     

Two-step conversion surgery after failed laparoscopic adjustable gastric banding. Comparison between laparoscopic Roux-en-Y gastric bypass and laparoscopic gastric sleeve

BackgroundDespite its worldwide popularity, laparoscopic adjustable gastric banding (LAGB) requires revisional surgery for failures or complications, in 20–60% of cases. The purpose of this study was to compare in terms of efficacy and safety, the conversion of failed LAGB to laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy. (LSG).MethodsThe bariatric database of our institution was reviewed to identify patients who had undergone conversion of failed LAGB to LRYGB or to LSG, from November 2007 to June 2012.ResultsA total of 108 patients were included. Of these, 74 (68.5%) underwent conversion to LRYGB and 34 to LSG. All of the procedures were performed in 2-stage and laparoscopically. The mean follow-up for the LRYGB group was 29.1±17.9 months while for the LSG patients was 24.2±14.3 months. The mean body mass index (BMI) prior LRYGB and LSG was 45.6±7.8 and 47.5±5.6 (P = .09), respectively. Postoperative complications occurred in 16.2% of the LRYGB patients and in 2.9% of the LSG group (P = .04). Mean percentage of excess weight loss was 59.9%±16.2% and 70.2%±16.7% in LRYGB, and it was 52.2%±11.4% and 59.9%±14.4% in LSG at 12 months (P = .007) and 24 months (P = .01) after conversion.ConclusionIn this series, LRYGB and LSG are both effective and adequate revisional procedure after failure of LAGB. While LRYGB seems to ensure greater weight loss at 24 months follow-up, LSG is associated with a lower postoperative morbidity.     

Early weight loss as a predictor of 3-year weight loss and weight regain in patients with good compliance after sleeve gastrectomy

BackgroundSleeve gastrectomy (SG) is the most common surgery for severe obesity. Patients lose weight post SG and regain some weight in the following years. Early weight loss predicts weight loss after SG. However, etiologies of weight loss and regain after SG remain unclear.ObjectivesTo investigate the effects of early weight loss on medium-term weight regain post SG.SettingTwo university hospitals in Taiwan.MethodsPatients with records within 1 and at 3 years after SG were enrolled retrospectively. Preoperative clinical variables and percentage of total weight loss (%TWL) were analyzed. Weight regain was defined as a weight increase from 1 year postoperatively of >25% of the lost weight. Linear and multiple logistic regression were applied to examine the associations of early weight loss, weight loss, and weight regain.ResultsA total of 363 patients were included. Body mass indexes before and 1, 3, 6, 12, and 36 months postoperatively were 40.7 ± 6.8 kg/m², 36.6 ± 6.2 kg/m², 33.5 ± 5.8 kg/m², 30.9 ± 5.5 kg/m², 28.4 ± 5.2, and 29.3 ± 5.4 kg/m², respectively. At 3 years after SG, 73 patients (20.1%) had weight regain. In multivariate linear analyses, initial age, waist circumference, type 2 diabetes, and %TWL at 1 or 3 months were associated with either 1-year or 3-year %TWL. Multiple logistic regression revealed %TWL at 3 months to be a predictor for 3-year weight regain after SG (odds ratio, .927; P = .02).ConclusionEarly weight loss predicted weight loss and regain 3 years after SG. Early lifestyle and behavioral interventions are suggested in patients at high risk of poor weight loss and weight regain outcomes after SG.     

Quality of Life,Weight Loss and Improvement of Co-morbidities After Primary and Revisional Laparoscopic Roux Y Gastric Bypass Procedure—Comparative Match Pair Study

Background

The prevalence of morbid obesity and its co-morbidities is dramatically increasing, as is the extent of weight loss surgery. A large number of patients after various bariatric procedures need revisional intervention for various reasons. We investigated the efficacy and the safety of revisional laparoscopic Roux Y gastric bypass (LRYGB) among our patients, who were revised as a consequence of inadequate weight loss or weight regain after previous bariatric interventions.

Methods

A comparative, double-centre, match pair study was performed comparing the data of 44 patients after revisional surgery with 44 patients after primary gastric bypasses, focusing on weight loss, life quality and improvement of co-morbidities. Matching criteria were age, gender, preoperative BMI and follow-up period. Previous procedures consisted of 23 gastric bandings, 13 sleeve resections, 4 LRYGB and 4 vertical banded gastroplasties.

Results

Extra weight loss (EWL) was significantly reduced after revisional gastric bypasses compared to primary intervention (EWL 66 vs. 91 %, p?p?=?0.22; Moorehead-Aldert II score 1.4 vs. 2.0, p?=?0.10). The resolution rate of co-morbidities (T2DM, hypertension, gastro-oesophageal reflux (GER), osteoarthrosis, sleep apnoea) was also higher after primary gastric bypasses.

Conclusions

Revisional LRYGB is an effective and safe method for patients with inadequate weight loss after previous bariatric surgery concerning weight reduction, life quality and improvement of co-morbidities. Our results indicate lower efficacy of revisional compared to primary LRYGB reaching statistical significance in regard to weight loss.     

Short- to medium-term results of single-anastomosis duodeno-ileal bypass compared with one-anastomosis gastric bypass for weight recidivism after laparoscopic sleeve gastrectomy

BackgroundSingle-anastomosis duodeno-ileal bypass (SADI) and the one-anastomosis gastric bypass (OAGB) are 2 revisional procedures to address the problem of weight recidivism after laparoscopic sleeve gastrectomy (LSG).ObjectivesTo evaluate the efficacy and safety of SADI and OAGB as revisional bariatric surgery (RBS) in initially super-obese patients (body mass index [BMI] >50 kg/m²).SettingAcademic hospital, bariatric center of excellence, Germany.MethodsObservational study of outcomes in 84 initially super-obese patients who had undergone RBS after LSG (SADI n = 42, OAGB n = 42) between July 2013 and April 2018. Follow-up examinations were performed at 1, 6, 12, 24, and 36 months after RBS. The variables analyzed included time between LSG and RBS, BMI, excess weight loss, total weight loss, operation time, and complications.ResultsThe time interval between LSG and RBS was 45.5 ± 22.8 and 43.5 ± 24.2 months for SADI and OAGB, respectively. At the time of RBS, the mean BMI was 42.8 ± 7.9 kg/m² for SADI and 43.4 ± 9.2 kg/m² for OAGB. The follow-up examinations rates (%) after SADI were 97.6, 92.8, 90.5, 78.6, 57.1, and 100, 97.6, 95.2, 85.7, and 59.5 after OAGB. The BMI at the follow-up examinations were 39.1 ± 7.2, 34.2 ± 6.9, 31.2 ± 5.8, 30.2 ± 5.3, 29.3 ± 5.1 for SADI, and 39.5 ± 8.1, 36.6 ± 7.4, 34.7 ± 7.9, 32.9 ± 6.3, and 31.6 ± 5.9 for OAGB. The mean operating times for SADI and OAGB were 138 ± 40 and 123 ± 39 minutes, respectively. Three patients in the SADI group and 1 patient in the OAGB group developed a major complication within the first 30 postoperative days.ConclusionSADI and OAGB were effective second-step procedures for further weight reduction after LSG in initially super-obese patients after short to medium follow-up. There was a trend toward higher weight loss for SADI though this did not reach statistical significance. Substantial differences concerning surgery time and complications between the 2 procedures were not observed.     

Comparison of weight loss and body composition changes with four surgical procedures

BackgroundA paucity of information is available on the comparative body composition changes after bariatric procedures. The present study reports on the body mass index (BMI) and body composition changes after 4 procedures by a single group.MethodsAt the initial consultation, the weight and body composition of the patients undergoing 4 different bariatric procedures were measured by bioimpedance (Tanita 310). Follow-up examinations were performed at 1 year and at subsequent visits after surgery. Analysis of variance was used to compare the postprocedure BMI and body composition. Analysis of covariance was used to adjust for baseline differences.ResultsA total of 101 gastric bypass (GB) patients were evaluated at 19.1 ± 10.6 months, 49 biliopancreatic diversion with the duodenal switch (BPD/DS) patients at 27.5 ± 16.3 months, 41 adjustable gastric band (AGB) patients at 21.4 ± 9.2 months, and 30 sleeve gastrectomy (SG) patients at 16.7 ± 5.6 months (P <.0001). No differences were found in patient age or gender among the 4 groups. The mean preoperative BMI was significantly different among the 4 groups (P <.0001): 61.4 kg/m², 53.2, 46.7, and 44.3 kg/m² for the SG, BPD/DS, GB, and AGB group, respectively. The postoperative BMI adjusted for baseline differences was 27.8 (difference 23.6 ± 8.3), 32.5 (difference 15.6 ± 5.0), 37.2 (difference 18.2 ± 8.2), and 39.5 kg/m² (difference 7.5 ± 4.3) for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The percentage of excess weight loss was 84%, 70%, 49%, and 38% for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The postoperative percentage of body fat adjusted for baseline differences was 25.7% (23.9% ± 7.0%) 32.7% (16.1% ± 10.5%) 37.7% (16.7% ± 5.6%), and 42% (6.0% ± 6.8%) for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The lean body mass changes were reciprocal.ConclusionAlthough the BPD/DS procedure reduced the BMI the most effectively and promoted fat loss, all the procedures produced weight loss. The AGB procedure resulted in less body fat loss within 21.5 months than SG within 16.7 months. Longer term observation is indicated.     

Laparoscopic Roux-en-Y gastric bypass versus laparoscopic adjustable gastric banding: five years of follow-up

BackgroundBariatric surgery is an effective treatment for morbid obesity. Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are commonly performed procedures. The aim of the present study was to evaluate and compare the long-term outcomes after LRYGB and LAGB.MethodsWe studied the data from a prospective database of all patients undergoing LRYGB or LAGB with 5 years of follow-up.ResultsFrom July 2001 to September 2003, 91 and 62 patients underwent LRYGB and LAGB, respectively. Of these patients, 73.6% of the LRYGB and 91.9% of the LAGB patients had 5 years of follow-up. Of the 91 and 62 patients, 89% and 82% were women, respectively. The mean age and body mass index was 34.5 ± 11.0 years and 39.6 ± 4.9 kg/m² for the LRYGB group and 38.4 ± 13.1 years and 35.8 ± 4.0 kg/m² for the LAGB group, respectively. The mean operative time was 150 ± 58 minutes for LYRGB and 73 ± 23 minutes for LAGB (P <.05). The conversion and reoperation rate was 8% and 4.3%, respectively, for the LRYGB group versus 0% for the LAGB group. Early postoperative complications were observed in 12 and 1 patient (P = .014) after LRYGB and LAGB, respectively. Late complications developed in 33 and 17 patients after LYRGB and LAGB, respectively (P = NS). The percentage of excess weight loss at 5 years postoperatively was 92.9% ± 25.6% and 59.1% ± 46.8% (P <.001) for LRYGB and LAGB, respectively. Surgical failure (percentage of excess weight loss <50%) at 5 years was 6% for LRYGB and 45.6% for LAGB. A late reoperation was needed in 24.1% of the LAGB patients.ConclusionA greater percentage of excess weight loss at 1 and 5 years was observed after LRYGB than LAGB. The LAGB group had a >40% rate of surgical failure and a 24.1% reoperation rate at 5 years of follow-up.     

One-year weight loss after primary or revisional Roux-en-Y gastric bypass for failed adjustable gastric banding

BackgroundAdjustable gastric banding has been widely used in Europe, but recently gastric bypass (Roux-en-Y gastric bypass [RYGB]) has become the procedure of choice. With a gastric banding failure rate of nearly 40% at 5 years, the need for revisional surgery is increasing. The effect of a failed previous bariatric surgery on the weight loss curve after RYGB is still a controversial issue.MethodsA total of 259 patients underwent RYGB from 2003 to 2007, 58 after failed gastric banding and 201 as primary surgery. All the procedures were laparoscopically performed by the same surgeon at a single institution. The postoperative course and the percentage of excess weight loss were compared between the 2 groups.ResultsThe 2 groups were similar in age and initial body mass index (46.3 ± 7.2 kg/m² for revision versus 47.7 ± 6.7 kg/m² for primary RYGB). In contrast, the prerevision body mass index was 43.2 ± 7.0 kg/m². Revisional RYGB required a significantly longer operative time (128.3 ± 25.9 minutes versus 89.0 ± 14.7 minutes, P <.0001) and the morbidity was greater (8.6% versus 5.5%), but no patient died in the postoperative period after revision. As determined from the initial body mass index, the 1-year percentage of excess weight loss was comparable between the 2 groups (66.1% ± 26.8% and 70.4% ± 18.9%).ConclusionWhen RYGB is performed after an adjustable gastric band failure to restore weight loss or because of a complication, the weight loss curve is similar to that after primary RYGB. Therefore, the strategy of adjustable gastric banding first is an option that does not seem to preclude satisfactory weight loss after revision to RYGB.     

Number of weight loss attempts and maximum weight loss before Roux-en-Y laparoscopic gastric bypass surgery are not predictive of postoperative weight loss

BackgroundMany insurance companies have mandated that bariatric surgery candidates already satisfying the National Institutes of Health criteria make an additional attempt at medically supervised weight loss. The objective of this study was to determine whether a correlation exists between the number of weight loss attempts (WLAs) or maximal preoperative weight loss (MWL) and the percentage of excess weight loss (%EWL) after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery.MethodsThe WLAs and MWL data were collected by bariatric medical record review. The postoperative %EWL was obtained by retrospective review of a prospectively enrolled bariatric database. Patients whose records contained 1 year of follow-up data and either the WLAs or MWL were included in the study. The data were analyzed using Pearson correlations and odds ratios.ResultsFrom September 2001 to 2006, 530 patients underwent LRYGB. Of these, 384 met the study criteria (82.6% were women). The mean WLAs was 4.3 ± 1.8. The mean MWL was 46.6 ± 31.2 lb (21.2 ± 14.2 kg). At surgery, the mean patient age was 43.3 ± 9.3 years, and the mean body mass index was 48.0 ± 5.9 kg/m². At 1 year after LRYGB, the mean body mass index was 30.2 ± 5.0 kg/m², and the mean %EWL was 72.3% ± 15.3%. Statistical analysis revealed no correlations between the %EWL at 1 year after LRYGB and the WLAs (R² = .011) or MWL (R² = .005).ConclusionNeither the WLAs nor the MWL correlated with the %EWL at 1 year after LRYGB. Our results showed no evidence that the WLAs or MWL before surgery correlates with the %EWL in patients undergoing LRYGB.     

Laparoscopic Roux-en-Y Gastric Bypass for Failed Vertical Banded Gastroplasty

Background

Although the vertical banded gastroplasty (VBG) is effective in achieving weight loss without metabolic side effects during the first few years, late failures cause weight regain in about 20% of the patients. The laparoscopic Roux-en-Y gastric bypass (LRYGB) is the procedure of choice to convert a failed VBG.

Materials and Methods

Between August 2014 and June 2016, 37 patients (23 females and 14 males) underwent revisional LRYGBs after failed VBGs. Thirty-four patients had open VBGs and two patients had laparoscopic butterfly gastroplasties. These patients completed follow-ups of at least 1 year.

Results

The median operating time was 164 min (range 132–246), and the mean length of the hospital stay was 2.4 days (range 2–7). The mean body mass index (BMI) of the study group was 42.5 kg/m², while the mean BMI and the percentage of excess body weight loss (%EBWL) for the patients 6 months after the operation were 31.7 kg/m² and 52.1%, respectively. The mean BMI and %EBWL for the patients 1 year after the operation were 29.5 kg/m² and 67.7%, respectively. There were neither intraoperative complications nor postoperative mortalities, but the overall complication rate was 22% (eight patients).

Conclusion

An LRYGB following a VBG is technically challenging, but safe, with low morbidity and mortality rates. Moreover, a revisional LRYGB provides excellent weight loss results.

     

Banded Roux-en-Y gastric bypass for the treatment of morbid obesity

BackgroundLaparoscopic Roux-en-Y gastric bypass (LRYGB) is the most effective treatment for morbid obesity. The additional benefit of placing a nonadjustable band around the pouch remains to be determined. The objective of this study was to compare outcomes between banded and nonbanded LRYGB patients in a single bariatric center.MethodsA matched cohort analysis was performed between patients who had undergone banded and nonbanded (standard) LRYGB. In the banded bypass cohort, an 8 F, 6.5 cm silastic ring was placed around the proximal gastric pouch. Both cohorts were matched for age, body mass index (BMI), and anastomotic technique. Endpoints included percentage excess weight loss (%EWL), postoperative morbidity, and band-related complications.ResultsBetween January 2007 and July 2010, 134 banded LRYGB were performed (55% female, mean age 45 years). They were compared with a matched cohort of 134 concurrent nonbanded LRYGB patients (67% female, mean age 45.4 years). Mean preoperative BMI was 54.6 and 52.8 kg/m², respectively (P = .084). At 24 months postoperatively, the average %EWL was 58.6% in banded bypass patients and 51.4% in the nonbanded group (P = .015). The difference in EWL was more pronounced in super-obese patients than in those with BMI<50 (among super-obese, 57.5% versus 47.6%, P = .003; among those with BMI<50, 62.9% versus 57.9%, P = .406]. There was no difference in early (19.4% versus 19.4%) or late complications (10.4% versus 13.4%, P = .451) between banded and nonbanded LRYGB patients.ConclusionBanding the pouch during LRYGB can be performed safely and may provide better weight loss, particularly in super-obese patients. Further prospective and long-term comparative studies of this technique are warranted.     

Conversion of failed laparoscopic adjustable gastric banding: Sleeve gastrectomy or Roux-en-Y gastric bypass?

BackgroundIn the literature, late complications and treatment failures in laparoscopic adjustable gastric banding (LAGB) have been reported. When the patient presents with failure of LAGB, surgeons have the option to convert it to a different procedure. The aim of our study is to evaluate and compare the safety and efficacy of converting LAGB to laparoscopic sleeve gastrectomy (LSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB).MethodsBetween March 2008 and October 2012, a total of 54 patients underwent conversion of LAGB at our institution. Of these patients, 41 (75.9%) were converted to LRYGB, and 13 (24.1%) patients were converted to LSG. A retrospective review of a prospectively collected database was performed, noting the outcomes and complications of the procedure.ResultsMean body mass index at the time of conversion was 41.8±6.5 kg/m² in LRYGB and 39.0±6.6 kg/m² in LSG. Mean percentage of excess weight loss was 57.4%±17.0% and 62.4%±19.6% in LRYGB, and it was 47.7%±4.2% and 65.6%±34.5% in LSG at 12 months (P>.34) and 24 months (P>.79) after conversion. Of LRYGB patients, 7 (17.5%) were readmitted as a result of abdominal pain, dehydration, and nausea/vomiting, and 4 (10.0%) patients required reoperation. One LSG patient (8.3%) was readmitted for new-onset severe reflux and underwent hiatal hernia repair. She was converted to LRYGB 32 months after the LSG procedure. Readmission rate (P>.61) and reoperation rate (P>.63) did not show statistical difference between the 2 procedures.ConclusionConverting LAGB to LSG and LRYGB both seem feasible and resulted in substantial further weight loss.     

Case-matched analysis comparing outcomes of revisional versus primary laparoscopic Roux-en-Y gastric bypass

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common approaches used to revise post-bariatric patients with inadequate weight loss or significant weight regain. Previous studies have analyzed the outcomes of open revisional RYGB versus primary RYGB, but no case–control matched analysis comparing revisional LRYGB versus primary LRYGB has been performed.

Methods

Our cohort includes 37 consecutive patients who underwent revisional LRYGB because of unsatisfactory weight loss or weight regain matched in a 1:2 ratio with 74 control patients who underwent primary LRYGB. Matching included the following parameters: age, gender, preoperative body mass index and comorbidities (diabetes, obstructive sleep apnea, and hypertension).

Results

The revisional group had longer length of stay compared with the primary group (3.8 vs. 2.4 days, P = 0.02) and a higher conversion to laparotomy rate (10.8 vs. 0 %, P = 0.01). The revisional group had a higher 30-day morbidity compared with the primary group (27 vs. 8.1 %, P = 0.02). There were no deaths in both groups. The two groups had similar 30-day readmission and 30 day reoperation rates. At 3, 6, and 12 months of follow-up, the revisional LRYGB group had significantly lower percent of excess weight loss (EWL) than the primary LRYGB group (3 months, 30 vs. 38.4, P = 0.001; 6 months, 36.3 vs. 52.9, P = 0.001; 12 months, 46.5 vs. 68.2, P = 0.001).

Conclusions

Revisional LRYGB is characterized by lower EWL and higher morbidity than primary LRYGB. However, our data suggest that revisional LRYGB is still capable of providing significant weight loss in these high-risk patients.     

Total weight loss after laparoscopic Roux-en-Y gastric bypass is influenced by preoperative weight loss: can we predict the outcome?

BackgroundPreoperative weight loss (WL) is associated with higher postoperative WL at 1- to 2-year follow-up in patients who undergo laparoscopic Roux-en-Y gastric bypass (LRYGB).ObjectiveTo evaluate the possible association between preoperative and postoperative WL at 3-year follow-up and identify risk factors for insufficient WL.SettingA single-center prospective cohort study in the Netherlands.MethodsPatients undergoing primary LRYGB and laparoscopic conversion from band to bypass (redo LRYGB) were instructed to lose weight preoperatively. Follow-up data were collected 1, 2, and 3 years postoperatively. WL was described as percentage total weight loss (%TWL) and percentage excess body mass index (BMI) loss. Patients were divided into 2 groups: group A lost any amount of weight; group B did not lose any weight or gained weight preoperatively.ResultsGroup A consisted of 230 patients (median preoperative %TWL, 4.8%), and group B consisted of 46 patients (median preoperative %TWL, −1.3%). Median BMI at intake was 44.1 kg/m². Baseline characteristics were similar. The %TWL and BMI for group A and B in the patients who underwent primary LRYGB at 1, 2, and 3 years was 32.2% (BMI, 28.6 kg/m²) versus 23.9% (BMI, 32.2 kg/m²), 31.8% (BMI, 28.9 kg/m²) versus 25.2% (BMI, 31.9 kg/m²), and 33.3% (BMI, 29.7 kg/m²) versus 21.9% (BMI, 34 kg/m²), respectively, all P < .05. In patients who underwent redo LRYGB no clinically significant differences in postoperative BMI were found.ConclusionsPreoperative WL in primary patients who undergo LRYGB can be useful to identify those at risk of inadequate postoperative WL. In patients who undergo redo LRYGB different risk factors should be considered for prediction of inadequate postoperative WL.     

Revisional Bariatric Surgery for Unsuccessful Weight Loss and Complications

Background

There are growing numbers of patients who require revisional bariatric surgery due to the undesirable results of their primary procedures. The aim of this study was to review our experience with bariatric patients undergoing revisional surgery.

Methods

We conducted a retrospective analysis to review the indications for revisional bariatric procedures and assess their postoperative outcomes.

Results

From 04/04 to 01/11, 2,918 patients underwent bariatric surgery at our institution. A total of 154 patients (5.3 %) of these cases were coded as revisional procedures. The mean age at revision was 49.1?±?11.3 and the mean BMI was 44.0?±?13.7 kg/m². Revisional surgery was performed laparoscopically in 121 patients (78.6 %). Laparoscopic revisions had less blood loss, shorter length of hospital stay, and fewer complications compared to open revisions. Two groups (A and B) were defined by the indication for revision: patients with unsuccessful weight loss (group A, n?=?106) and patients with complications of their primary procedures (group B, n?=?48). In group A, 74.5 % of the patients were revised to a bypass procedure and 25.5 % to a restrictive procedure. Mean excess weight loss was 53.7?±?29.3 % after revision of primary restrictive procedures and 37.6?±?35.1 % after revision of bypass procedures at >1-year follow-up (p?<?0.05). In group B, the complications prompting revision were effectively treated by revisional surgery.

Conclusions

Revisional bariatric surgery effectively treated the undesirable results from primary bariatric surgery. Laparoscopic revisional surgery can be performed after both failed open and laparoscopic bariatric procedures without a prohibitive complication rate. Carefully selected patients undergoing revision for weight regain have satisfactory additional weight loss.     

Laparoscopic biliopancreatic diversion/duodenal switch or laparoscopic Roux-en-Y gastric bypass for super-obesity—weight loss versus side effects

BackgroundLaparoscopic biliopancreatic diversion/duodenal switch (LDS) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the main surgical options for super-obese patients (body mass index >50 kg/m²).MethodsWe performed a medium long-term evaluation of 13 super-obese patients who had undergone LDS compared with a control group of 19 patients who had undergone LRYGB. The patients were assessed 31 months (range 17–38) and 34 months (range 26–62) after LDS and LRYGB, respectively, for body mass index changes, relief of co-morbidities, nutrition, quality of life, postoperative bowel function, and accumulated healthcare consumption.ResultsThe mean body mass index decreased from 54.9 to 30.0 kg/m² in the LDS group and 57.8 to 39.8 kg/m² in the LRYGB group (P = .005). The hemoglobin A1c level was lower in the LDS group than in the LRYGB group (3.8 ± .31% versus 4.3 ± .43%, respectively; P = .01). The LDS patients reported greater energy intake than the LRYGB patients (3132 ± 1392 kcal versus 2014 ± 656 kcal, respectively; P = .021). The number of stools daily was 4.1 ± 3.3 in the LDS group and 1.9 ± 1.1 in the LRYGB group, P = .0482). Of the 12 patients in the LDS group, 6 reported fecal incontinence or soiling compared with 2 of 16 in the LRYGB group (P = .034). The number of outpatient visits was 5.6 ± 4.6 for the LDS group and 2.0 ± 1.9 for the LRYGB group (P = .016), and the number of telephone consultations was 5.0 ± 5.6 and 1.4 ± 1.6 for the LDS and LRYGB groups, respectively (P = .043).ConclusionLDS resulted in greater weight loss than LRYGB in super-obese patients. However, the LDS patients in our series had more frequent gastrointestinal side effects, required greater doses of calcium and vitamin supplementation, and required more postoperative monitoring. Patient satisfaction was high in both groups.     

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.     

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.