An Unusual Suspect: Coconut Bezoar After Laparoscopic Roux-en-Y Gastric Bypass

Nausea and vomiting after gastric bypass are common, but some of the underlying causes may be life threatening or, in some cases, unusual. This case report describes a patient who underwent laparoscopic Roux-en-Y gastric bypass and whose postoperative course was complicated by a bezoar in the gastric pouch. To our knowledge, this is the first published report addressing a coconut bezoar in the gastric pouch after gastric bypass surgery. Coconut (cocos nucifera) is known to form emulsions and suspensions, properties likely to have contributed to this patient’s condition. Nutritional counseling should be an ongoing process in the postoperative care of gastric bypass patients in an effort to prevent serious complications that may arise from dietary indiscretions.     

Reconstruction of short bowel syndrome after internal hernia in a pregnant woman with previous bariatric surgery

INTRODUCTIONBariatric surgery is most often performed with the laparoscopic Roux-en-Y gastric bypass. A complication to the laparoscopic Roux-en-Y gastric bypass is internal hernia, which occurs in up to 16% of the patients. Since the laparoscopic Roux-en-Y gastric bypass is performed in women of fertile age, internal hernia may occur during pregnancy.PRESENTATION OF CASEA 22-year old woman with a history of laparoscopic Roux-en-Y gastric bypass suffered from massive internal hernia during pregnancy with widespread bowel necrosis. Extensive surgery was performed leaving the patient with an intact duodenum, 15 cm of jejunum, 35 cm of ileum and colon. Parenteral nutrition was initiated and ten months after the internal hernia, intestinal continuity was re-established. Ten weeks later the patient reached parenteral nutrition independence.DISCUSSIONInternal hernia after laparoscopic Roux-en-Y gastric bypass can be difficult to diagnose, especially during pregnancy and might be severe and life threatening for both mother and child.CONCLUSIONObstetricians and abdominal surgeons must be aware of this condition. Surgery should be performed on a wide indication. When bowel necrosis is found it should be resected and in case of extensive bowel resection the patient should be evaluated in centres specialized in intestinal failure.     

Narcotic Addiction Following Gastric Bypass Surgery—A Case Study

Addictive behavior following gastric bypass surgery is widely discussed in the lay press, but published reports provide conflicting evidence regarding the prevalence of postoperative substance abuse among bariatric surgery patients. We present a case report of a Roux-en-Y gastric bypass patient who presented with recurrent and various pain and nausea complaints postoperatively. These symptoms resulted in multiple radiological and operative procedures before her narcotic addiction was identified. Physicians caring for bariatric surgical patients postoperatively need to be aware of this risk and need to be able to identify early signs of potential postoperative addictions.     

Análisis de la pérdida ponderal a medio plazo después del bypass gastroyeyunal en Y de Roux y de la gastrectomía vertical: propuesta de gráficos de percentiles del porcentaje de peso total perdido para su uso en la práctica clínica diaria

IntroductionThe aim of this study is to analyze weight evolution after the main bariatric surgical techniques (Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]) performed at a representative sample of Spanish hospitals in order to develop percentile charts for the percentage of total weight loss during the first 3 years after surgery.MethodsA retrospective longitudinal cohort study was conducted based on the data provided by 9 Spanish hospitals. Weight data were analyzed both in % total weight loss and % excess weight lost corresponding to the RYGB (n = 1,887) and SG (n = 1,210).ResultsRYGB continues to be the most frequently performed technique in our sample. In both surgical techniques, maximum weight loss occurred 18 months after surgery. Both techniques followed the same weight evolution, although the % total weight loss values were lower in the case of the SG after 36 months (29.3 ± 10 vs. 33.6 ± 10). Age and gender are decisive in the weight results (better in younger patients for both techniques and better in women for RYGB).ConclusionsPercentile charts of % total weight loss after bariatric surgery represent a very useful tool and an important advance in the quality of patient management.     

Upper endoscopy after Roux-en-Y gastric bypass: diagnostic yield and factors associated with relevant findings

BackgroundAfter laparoscopic Roux-en-Y gastric bypass many patients present with complaints for which an upper endoscopy is performed. However, often no abnormalities are found.ObjectivesTo investigate the incidence of relevant findings at upper endoscopy and identify patient characteristics associated with a relevant finding.SettingA high-volume bariatric center.MethodsA retrospective cohort study was performed. All patients presenting with complaints after laparoscopic Roux-en-Y gastric bypass who consequently underwent a diagnostic upper endoscopy were identified from a prospective endoscopic database. Primary outcomes were the number and type of relevant findings at upper endoscopy and its association with patient characteristics. Relevant findings were defined as abnormalities requiring treatment.ResultsNinety-eight (39.2%) of 250 patients had a relevant finding at upper endoscopy, mostly marginal ulcer and stomal stenosis. Male sex (odds ratio [OR] 3.47 [1.12–10.76]), alcohol consumption (OR 7.27 [1.58–33.36]), dysphagia or suspicion of bleeding as referral reason (OR 3.62 [1.54–8.52] and 39.93 [4.96–321.47], respectively, compared with abdominal pain), an abnormal upper gastrointestinal series (OR 6.81 [2.06–22.48]), and no abdominal ultrasound (OR 7.41 [1.48–37.08] compared with a normal ultrasound) were significantly associated with a relevant finding at upper endoscopy.ConclusionsIn this study sex, alcohol consumption, referral reason, and prior imaging studies were associated with a relevant finding at upper endoscopy after laparoscopic Roux-en-Y gastric bypass.     

Repair of post–bariatric surgery,recurrent, and de novo hiatal hernias improves bloating,abdominal pain,regurgitation, and food intolerance

BackgroundPost–bariatric surgery hiatal hernias are associated with a cluster of symptoms, including bloating (nausea/vomiting or fullness), abdominal pain, regurgitation, and food intolerance or dysphagia (BARF).ObjectivesTo report the short-term outcomes of repairing post–bariatric surgery hiatal hernias in patients with BARF.SettingLarge, multispecialty group practice with university affiliation.MethodsWe reviewed the records of all consecutive patients who underwent repair of post–bariatric surgery hiatal hernias (2012–2020). Data are shown as means ± standard deviations.ResultsWe repaired hiatal hernias in 52 patients (age, 57 ± 10 yr), 4 ± 3 years post sleeve gastrectomy (SG; n = 27), 11 ± 6 years following Roux-en-Y gastric bypass (RYGB; n = 24), and 11 years post duodenal switch with SG (DS-SG; n = 1). Diagnoses were made by upper gastrointestinal contrast study (80%), computed tomography (70%), and/or endoscopy (56%). Hernias in patients with SG were repaired by a posterior cruroplasty after reducing the neo-stomach into the abdomen (n = 11 SG patients; n = 1 DS-SG patient) or converting the SG to RYGB (n = 16). All 24 RYGB patients underwent hernia repair similarly. At 12 ± 10 months of follow-up, dysphagia or regurgitation improved in >80% of patients; nausea, vomiting, or abdominal pain improved in 70% of patients; and heartburn persisted in 56% of patients. Subsequent recurrent hernias that required operative repair developed in 3 patients.ConclusionsHiatal hernias containing the neo-stomach present earlier after SG than RYGB. The diagnosis can be made with a combination of imaging studies and endoscopy. Repair of post–bariatric surgery hiatal hernias markedly improves symptoms of BARF in most patients.     

Realización de procedimientos bariátricos por residentes de cirugía general. ¿Compromete la efectividad de la intervención y los resultados postoperatorios?

IntroductionLaparoscopic bariatric procedures such as laparoscopic Roux-en-Y gastric bypass (LRYGB) are technically demanding and require a long learning curve. Little is known about whether surgical resident (SR) training programs to perform these procedures are safe and feasible. This study aims to evaluate the results of our SR training program to perform LRYGB.MethodsWe designed a retrospective study including patients with LRYGB between January 2014 and December 2018, comparing SR results to experienced bariatric surgeons (EBS). In our country, SR have a five-year surgical formative period, and in the fourth year they are trained for 6 months in our bariatric surgery unit, from January to June. In the beginning, they perform different steps of this procedure, to finally complete an LRYGB. We collected demographic data, comorbidities, intraoperative outcomes, and postoperative complications and outcomes after a one-year follow-up.ResultsTwo hundred and eight patients were eligible for inclusion: 67 in group I (SR), and 141 in group II (EBS). Both groups were comparable. There was no statistically significant difference in operating time (166.45 min in group I vs. 156.69 min in group II; P=0.156). Conversion to open surgery, hospital stay, postoperative complications, and short-term outcomes had no significant differences between the two groups. There was no mortality registered during this period.ConclusionImplementation of LRYGB stepwise learning as part of an SR training program is safe, and results are comparable to EBS, without loss of efficiency. Therefore, it is feasible to train SR in bariatric surgery under EBS supervision.     

Cirugía bariátrica de conversión por fallo de la técnica inicial: 25 años de experiencia en una Unidad especializada de Cirugía de la Obesidad en España

ObjectivesTo evaluate the effectiveness of conversion surgery in a bariatric surgery unit with 25 years of experience.MethodRetrospective observational study of patients with type II obesity or higher who were reoperated by means of conversion surgery due to weight regain, residual body mass index (BMI) >35 kg/m² or < 50% of excess weight loss. The demographic and anthropometric data, comorbidities and perioperative data were analyzed in 5 periods of time: initial, post-surgery1, pre-surgery2, post-surgery2 and current.ResultsA total of 112 patients were included, with a mean age of 40.2 years, who initially underwent vertical banded gastroplasty (VBG) (32.1%), gastric banding (GB) (23.2%), Roux-en-Y gastric bypass (RYGB) (21.4%) and sleeve gastrectomy (SG) (23.2%). The conversion techniques, with a median time between the two surgeries of 70 months, included: RYGB, SG, one-anastomosis gastric bypass (OAGB), shortening of the common loop (SCL) and biliopancreatic diversion (BPD). There was a reduction of the initial weight from 144.2 ± 30.3 to 101.5 ± 21.8 kg after surgery-1; from 115.6 ± 24.0 to 91.5 ± 19.0 kg after surgery-2. The weight at present is 94.7 ± 16.4 kg, with a median follow-up of 27.5 months. Similar results were seen with the BMI. The improvement of comorbidities mainly occurred after the first intervention.ConclusionsConversion surgery causes a weight reduction that does not exceed the loss achieved after the first surgery; however, it does manage to stabilize weight over time. The perioperative morbidity rate is acceptable and would justify its application, despite the limited impact on comorbidities.     

Preoperative upper endoscopy is useful before revisional bariatric surgery.

BACKGROUND AND OBJECTIVES: We hypothesized that patients who have previously had bariatric surgery and are undergoing revision to laparoscopic Roux-en-Y gastric bypass would have abnormal findings detected by upper endoscopy that could potentially influence patient management. The procedures that are being revised include vertical banded gastroplasty, laparoscopic adjustable gastric bands, nonadjustable gastric bands and previous Roux-en-Y gastric bypass (open and laparoscopic). METHODS: We conducted a retrospective chart review of patients who previously had undergone vertical banded gastroplasty or nonadjustable gastric banding. We preoperatively performed an upper endoscopy on all patients. The endoscopy reports were reviewed and the findings entered into a database. RESULTS: Eighty-five percent of 46 patients undergoing revisional bariatric surgery had an abnormal upper endoscopy. Eleven percent had a gastrogastric fistula. Gastritis and esophagitis were noted in 65% and 37%, respectively. Eleven percent of patients had band erosion, 2 from a nonadjustable band, and 5 from vertical banded gastroplasties. Based on our findings, 65% of our patients required medical treatment. CONCLUSIONS: Preoperative upper endoscopy provides valuable information before revisional laparoscopic bariatric surgery. In addition to identifying patients who need preoperative medications, the preoperative upper endoscopy also provided valuable information regarding pouch size and anatomy. Preoperative upper endoscopy should be performed by the operating surgeon on every patient undergoing revisional bariatric surgery.     

All strictures are not alike: laparoscopic removal of nonadjustable Silastic bands after banded Roux-en-Y gastric bypass

BackgroundThe concept of a nonadjustable Silastic band (NASB) has been used to promote surgically induced weight loss for >30 years. Vertical banded Roux-en-Y gastric bypass is an example. Some patients develop serious, band-related complications requiring treatment. Narrowing at the NASB will lead to refractory nausea, vomiting, regurgitation, and, even, malnutrition, requiring revision of their bariatric operation. We report on the evaluation, diagnosis, and laparoscopic treatment of proximal obstructive symptoms secondary to a NASB.MethodsFrom February 2005 to January 2009, we retrospectively reviewed the preoperative and perioperative data for 6 patients who had presented with proximal obstructive symptoms after undergoing banded Roux-en-Y gastric bypass.ResultsThe mean interval from primary NASB placement to surgery was 58 months (range 25–110). The mean duration of symptoms was 29 months (range 8–70). All patients presented with multiple symptoms, but all had nausea, vomiting, regurgitation, and dysphagia to liquids and solids. The patients had undergone multiple upper endoscopies (mean 4, range 3–6) and dilations (mean 1.3, range 1–2) without relief of their symptoms. All patients underwent successful laparoscopic removal of the NASB. Their mean hospital stay was 1 day (range 0–2). No operative or postoperative complications occurred. The reflux and obstructive symptoms had resolved immediately postoperatively in all patients.ConclusionPatients with a NASB in place can experience proximal obstructive symptoms. Endoscopy is deceptive in judging the stomal size, because the endoscope can be pushed through the band area. Moreover, endoscopic dilation will offer no benefit in most patients with symptomatic banded Roux-en-Y gastric bypass. Laparoscopic removal of the NASB is safe, relieves the symptoms immediately, and can be applied to patients who have undergone both open and laparoscopic Silastic banded bariatric procedures.     

Biopsy-proven progressive fatty liver disease nine months post mini-gastric bypass surgery: A case study

IntroductionMini-gastric bypass (MGB) is a popular bariatric procedure. Its effect on non-alcoholic fatty liver disease (NAFLD), however, has not yet been comprehensively studied.Presentation of caseA 57 year-old non-alcoholic female with a body mass index of 42.8 kg/m² underwent MGB without any incident. A concurrent liver biopsy showed an NAFLD activity score (NAS) of 2/8 without fibrosis. She presented at postoperative month eight with edema, vague abdominal pain, nausea, and vomiting and was hospitalized. Her BMI had dropped to 25.7 kg/m². Her blood workup revealed mild anemia, mildly elevated liver enzymes, and hypoalbuminemia (2.5 g/dL). Liver ultrasound revealed grade-2 fatty liver. She received parenteral nutrition and intensive nutrient supplementation. Nevertheless, with regard to unsuccessful supportive measures and rising liver enzymes, revisional surgery −gastrogastrostomy- was performed. Her liver biopsy demonstrated a NAS of 7/8 at the time of revisional surgery. Her postoperative course was uneventful and she was discharged after one week.DiscussionBariatric surgery has shown favorable results regarding improvement of NAFLD in morbid obesity. This beneficial effect has been linked to the amount of weight loss. However, case reports have shown deteriorating liver function and NAFLD even after significant weight loss. They all have in common significant weight loss in a relatively short period of time. There may also be a connection between specific bariatric surgery procedures and this phenomenon.ConclusionFuture studies comparing the effect of various bariatric procedures, including MGB, are necessary to help clinicians decide the optimal procedure for patients with this liver condition.     

Alternative operative techniques in laparoscopic Roux-en-Y gastric bypass for morbid obesity.

The only effective treatment for patients with morbid obesity is surgery. Laparoscopic bariatric surgery has become quite popular in attempts to decrease the morbidity associated with laparotomy. In this article, we describe the technical details of laparoscopic Roux-en-Y gastric bypass with three different techniques for creating the 15-cc gastric pouch. These techniques avoid upper endoscopy for the transoral introduction of the 21-mm circular stapler anvil down to the gastric pouch.     

Comparação entre palonosetrona‐dexametasona e ondansetrona‐dexametasona na prevenção de náuseas e vômitos no pós‐operatório de cirurgia do ouvido médio: estudo clínico randomizado

BackgroundPostoperative nausea and vomiting is the second most common complaint in the postoperative period after pain. The incidence of postoperative nausea and vomiting was 60−80% in middle ear surgeries in the absence of antiemetic prophylaxis. Because of this high incidence of postoperative nausea and vomiting, we aimed to assess the effect of palonosetron‐dexamethasone and ondansetron‐dexamethasone combination for the prevention of postoperative nausea and vomiting in patients of middle ear surgery.MethodsSixty‐four patients, scheduled for middle ear surgery, were randomized into two groups to receive the palonosetron‐dexamethasone and ondansetron‐dexamethasone combination intravenously before induction of anesthesia. Anesthesia technique was standardized in all patients. Postoperatively, the incidences and severity of nausea and vomiting, the requirement of rescue antiemetic, side effects and patient satisfaction score were recorded.ResultsDemographics were similar in the study groups. The incidence difference of nausea was statistically significant between groups O and P at a time interval of 2−6 hours only (p = 0.026). The incidence and severity of vomiting were not statistically significant between groups O and P during the whole study period. The overall incidence of postoperative nausea and vomiting (0−24 hours postoperatively) was 37.5% in group O and 9.4% in group P (p = 0.016). Absolute risk reduction with palonosetron‐dexamethasone was 28%, the relative risk reduction was 75%, and the number‐needed‐to‐treat was 4. The patient's satisfaction score was higher in group P than group O (p = 0.016). The frequency of rescue medication was more common in group O than in group P patients (p = 0.026).ConclusionThe combination of palonosetron‐dexamethasone is superior to ondansetron‐dexamethasone for the prevention of postoperative nausea and vomiting after middle ear surgeries.     

Hepaticojejunostomy for the management of sump syndrome arising from choledochoduodenostomy in a patient who underwent bariatric Roux-en-Y gastric bypass: A case report

IntroductionRapid weight loss following bariatric surgery is associated with high incidence of gallstones and complications that may need bilioenteric diversion. This presents a specific challenge in the management of this group of patients.Case presentationA 37 years old female underwent a Roux-en-Y gastric bypass (RYGB) in 2008 for morbid obesity. In 2009 she presented with obstructive jaundice and was diagnosed with choledocholithiasis successfully managed by open cholecystectomy and choledochoduodenostomy. In the following years, she developed recurrent attacks of fever, chills, jaundice, and right upper quadrant pain and her weight loss was not satisfactory. Imaging of the liver showed multiple cholangitic abscesses. Reflux at the choledochoduodenostomy site was suggestive of sump syndrome as a cause of her recurrent cholangitis and a definitive surgical treatment was indicated. Intraoperative findings confirmed sump at the choledochoduodenostomy site and also revealed the presence of a large superficial accessory duct arising from segment four of the liver with separate drainage into the duodenum distal to the choledochoduodenostomy site. A formal hepaticojejunostomy was done after ductoplasty. The Roux limb was created by transecting the jejunum 40 cm distal to the foot anastomosis of the RYGB. The gastric limb was lengthened as part of this procedure which afforded the patient the additional benefit of weight loss.ConclusionCholedochoduodenostomy should be avoided in patients with RYGB due to the risk of sump syndrome which requires conversion to a formal hepaticojejunostomy.     

Blood bezoar causing obstruction after laparoscopic Roux-en-Y gastric bypass

INTRODUCTION

Bowel obstruction is a known complication after bariatric surgery especially Roux-en-Y gastric bypass. The known etiologies include internal hernia, jejunojejunostomy stricture, ileus, intussusceptions, superior mesenteric artery syndrome, incarcerated port site hernia, and adhesions. Blood bezoar is a rare cause of small intestinal obstruction after Roux-en-Y gastric bypass.

PRESENTATION OF CASE

We are going to present two cases of small bowel obstruction after Roux-en-Y gastric bypass due to blood bezoar.

DISCUSSION

Blood clot as the etiology of small bowel obstruction after Roux-en-Y gastric bypass is an unusual event. In the presence of postoperative small intestinal obstruction an obstructive blood bezoar should be in differential diagnosis. As any other etiology of postoperative obstruction it should be treated immediately to prevent its adverse lethal complications.

CONCLUSION

The best way for prevention of blood bezoar is prevention of bleeding at staple line and doing hemostasis at stapler line.     

Gastric Bezoar after Laparoscopic Roux-en-Y Gastric Bypass

Gastric bezoar is an uncommon complication following Roux-en-Y gastric bypass (RYGBP). We report two cases of bezoar formation that occurred following laparoscopic RYGBPs. In both cases, the patients presented with abdominal pain, nausea, and "frothy" vomiting. The patients were successfully treated by endoscopic fragmentation and removal of the bezoar.     

Efeitos da acupuntura para a prevenção de náuseas e vômitos após colecistectomia laparoscópica: estudo clínico randomizado

Background and objectivesPostoperative nausea and vomiting (PONV) is a common and undesirable complication observed after laparoscopic cholecystectomy (LC). We investigated the effects of auriculoacupuncture (AA) on the prevention of postoperative nausea and vomiting in the immediate postoperative period of uncomplicated laparoscopic cholecystectomy.MethodsSixty‐eight patients were randomly divided into two groups, auriculoacupuncture (n = 35) and control (n = 33) and then they were evaluated prospectively. The needle was placed before anaesthesia induction and remained for 20 minutes. Nausea intensity was evaluated using an analogic visual scale and PONV events were registered immediately after anaesthesia care unit admission and in the second, fourth and sixth hours after the surgery.ResultsThe auriculoacupuncture group had a significantly smaller incidence of nausea and vomiting than the control group throughout the whole postoperative period (16/35 vs. 27/33, p = 0.03 and 4/35 vs. 15/33, p = 0.005, respectively); the AA group had fewer nausea events 2 hours (p = 0.03) and 6 hours (p = 0.001) after surgery and fewer vomiting events 2 hours (p = 0.01) and 6 hours (p = 0.02) after surgery.ConclusionsAuriculoacupuncture can partially prevent postoperative nausea and vomiting when compared to metoclopramide alone after uncomplicated laparoscopic cholecystectomy. Auriculoacupuncture can be recommended as an adjuvant therapy for postoperative nausea and vomiting prevention in selected patients.     

Technique of resection of esophageal adenocarcinoma after Roux-en-Y gastric bypass and literature review of esophagogastric tumors after bariatric procedures

BackgroundThe number of bariatric procedures has continued to increase worldwide. However, experience with tumors arising in the esophagus or stomach after gastric bypass is lacking. We report our technique for curative resection of esophageal adenocarcinoma in a patient who had undergone previous gastric bypass and review the reported data on esophagogastric tumors after bariatric surgery.MethodsWe have described the operative details of esophagectomy after gastric bypass and reviewed the published data regarding type of bariatric surgery, gender predilection, presentation, symptom duration, cancer stage, and prognosis of patients with esophagogastric tumors occurring after bariatric surgery.ResultsOnly 22 esophagogastric tumors have been reported so far after bariatric surgery. The majority of them are locally advanced or metastatic at presentation.ConclusionEsophagogastric tumors after bariatric surgery are uncommon. This operative technique pays particular attention to the altered anatomy, dissection of the gastric pouch, and preservation of the blood supply to the excluded stomach. This technique can also be applied to manage tumors arising in the gastric pouch after previous gastric bypass. Close collaboration with the bariatric surgeon during surgery is essential to achieve a successful oncologic outcome in this subset of patients.     

The first case report of failed single-anastomosis-duodeno-ileal bypass converted to One anastomosis gastric bypass/Mini-gastric bypass

IntroductionThe established single-anastomosis-duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is based on a sleeve gastrectomy (SG) as the restrictive part of the procedure. Due to preserved pylorus, SG has the disadvantage of a high-pressure system with de novo or worsening of existing gastroesophageal reflux disease (GERD).Case presentationA female patient presented herself due to protracted GERD and weight regain after multiple bariatric surgeries. At an initial weight of 158 kg (BMI 62.5 kg/m²) the patient underwent adjustable gastric banding in 2009. After band removal in slippage, the patient underwent SG at a weight of 135 kg in 2012. Nine months after SG, SADI-S was performed as a malabsorptive second step procedure. After 32 months the patient suffered from severe GERD under proton pump inhibitor therapy. Actual weight was 107.9 kg (BMI 42.7 kg/m²). Upper endoscopy showed a hiatal hernia and esophagitis B and dorsal hiatoplasty was performed. After 6 months in still existing severe GERD and weight regain indication for laparoscopic conversion to One anastomosis gastric bypass/Mini-gastric bypass (OAGB/MGB) was given, aiming to reduce the high-pressure system of SG in a low-pressure system of OAGB/MGB. One year after revisional surgery reflux was reported to be only occasionally. Further weight loss was seen (91 kg, BMI 36 kg/m², EWL 67.7%).ConclusionSG as the restrictive part of SADI-S may lead to GERD and consequently to pathologic eating of “soft” calories, that defeats the operation and results in weight regain. OAGB/MGB might be a simple method to rescue such failed SADI-S patients.