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Wills MV, Chaivanijchaya K, Barajas-Gamboa JS, Restrepo-Rodas G, Mocanu V, Farah A, Lee S, Navarrete S, Rodriguez J, Allemang M, Corcelles R, Kroh M, Strong AT, Dang J. Evaluating the impact of the COVID-19 pandemic on outcomes of conversion and revisional bariatric surgery: a Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP) study. Surg Obes Relat Dis 2025:S1550-7289(25)00111-X. [PMID: 40234141 DOI: 10.1016/j.soard.2025.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2024] [Revised: 01/20/2025] [Accepted: 03/06/2025] [Indexed: 04/17/2025]
Abstract
BACKGROUND The COVID-19 pandemic significantly impacted healthcare delivery worldwide, including bariatric surgery. While revisional procedures remained essential for weight recurrence and complications, practice patterns evolved during different phases of the pandemic. OBJECTIVES To evaluate the effect of COVID-19 on revisional bariatric procedures by comparing trends across pandemic (2020), vaccination rollout (2021), and postpandemic (2022) periods. SETTING Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, United States. METHODS Retrospective analysis of 72,189 bariatric surgeries (of which 55,854 conversions and 16,335 revisions) from 2020 to 2022. Outcomes included surgical volume, indications, complications, and mortality. RESULTS Of 609,240 bariatric procedures, 72,189 (11.8%) were revisional or conversion procedures, with conversions representing 9.2% (55,854) and revisions 2.7% (16,335). The combined proportion remained stable (12.1%, 12.1%, 11.5%, P < .001), but urgent revision rates were higher during the pandemic (3.1% versus 2.2% versus 1.8%, P < .001). Pandemic-era cases focused on severe complications (fistula, perforation, stricture), shifting postpandemic toward weight recurrence and reflux. Sleeve-to-bypass conversions increased from 41.2% to 53.6%. Serious complications were highest in 2020-2021 (6.6%, 6.4%) compared to 2022 (5.8%, P < .001), while mortality remained unchanged (.15%). CONCLUSIONS The study demonstrates distinct trends throughout pandemic periods, reflecting Centers for Disease Control and Prevention guidance on surgical urgency . While complication rates were slightly higher during the pandemic, procedures remained safe with stable mortality. Postpandemic shifts toward elective indications and increasing conversion procedures suggest adaptation to accumulated surgical needs.
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Affiliation(s)
- Mélissa V Wills
- Digestive Diseases & Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Komol Chaivanijchaya
- Digestive Diseases & Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Juan S Barajas-Gamboa
- Digestive Diseases Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | | | - Valentin Mocanu
- Digestive Diseases & Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Ayan Farah
- Digestive Diseases & Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Sol Lee
- Department of General Surgery, Seoul Medical Center, Seoul, Republic of Korea
| | - Salvador Navarrete
- Digestive Diseases & Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - John Rodriguez
- Digestive Diseases Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Matthew Allemang
- Digestive Diseases & Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Ricard Corcelles
- Digestive Diseases & Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Matthew Kroh
- Digestive Diseases & Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Andrew T Strong
- Digestive Diseases & Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Jerry Dang
- Digestive Diseases & Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.
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Wunker C, Kumar S, Hallowell P, Collings A, Loss L, Bansal V, Kushner B, Zoumpou T, Kindel TL, Overby DW, Chang J, Ayloo S, Sabour AF, Ghanem OM, Aleassa E, Reid A, Rodriguez N, Haskins IN, Hilton LR, Slater BJ, Palazzo F. Bariatric surgery and relevant comorbidities: a systematic review and meta-analysis. Surg Endosc 2025; 39:1419-1448. [PMID: 39920373 PMCID: PMC11870965 DOI: 10.1007/s00464-025-11528-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2024] [Accepted: 01/02/2025] [Indexed: 02/09/2025]
Abstract
BACKGROUND Obesity is a growing epidemic in the United States, and with this, has come an increasing volume of metabolic surgery operations. The ideal management of obesity-associated medical conditions surrounding these operations is yet to be determined. This review sought to investigate the routine use of intraoperative cholangiogram (IOC) with cholecystectomy during or after a bypass-type operation, the ideal management of post-sleeve gastrectomy gastroesophageal reflux disease (GERD), and the optimal bariatric operation in patients with known inflammatory bowel disease (IBD). METHODS Using medical literature databases, searches were performed for randomized controlled trials (RCTs) and non-randomized comparative studies from 1990 to 2022. Each study was screened by two independent reviewers from the SAGES Guidelines Committee for eligibility. Data were extracted while assessing the risk of bias using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale for RCTs and cohort studies, respectively. A meta-analysis was performed using random effects. RESULTS Routine use of IOC was associated with a significantly decreased rate of common bile duct injury and a trend towards decreased intraoperative complications, perioperative complications, and mortality. The rates of reoperation, postoperative pancreatitis, cholangitis, and choledocholithiasis were low in the routine use of the IOC group, but no non-routine use studies evaluated these outcomes. After sleeve gastrectomy, GERD-specific quality of life was significantly higher in the surgically treated group compared to the medically treated group. Bypass-type operations had worse outcomes of IBD sequelae than sleeve gastrectomy, including pain, patient perception, and fistula formation. Sleeve patients had lower mortality and fewer short- and long-term complications. CONCLUSIONS Low-quality data limited the conclusions that were drawn; however, trends were observed favoring the routine use of IOC during cholecystectomy for patients with bypass-type anatomy, surgical treatment of GERD post-sleeve gastrectomy, and sleeve gastrectomy in IBD patients. Future research proposals are suggested to further answer the questions posed.
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Affiliation(s)
- Claire Wunker
- Department of Surgery, Saint Louis University, St. Louis, USA
| | - Sunjay Kumar
- Department of Surgery, Jefferson University, Philadelphia, USA
| | - Peter Hallowell
- Department of Surgery, University of Virginia, Charlottesville, USA
| | - Amelia Collings
- Department of Surgery, University of Louisville, Louisville, USA
| | - Lindsey Loss
- Department of Surgery, Oregon Health and Science University, Portland, USA
| | - Varun Bansal
- Department of Surgery, University of Colorado, Boulder, USA
| | - Bradley Kushner
- Department of Surgery, Washington University in St. Louis, St. Louis, USA
| | - Theofano Zoumpou
- Department of Surgery, Rutgers New Jersey Medical School, Newark, USA
| | - Tammy Lyn Kindel
- Department of Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - D Wayne Overby
- Department of Surgery, University of North Carolina, Chapel Hill, USA
| | - Julietta Chang
- Department of Surgery, Kaiser Permanente Bellevue Medical Center, Bellevue, USA
| | | | | | | | - Essa Aleassa
- Department of Surgery, Cleveland Clinic, Cleveland, USA
| | - Adam Reid
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, USA
| | - Noe Rodriguez
- Department of Surgery, Cleveland Clinic, Cleveland, USA
| | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, USA
| | - L Renee Hilton
- Department of Surgery, Medical College of Georgia, Augusta, USA
| | | | - Francesco Palazzo
- Department of Surgery, Medical Office Building, Thomas Jefferson University Hospital, 1100 Walnut Street, 5 Floor, Philadelphia, PA, 19107, USA.
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Marwaha JS, Belayneh M, Bloomfield GC, Clarke N, Vadlamudi C, Pardo Lameda IL, Alimi YR. 1- and 2-year outcomes and predictors of weight loss after gastric sleeve to Roux-en-Y gastric bypass conversion: a retrospective cohort study. Surg Endosc 2025; 39:459-464. [PMID: 39369375 DOI: 10.1007/s00464-024-11280-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 09/13/2024] [Indexed: 10/07/2024]
Abstract
BACKGROUND Sleeve gastrectomy to Roux-en-Y bypass conversion is a commonly performed procedure, yet data are limited on outcomes and their predictors. The purpose of this study is to characterize the long-term outcomes of patients after sleeve-to-bypass conversion and identify predictors of post-conversion outcomes. METHODS We performed a retrospective cohort study of patients who underwent sleeve-to-bypass conversion for obesity across four hospitals from 06/2017 to 04/2023. Predictors of the below-average percent excess weight loss (%EWL; relative to pre-conversion weight) at 1 and 2 years following conversion were identified using multivariate logistic regression models adjusting for comorbidities, demographics, and neighborhood socioeconomic status. RESULTS 150 Patients undergoing sleeve-to-bypass conversion were identified. 99 had 1-year data and 63 had 2-year data. Mean %EWL at 1- and 2-years following conversion were 40.2% and 37.4%, respectively. EWL > 40% after sleeve gastrectomy was an independent predictor of the below-average %EWL 1-year post-conversion (OR 10.0, 95% CI 2.2-63.0, p < 0.01), and BMI > 40 kg/m2 at the time of conversion was an independent predictor of both 1- and 2-year below-average %EWL post-conversion (p = 0.01 and 0.05, respectively). Insignificant predictors of the below-average %EWL after conversion included: weight regain after sleeve, time between sleeve and conversion, alimentary limb length, and any bariatric surgery prior to sleeve gastrectomy. CONCLUSION Patients should be counseled that the typical expected %EWL for sleeve-to-bypass conversion is less than the 50% EWL benchmark of success for index bariatric operations. The main predictors of a suboptimal conversion outcome are > 40% EWL after sleeve or > 40 BMI kg/m2 at the time of conversion. Most variables in our analysis were not predictors of post-conversion %EWL, including weight regain between sleeve and conversion, alimentary limb length, and time interval between procedures, which suggests that these factors should not play a large role when considering sleeve-to-bypass conversion.
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Affiliation(s)
- Jayson S Marwaha
- Department of Surgery, Georgetown University Medical Center, Washington, DC, USA
- Department of Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Miskir Belayneh
- Georgetown University School of Medicine, Washington, DC, USA
| | | | - Narica Clarke
- Department of Surgery, Georgetown University Medical Center, Washington, DC, USA
- Department of Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Chaitanya Vadlamudi
- Department of Surgery, Georgetown University Medical Center, Washington, DC, USA
- Department of Surgery, Medstar Washington Hospital Center, Washington, DC, USA
- Department of Surgery, Medstar Southern Maryland Hospital, Washington, DC, USA
| | - Ivanesa L Pardo Lameda
- Department of Surgery, Georgetown University Medical Center, Washington, DC, USA
- Department of Surgery, Medstar Washington Hospital Center, Washington, DC, USA
| | - Yewande R Alimi
- Department of Surgery, Georgetown University Medical Center, Washington, DC, USA.
- Department of Surgery, Medstar Washington Hospital Center, Washington, DC, USA.
- Department of Surgery, Medstar Georgetown University Hospital, Washington, DC, USA.
- , 3800 Reservoir Rd NW, PHC4, Washington, DC, 20007, USA.
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Petriuk Y, Rayman S, El-On R, Dayan D, Eldar S, Abu-Abeid A, Keidar A. Conversion of sleeve gastrectomy to Roux-en-Y laparoscopic gastric bypass: a comprehensive 14-year follow-up study on efficacy and outcomes. Surg Obes Relat Dis 2024; 20:1279-1287. [PMID: 39299882 DOI: 10.1016/j.soard.2024.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 07/15/2024] [Accepted: 08/08/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Failed sleeve gastrectomy (SG), defined by inadequate weight loss or weight regain and by reflux and structural complications, can be treated by a laparoscopic conversion to Roux-en-Y gastric bypass (RYGB). OBJECTIVES To examine the efficacy and outcomes of conversion surgery over a 14-year follow-up period. SETTING Government and private medical centers in university settings. METHODS We conducted a cohort study of 58 patients who underwent conversion of SG to RYGB for 2 indications: invalidating reflux or weight recurrence during 2009-2023. Weight dynamics analysis was performed with 2 references of weight: before SG (with intention to treat) and before conversion. RESULTS At conversion surgery, the mean weight, body mass index (BMI), percentage of excess weight loss (%EWL), and percentage of total weight loss (%TWL) (calculated with intention to treat, from the weight before SG) were 92.2 ± 25.2 kg, 34.3 ± 8.0 kg/m2, 55.2% ± 39.9%, and 22.8% ± 15.2%, respectively. Mean nadir weight, BMI, %EWL, and %TWL after conversion (calculated from the weight before SG) were 71.1 ± 18.4 kg, 26.7 ± 5.5 kg/m2, 96.5% ± 30.5%, and 40.2% ± 10.6%, respectively. At follow-up, the mean weight, BMI, %EWL, and %TWL (calculated from the weight before SG) were 80.4 ± 17.7 kg, 29.6 ± 5.4 kg/m2, 78.9% ± 26.8%, and 33.3% ± 11.2%, respectively. The mean percentages of %EWLio and %TWLio (calculated from the weight before conversion = EWL from index operation) at nadir were 73.2% ± 92.7% and 20.1% ± 12.2% after conversion, respectively, and decreased to 41.9% ± 94.0% and 13.2% ± 15.2% at last follow-up (mean 6.6 yr), respectively. CONCLUSIONS SG to RYGB conversion provides moderate to low complementary weight loss in the short term. By 3-4 years, there is a clear trend toward weight gain.
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Affiliation(s)
- Yulia Petriuk
- The Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel.
| | - Shlomi Rayman
- Department of Surgery, Samson Assuta Ashdod Public Hospital, Affiliated with Ben-Gurion University of the Negev, Ashdod, Israel
| | - Reut El-On
- Department of Surgery, Tel-Aviv Sourasky Medical Center, Affiliated with Tel-Aviv University Medical School, Tel-Aviv, Israel
| | - Danit Dayan
- Department of Surgery, Tel-Aviv Sourasky Medical Center, Affiliated with Tel-Aviv University Medical School, Tel-Aviv, Israel
| | - Shai Eldar
- Department of Surgery, Tel-Aviv Sourasky Medical Center, Affiliated with Tel-Aviv University Medical School, Tel-Aviv, Israel
| | - Adam Abu-Abeid
- Department of Surgery, Tel-Aviv Sourasky Medical Center, Affiliated with Tel-Aviv University Medical School, Tel-Aviv, Israel
| | - Andrei Keidar
- Department of Surgery, Tel-Aviv Sourasky Medical Center, Affiliated with Tel-Aviv University Medical School, Tel-Aviv, Israel
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van Dam KAM, de Witte E, Broos PPHL, Greve JWM, Boerma EJG. Short-term safety and effectiveness of conversion from sleeve gastrectomy to Ring augmented Roux-en-Y gastric bypass. BMC Surg 2024; 24:266. [PMID: 39300438 DOI: 10.1186/s12893-024-02552-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 09/02/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND Weight recurrence, suboptimal clinical response and functional disorder (such as reflux) after a Sleeve Gastrectomy (SG) are problems that may require conversional surgery. For reflux, conversion to Roux-en-Y Gastric Bypass (RYGB) is considered effective. Regarding treatment for suboptimal clinical response, the technique of choice remains a subject of debate. This study aims to evaluate the safety and effectiveness of conversion from SG to Ring-augmented RYGB ( RaRYGB). METHODS All laparoscopic SG to RaRYGB conversions performed between January 2016 and January 2022 were included. Primary outcome was percentage total weight loss (%TWL) after 1-year follow-up. Secondary outcomes consisted of cumulative %TWL, complications (with a focus on ring-related complications), and resolution of medical-associated problems. RESULTS We included 50 patients of whom 44 were female. Mean pre-conversion BMI was 37.6 kg/m2. All patients have reached the 1-year follow-up point, however 10 were lost to follow-up. After 1-year mean TWL was 17.8% while mean cumulative TWL, calculated from primary SG, was 32%. A total of 10 complications occurred in 8 patients within 30 days, 6 of which were ≤ CD3a and 4 ≥ CD3b. One MiniMizer was removed for complaints of severe dysphagia. Of the 35 medical-associated problems present at screening 5 remained unchanged(14.2%), 15 improved(42.9%) and 15 achieved remission(42.9%). CONCLUSION Our series of 50 patients undergoing conversion from SG to RaRYGB is adequate and successful regarding additional weight loss 1 year after conversion, cumulative weight loss, complication rate and achievement of improvement or remission of medical-associated problems.
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Affiliation(s)
- Kayleigh Ann Martina van Dam
- Surgery, Zuyderland Medical Center, Henri Dunantstraat 5, Heerlen, 6419 PC, The Netherlands.
- Department of Surgery, Institute for Nutrition and Translational Research in Metabolism, NUTRIM, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Evelien de Witte
- Surgery, Zuyderland Medical Center, Henri Dunantstraat 5, Heerlen, 6419 PC, The Netherlands
- Nederlandse Obesitas Kliniek (Dutch Obesity Clinic), Heerlen, The Netherlands
| | - Pieter Petrus Henricus Luciën Broos
- Surgery, Zuyderland Medical Center, Henri Dunantstraat 5, Heerlen, 6419 PC, The Netherlands
- Nederlandse Obesitas Kliniek (Dutch Obesity Clinic), Heerlen, The Netherlands
| | - Jan Willem M Greve
- Department of Surgery, Institute for Nutrition and Translational Research in Metabolism, NUTRIM, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Evert-Jan Gijsbert Boerma
- Surgery, Zuyderland Medical Center, Henri Dunantstraat 5, Heerlen, 6419 PC, The Netherlands
- Nederlandse Obesitas Kliniek (Dutch Obesity Clinic), Heerlen, The Netherlands
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Trujillo AB, Sagar D, Amaravadhi AR, Muraleedharan D, Malik MZ, Effa-Ababio K, Nsengiyumva M, Tesfaye T, Walędziak M, Różańska-Walędziak A. Incidence of Post-operative Gastro-esophageal Reflux Disorder in Patients Undergoing Laparoscopic Sleeve Gastrectomy: A Systematic Review and Meta-analysis. Obes Surg 2024; 34:1874-1884. [PMID: 38483740 DOI: 10.1007/s11695-024-07163-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/03/2024] [Accepted: 03/06/2024] [Indexed: 04/20/2024]
Abstract
Gastroesophageal reflux disease (GERD) is a common concern following laparoscopic sleeve gastrectomy (LSG). This paper aimed to assess the incidence of reflux disease following these bariatric procedures. A literature search was conducted to identify observational studies and clinical trials reporting patients developed GERD disease after LSG. Twenty-two studies included in the analysis, involve 20,495 participants, indicated that the estimated proportion of patients who developed post-surgery GERD was 0.35 (95% CI 0.30-0.41). Subgroup analysis revealed a proportion of 0.33 (95% CI 0.27-0.38) in observational studies and 0.58 (95% CI 0.39-0.75) in clinical trials. High heterogeneity was noted across studies (I2 = 98%). Sensitivity analyses and publication bias assessments were performed to enhance the robustness of the results. Our findings highlight a moderate to high risk of developing GERD following LSG surgery.
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Affiliation(s)
| | - Drishti Sagar
- Aakash Healthcare Superspeciality Hospital, Sector-3, Dwarka, Delhi, 110075, India
| | - Amoolya Rao Amaravadhi
- Internal Medicine, Malla Reddy Institute of Medical Sciences, GHMC Quthbullapur, Jeedimetla, Hyderabad, 500055, India
| | | | | | - Kofi Effa-Ababio
- University of Texas MD Anderson Cancer Center, Holcombe Boulevard, Houston, TX, 77030-4009, USA
| | | | - Tadele Tesfaye
- CareHealth Medical Practice, Jimma Road, Addis Ababa, Ethiopia
| | - Maciej Walędziak
- Department of General, Oncologic, Metabolic, and Thoracic Surgery, Military Institute of Medicine - National Research Institute, 04-141, Warsaw, Poland.
| | - Anna Różańska-Walędziak
- Department of Human Physiology and Patophysiology, Faculty of Medicine, Collegium Medicum, Cardinal Stefan Wyszynski University in Warsaw, 01-938, Warsaw, Poland
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Hany M, Torensma B, Zidan A, Ibrahim M, Abouelnasr AA, Agayby ASS, Sayed IE. Outcomes of primary versus conversional Roux-En-Y gastric bypass after laparoscopic sleeve gastrectomy: a retrospective propensity score-matched cohort study. BMC Surg 2024; 24:84. [PMID: 38448841 PMCID: PMC10919008 DOI: 10.1186/s12893-024-02374-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 02/27/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Conversional surgery is common after laparoscopic sleeve gastrectomy (LSG) because of suboptimal weight loss (SWL) or poor responders and gastroesophageal reflux disease (GERD). Roux-en-Y gastric bypass (RYGB) is the most common conversional procedure after LSG. METHODS A retrospective cohort study analyzed patients who underwent primary RYGB (PRYGB) or conversional RYGB (CRYGB) at three specialized bariatric centers between 2008 and 2019 and tested for weight loss, resolution of GERD, food tolerance (FT), early and late complications, and the resolution of associated medical problems. This was analyzed by propensity score matching (PSM). RESULTS In total, 558 (PRYGB) and 155 (CRYGB) completed at least 2 years of follow-up. After PSM, both cohorts significantly decreased BMI from baseline (p < 0.001). The CRYGB group had an initially more significant mean BMI decrease of 6.095 kg/m2 at 6 months of follow-up (p < 0.001), while the PRYGB group had a more significant mean BMI decrease of 5.890 kg/m2 and 8.626 kg/m2 at 1 and 2 years, respectively (p < 0.001). Food tolerance (FT) improved significantly in the CRYGB group (p < 0.001), while CRYGB had better FT than PRYGB at 2 years (p < 0.001). A GERD resolution rate of 92.6% was recorded in the CRYGB (p < 0.001). Both cohorts had comparable rates of early complications (p = 0.584), late complications (p = 0.495), and reoperations (p = 0.398). Associated medical problems at 2 years significantly improved in both cohorts (p < 0.001). CONCLUSIONS CRYGB is a safe and efficient option in non- or poor responders after LSG, with significant weight loss and improvement in GERD. Moreover, PRYGB and CRYGB had comparable complications, reoperations, and associated medical problem resolution rates.
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Affiliation(s)
- Mohamed Hany
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Alexandria, 21561, Egypt.
- Consultant of bariatric surgery at Madina Women's hospital (IFSO-certified bariatric center), Alexandria, Egypt.
| | - Bart Torensma
- Clinical Epidemiologist, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Ahmed Zidan
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Alexandria, 21561, Egypt
| | - Mohamed Ibrahim
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Alexandria, 21561, Egypt
| | - Anwar Ashraf Abouelnasr
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Alexandria, 21561, Egypt
| | - Ann Samy Shafiq Agayby
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Alexandria, 21561, Egypt
| | - Iman El Sayed
- Biomedical Informatics and Medical Statistics Department, Medical Research Institute, Alexandria University, Alexandria, Egypt
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Hany M, Ibrahim M, Zidan A, Agayaby ASS, Aboelsoud MR, Gaballah M, Torensma B. Two-Year Results of the Banded Versus Non-banded Re-sleeve Gastrectomy as a Secondary Weight Loss Procedure After the Failure of Primary Sleeve Gastrectomy: a Randomized Controlled Trial. Obes Surg 2023; 33:2049-2063. [PMID: 37156932 PMCID: PMC10166688 DOI: 10.1007/s11695-023-06598-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/06/2023] [Accepted: 04/10/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Insufficient weight loss or weight regain has been reported in up to 30% of patients after laparoscopic sleeve gastrectomy (LSG). Approximately 4.5% of patients who undergo LSG need revisional surgery for a dilated sleeve. METHODS This randomized controlled trial compared the outcomes between banded (BLSG) and non-banded re-LSG (NBLSG) after weight regain. Percentage excess body weight loss (%EWL), percentage total weight loss (%TWL), associated medical problems, gastric volume measurement, and endoscopy were measured preoperatively and 1 and 2 years postoperatively. RESULTS Both groups (25 patients each) achieved similar % EWL and %TWL at six months, one year, and two years postoperatively (%EWL 46.9 vs. 43.6, 83.7 vs. 86.3, and 85.7 vs. 83.9) (p= > 0.151) (%TWL 23.9 vs. 21.8, 43.1 vs .43.3, 44.2 vs. 42.2) (p=>0.342), respectively. However, the body mass index was significantly lower with BLSG (24.9 vs. NBLSG, 26.9). Both groups showed a significant reduction in stomach volume after two years (BLSG -248.4 mL vs. NBLSG -215.8 mL). Food tolerance (FT) scores were significantly reduced in both groups, whereby BSLG had significantly lower FT with an average of -1.1 point. No significant differences were observed regarding improvement of the associated medical problems after the first and two years after revisional LSG or the postoperative complications between both groups. CONCLUSION Laparoscopic re-LSG is feasible and safe with satisfactory outcomes in patients with weight regain after LSG who have gastric dilatation without reflux esophagitis. Both groups had comparable significant weight loss effects and improvement of associated medical problems. The BLSG tends to have a more stable weight loss after two years with a significantly lower BMI, lower stomach volume, and less weight regain. Food tolerance decreased in both groups but reduced more in the BLSG group. After a 2-year follow-up, we may regard both procedures are safe, with no significant differences in the occurrence of complications and nutritional deficits.
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Affiliation(s)
- Mohamed Hany
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt.
- Madina Women's Hospital, Alexandria, Egypt.
| | - Mohamed Ibrahim
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Ahmed Zidan
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Ann Samy Shafiq Agayaby
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Moustafa R Aboelsoud
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Muhammad Gaballah
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Bart Torensma
- Leiden University Medical Center (LUMC), Leiden, The Netherlands
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Huang BW, Shahul SS, Ong MKH, Fisher OM, Chan DL, Talbot ML. Medium Term Outcomes of Revision Laparoscopic Sleeve Gastrectomy after Gastric Banding: A Propensity Score Matched Study. Obes Surg 2023; 33:2005-2015. [PMID: 37212965 PMCID: PMC10289990 DOI: 10.1007/s11695-023-06629-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 04/26/2023] [Accepted: 05/04/2023] [Indexed: 05/23/2023]
Abstract
PURPOSE Revision bariatric surgery may be undertaken after weight loss failure and/or complications following primary bariatric surgery. This study aims to compare the efficacy and safety of revision laparoscopic sleeve gastrectomy (RLSG) after gastric banding (GB) to those of primary laparoscopic sleeve gastrectomy (PLSG). MATERIALS AND METHODS A retrospective, propensity-score matched study was conducted to compare between PLSG (control) patients and RLSG after GB (treatment) patients. Patients were matched using 2:1 nearest neighbor propensity score matching without replacement. Patients were compared on weight loss outcomes and postoperative complications for up to five years. RESULTS 144 PLSG patients were compared against 72 RLSG patients. At 36 months, PLSG patients had significantly higher mean %TWL than RLSG patients (27.4 ± 8.6 [9.3-48.9]% vs. 17.9 ± 10.2 [1.7-36.3]%, p < 0.01). At 60 months, both groups had similar mean %TWL (16.6 ± 8.1 [4.6-31.3]% vs. 16.2 ± 6.0 [8.8-22.4)]%, p > 0.05). Early functional complication rates were slightly higher with PLSG (13.9% vs. 9.7%), but late functional complication rates were comparatively higher with RLSG (50.0% vs. 37.5%). The differences were not statistically significant (p > 0.05). Both early (0.7% vs 4.2%) and late (3.5% vs 8.3%) surgical complication rates were lower in PLSG patients compared to RLSG patients but did not reach statistical significance (p > 0.05). CONCLUSION RLSG after GB has poorer weight loss outcomes than PLSG in the short-term. Although RLSG may carry higher risks of functional complications, the safety of RLSG and PLSG are overall comparable.
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Affiliation(s)
- Brenda W Huang
- Faculty of Medicine, University of New South Wales, 18 High St, Kensington, NSW, 2052, Australia.
| | - Sarfraz S Shahul
- Faculty of Medicine, University of New South Wales, 18 High St, Kensington, NSW, 2052, Australia
| | - Marcus K H Ong
- Faculty of Medicine, University of New South Wales, 18 High St, Kensington, NSW, 2052, Australia
| | - Oliver M Fisher
- Faculty of Medicine, University of New South Wales, 18 High St, Kensington, NSW, 2052, Australia
- Upper Gastrointestinal Surgery Unit, Department of Surgery, St George Hospital, Gray St, Kogarah, NSW, 2217, Australia
| | - Daniel L Chan
- Faculty of Medicine, University of New South Wales, 18 High St, Kensington, NSW, 2052, Australia
- Upper Gastrointestinal Surgery Unit, Department of Surgery, St George Hospital, Gray St, Kogarah, NSW, 2217, Australia
- School of Medicine, Western Sydney University, Narellan Rd & Gilchrist Dr, Campbelltown, NSW, 2560, Australia
| | - Michael L Talbot
- Faculty of Medicine, University of New South Wales, 18 High St, Kensington, NSW, 2052, Australia
- Upper Gastrointestinal Surgery Unit, Department of Surgery, St George Hospital, Gray St, Kogarah, NSW, 2217, Australia
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10
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Nduma BN, Mofor KA, Tatang J, Amougou L, Nkeonye S, Chineme P, Ekhator C, Ambe S. Revision Endoscopic Gastroplasty: An Overview and Review of Literature. Cureus 2023; 15:e42099. [PMID: 37476295 PMCID: PMC10354344 DOI: 10.7759/cureus.42099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 07/22/2023] Open
Abstract
The main aim of this paper was to examine the efficacy and safety of revision endoscopic gastroplasty and some of the adverse events likely to arise from the procedure, as well as the implications for future scholarly research. The study is a systematic review in which the PRISMA protocol was used to govern the article's inclusion and exclusion criteria. The selected studies include those on revising endoscopic gastroplasty's effectiveness and safety. The studies were selected based on multiple parameters. The outcome included weight recidivism, excessive BMI loss, and absolute, total, or percentage weight loss. The outcome of this review confirmed that revision endoscopic gastroplasty is effective and safe. Mainly, revision endoscopic gastroplasty (R-EG) was found to counter-weight recidivism, especially short-term and mid-term. However, there is a need for additional scholarly investigations that would last several years to decades to inform the long-term efficacy of R-EG with precision.
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Affiliation(s)
- Basil N Nduma
- Internal Medicine, Merit Health Wesley, Hattiesburg, USA
| | - Kelly A Mofor
- Gastroenterology, Paul L. Foster School of Medicine, El Paso, USA
| | - Jason Tatang
- Gastroenterology, Sam Houston State University, Huntsville, USA
| | - Loica Amougou
- Gastroenterology, School of Natural Sciences and Mathematics, University of Texas at Dallas, Richardson, USA
| | - Stephen Nkeonye
- Oncology, University of Texas Rio Grande Valley, Houston, USA
| | - Princess Chineme
- Gastroenterology, University of Texas at San Antonio, San Antonio, USA
| | - Chukwuyem Ekhator
- Neuro-Oncology, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, USA
| | - Solomon Ambe
- Neurology, Baylor Scott & White Health, Dallas, USA
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11
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Fehervari M, Banh S, Varma P, Das B, Al-Yaqout K, Al-Sabah S, Khwaja H, Efthimiou E, Ashrafian H. Weight loss specific to indication, remission of diabetes, and short-term complications after sleeve gastrectomy conversion to Roux-en-Y gastric bypass: a systematic review and meta-analysis. Surg Obes Relat Dis 2023; 19:384-395. [PMID: 36581551 DOI: 10.1016/j.soard.2022.11.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/03/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022]
Abstract
Laparoscopic sleeve gastrectomy (SG) is the most frequently performed bariatric procedure worldwide. Long-term complications such as insufficient weight loss (IWL) and gastroesophageal reflux disease (GERD) may necessitate SG conversion to Roux-en-Y gastric bypass (RYGB). The aim of this review was to determine the indication-specific weight loss and diabetes remission after SG conversion to RYGB (STOBY). Our objective was to extract all available published data on indication for conversion, weight loss, remission of diabetes, and short-term complications after STOBY. A systematic literature search was conducted to identify studies reporting outcomes following STOBY. A random effects model was used for meta-analysis. The search identified 44 relevant studies. Overall short-term (12-mo) excess weight loss (EWL) was 54.6% (95% confidence interval [CI], 46%-63%) in 23 studies (n = 712) and total weight loss (TWL) was 19.9% (95% CI, 14%-25%) in 21 studies (n = 740). For IWL, short-term (12-mo) pooled weight loss outcomes were 53.9% EWL (95% CI, 48%-59%) in 14 studies (n = 295) and 22.7% TWL (95% CI, 17%-28%) in 12 studies (n = 219), and medium-term (2-5 yr) outcomes were 45.8% EWL (95% CI, 38%-53%) in 7 studies (n = 154) and 20.6% TWL (95% CI, 15%-26%) in 9 studies (n = 206). Overall diabetes remission was 53% (95% CI, 33%-72%), and the perioperative complication rate was 8.2% (95% CI, 7.6%-8.7%). Revisional SG conversion to RYGB for IWL can achieve good weight loss outcomes and diabetes remission.
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Affiliation(s)
- Matyas Fehervari
- Department of Bariatric and Metabolic Surgery, Chelsea and Westminster Hospital, London, United Kingdom; Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
| | - Serena Banh
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Piyush Varma
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Bibek Das
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | | | | | - Haris Khwaja
- Department of Bariatric and Metabolic Surgery, Chelsea and Westminster Hospital, London, United Kingdom; Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | | | - Hutan Ashrafian
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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12
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Strauss AL, Triggs JR, Tewksbury CM, Soriano I, Wernsing DS, Dumon KR, Williams NN, Shao JM. Conversion to Roux-En-Y Gastric Bypass: a successful means of mitigating reflux after laparoscopic sleeve gastrectomy. Surg Endosc 2023:10.1007/s00464-023-10024-x. [PMID: 36997653 DOI: 10.1007/s00464-023-10024-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/12/2023] [Indexed: 04/01/2023]
Abstract
INTRODUCTION Laparoscopic sleeve gastrectomy (LSG) has become the most common bariatric procedure due to the technical ease and weight loss success of the operation. However, there has been concern that LSG contributes to gastroesophageal reflux disease (GERD) postoperatively with a proportion of patients requiring conversion to a Roux-En-Y Gastric Bypass (RYGB). The objective of this study was to characterize the patients who underwent revision in our hospital system and to better understand pre-operative predictors of GERD and revision. METHODS After IRB approval, a retrospective review was conducted assessing for patients who had conversion of LSG to RYGB at three hospitals within the University of Pennsylvania Health System from January 2015 to December 2021. The patients' charts were then reviewed to evaluate for demographics, BMI, operative findings, imaging and endoscopic reports, and post-operative outcomes. RESULTS 97 patients were identified who underwent conversion of LSG to RYGB between January 2015 and December 2021. The cohort was predominantly female (n = 89, 91.7%) with an average age of 42.7 ± 10.6 years at the time of conversion. The most common indications for revision were GERD (72.2%) and obesity/insufficient weight loss (24.7%). Patients lost an average of 11.1 ± 12.9 kg after revision to RYGB. Of the patients who underwent revision for GERD, 80.2% noted global symptomatic improvement after revision and 19.4% were able to stop their proton pump inhibitor (PPI) postoperatively, with most patients decreasing the frequency of the PPI use postoperatively. CONCLUSION The majority of patients who underwent conversion from LSG to RYGB due to GERD and saw marked improvements in GERD symptoms and outcomes. These findings illuminate the real-world practices and outcomes of bariatric revisional procedures for reflux and the need for more research on standardized practice.
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Affiliation(s)
- Alexandra L Strauss
- Division of Gastroenterology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | | | - Ian Soriano
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - David S Wernsing
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristoffel R Dumon
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Noel N Williams
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jenny M Shao
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
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13
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Indja B, Chan DL, Talbot ML. Hiatal reconstruction is safe and effective for control of reflux after laparoscopic sleeve gastrectomy. BMC Surg 2022; 22:347. [PMID: 36131312 PMCID: PMC9490990 DOI: 10.1186/s12893-022-01800-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background Gastroesophageal reflux is a known complication following laparoscopic sleeve gastrectomy (LSG) as anatomical changes predispose to reduced lower esophageal sphincter pressure and development of hiatus hernia. The mainstay of surgical management has been Roux-en-Y gastric bypass (RYGB) which is not without risk. Hiatus hernia repair (HHR) with surgical reattachment of the oesophagus to the crura, recreating the phreno-esophageal ligament is a simple procedure specifically targeting a number of anatomical changes responsible for reflux in this population. Methods We conducted a single centre retrospective analysis of adult patients with post-sleeve reflux refractory to medical treatment, managed with either HHR, RYGB or One-anastomosis Duodenal switch (OADS). PPI use and symptoms of reflux were assessed at early and mid-term time points via validated questionnaires.
Results 99 patients were included, of these the surgical procedure was HHR alone in 58, RYGB in 29 and OADS in 12. At early follow-up control of reflux symptoms was achieved in 72.4% after HHR, 82.1% after RYGB and 100% after OADS with no significant difference between groups (p = 0.09). At mid-term followup (median 10 months IQR 7–21) there was no significant difference in the presence of symptomatic reflux as determined by post-op Visick score nor a difference in PPI use. The GerdQ score was significantly lower after OADS as compared to HHR and RYGB (4.6 ± 2.3 vs 7.7 ± 2.2 vs 8.7 ± 3.5, p = 0.006). Conclusion HHR with reconstruction of the phreno-esophageal ligament is a safe and effective procedure for patients with reflux after LSG, that avoids more complex operations such as RYGB and OADS and their associated long-term sequelae.
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Affiliation(s)
- Ben Indja
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia. .,Department of Surgery, St George Hospital, Sydney, NSW, Australia. .,Upper GI Surgery, St George Private Hospital, Suite 3, Level 5, 1 South, Sydney, NSW, 2217, Australia.
| | - Daniel L Chan
- Department of Surgery, St George Hospital, Sydney, NSW, Australia.,Department of Surgery, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia
| | - Michael L Talbot
- Department of Surgery, St George Hospital, Sydney, NSW, Australia.,Department of Surgery, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia.,Upper GI Surgery, St George Private Hospital, Suite 3, Level 5, 1 South, Sydney, NSW, 2217, Australia
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14
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Revisional Roux-en-Y Gastric Bypass Versus Revisional One-Anastomosis Gastric Bypass After Failed Sleeve Gastrectomy: a Randomized Controlled Trial. Obes Surg 2022; 32:3491-3503. [PMID: 36098907 PMCID: PMC9469810 DOI: 10.1007/s11695-022-06266-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 12/02/2022]
Abstract
Background
High rates of revision surgery have been reported for laparoscopic sleeve gastrectomy (LSG), with weight regain (WR) as the most frequently reported cause. Roux-en-Y gastric bypass (RYGB) is the most commonly performed revision procedure, whereas one-anastomosis gastric bypass (OAGB) is a less popular approach. Methods A single-blinded randomized controlled trial was conducted. One hundred seventy-six patients were enrolled and randomized. After loss to follow-up, 80 patients for RYGB and 80 patients for OAGB were analyzed, with a 2-year follow-up. Patients with grade B or higher gastroesophageal reflux disease (GERD) were excluded. Early and late postoperative complications were recorded. Body mass index (BMI), percentage of excess BMI loss (%EBMIL), nutritional laboratory test results, and the resolution of associated medical problems were assessed after revision surgery. Results After 2 years, both groups achieved significantly lower BMI than their post-LSG nadir BMI (p < 0.001). The %EBMIL changes showed significantly faster weight loss in the OAGB group than in the RYGB at the 6-month follow-up (mean difference: 8.5%, 95% confidence interval [CI]: 0.2 to 16.9%). However, at 1-year and 2-year follow-ups, the differences were statistically insignificant (p > 0.05). Early and late complications were similar between two groups. Both groups showed improvement or resolution of associated medical problems, with no statistically significant differences after 2 years (p = 1.00). Conclusion Both revisional RYGB and OAGB have comparable significant weight loss effects when performed for WR after LSG. After a 2-year follow-up, both procedures were safe, with no significant differences in the occurrence of complications and nutritional deficits. Graphical abstract ![]()
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15
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Oyefule O, Do T, Karthikayen R, Portela R, Dayyeh BA, McKenzie T, Kellogg T, Ghanem OM. Secondary Bariatric Surgery-Does the Type of Index Procedure Affect Outcomes After Conversion? J Gastrointest Surg 2022; 26:1830-1837. [PMID: 35715643 DOI: 10.1007/s11605-022-05385-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/04/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although revisions account for 17% of cases performed at bariatric centers of excellence, scarce data exists on whether index operation type influences outcomes after secondary operations. OBJECTIVE We designed a study investigating the effect of primary procedure type on weight loss and perioperative complications after conversion bariatric surgery. SETTING Tertiary Referral Hospital, USA. METHODS We performed a retrospective review of patients undergoing conversion from sleeve gastrectomy (SG) or adjustable gastric band (AGB) to Roux-en-Y gastric bypass (RYGB) from 2009 to 2019. Post-operatively, we measured short- and medium-term complications and changes in body weight at various time points. Univariate and regression analyses were performed. RESULTS Forty-two (SG) patients and 116 (AGB) patients underwent conversion to RYGB, most commonly for GERD (57.1%) in SG patients vs. weight regain (77.6%) in AGB patients. Mean pre-conversion BMI was 36.7 kg/m2 (SG) vs 43.8 kg/m2 (AGB). Mean time to conversion (months) was 52.9 (SG) vs 94.7 (AGB). Complication rate was 9.5% (SG) vs 6% (AGB) at 30 days (p = 0.48) and 31%(SG) vs 14.5% (AGB) (p = 0.02) at 2 years. Mean post conversion %TWL was 11.6% (SG) vs 24.6% (AGB) in patients with GERD/dysphagia (p = 0.014) and 20.7% (SG) vs 27.6% (AGB) in patients converted for weight-related reasons (p = 0.027) at 1 year. Overall mean %TWL was 13.2% (SG) vs 24.7% (AGB) at 2 years (p < 0.0035). CONCLUSION After conversion to RYGB, patients with AGB experience better short- and medium-term weight loss than those with SG, even after accounting for conversion indications. SG to RYGB conversions have a higher resolution of reflux disease.
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Affiliation(s)
- Omobolanle Oyefule
- Department of Surgery, Emory University School of Medicine, 550 Peachtree Street NE, Atlanta, GA, 30308, USA
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Timothy Do
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Raveena Karthikayen
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ray Portela
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Barham Abu Dayyeh
- Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Travis McKenzie
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Todd Kellogg
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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16
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Chiappetta S, Lainas P, Kassir R, Valizadeh R, Bosco A, Kermansaravi M. Gastroesophageal Reflux Disease as an Indication of Revisional Bariatric Surgery-Indication and Results-a Systematic Review and Metanalysis. Obes Surg 2022; 32:3156-3171. [PMID: 35776239 DOI: 10.1007/s11695-022-06183-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/19/2022] [Accepted: 06/22/2022] [Indexed: 11/25/2022]
Abstract
This systematic review evaluates the indications and results of revisional bariatric surgery (RBS) in gastroesophageal reflux disease (GERD). A systematic literature search and meta-analysis was performed for articles published by April 1, 2021. After examining 722 papers involving 17,437 patients, 48 studies were included (n = 915 patients). RBS for GERD was mostly reported after sleeve gastrectomy (n = 796, 87%) and one anastomosis gastric bypass (n = 62, 6.8%) and was performed due to intractable GERD (71.6%), GERD and weight issues (16%), and biliary reflux (6.2%). Mean follow-up of the studies was 31.5 (3-84) months. Pooled estimation of a meta-analysis of studies reported 7% of GERD following primary surgery needing RBS, in which 99% of the patients experienced remission.
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Affiliation(s)
- Sonja Chiappetta
- Bariatric and Metabolic Surgery Unit, Department of General Surgery, Ospedale Evangelico Betania, Via Argine 604, 80147, Naples, Italy.
| | - Panagiotis Lainas
- Department of Digestive Surgery, Metropolitan Hospital, HEAL Academy, Athens, Greece
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Paris-Saclay University, Clamart, France
| | - Radwan Kassir
- Digestive Surgery Unit, University Hospital of La Réunion -Félix Guyon Hospital, Saint-Denis, La Réunion, France
- Diabète Athérothrombose Thérapies Réunion Océan Indien (DéTROI), UMR 1188, INSERM, Université de La Réunion, 97400, Saint Denis, France
| | - Rohollah Valizadeh
- Department of Epidemiology, School of Public Health, University of Medical Sciences, Tehran, Iran
| | - Alfonso Bosco
- Bariatric and Metabolic Surgery Unit, Department of General Surgery, Ospedale Evangelico Betania, Via Argine 604, 80147, Naples, Italy
| | - Mohammad Kermansaravi
- Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Department of SurgeryRasool-E Akram Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
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17
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Elmahdy TM, Elsherpiny WY, Barakat HB. Laparoscopic one anastomosis gastric bypass: A revisional Procedure For Failed Laparoscopic Sleeve Gastrectomy. SURGICAL PRACTICE 2022. [DOI: 10.1111/1744-1633.12568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Tamer M. Elmahdy
- Gastrointestinal and laparoscopic Surgery Unit, General Surgery Department Faculty of Medicine, Tanta University
| | - Waleed Y. Elsherpiny
- Gastrointestinal and laparoscopic Surgery Unit, General Surgery Department Faculty of Medicine, Tanta University
| | - Hossam B. Barakat
- Gastrointestinal and laparoscopic Surgery Unit, General Surgery Department Faculty of Medicine, Tanta University
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18
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Treatment Options for Weight Regain or Insufficient Weight Loss After Sleeve Gastrectomy: a Systematic Review and Meta-analysis. Obes Surg 2022; 32:2035-2046. [PMID: 35366738 DOI: 10.1007/s11695-022-06020-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 12/19/2022]
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19
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Abstract
Patients with obesity who present with gastroesophageal reflux disease (GERD) require a nuanced approach. Those with lower body mass index (BMI) (less than 33) can be counseled on weight loss, and if successful may be approached with laparoscopic fundoplication. Those who are unable to achieve weight loss or those who present with a BMI greater than or equal to 35 should proceed with laparoscopic Roux-en-Y gastric bypass (LRYGB). Conversion to LRYGB from sleeve gastrectomy is a safe and effective way to manage GERD after sleeve gastrectomy.
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20
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Mazzini GS, Campos GM. Surgical Management of Gastroesophageal Reflux in Patients With Obesity. FOREGUT: THE JOURNAL OF THE AMERICAN FOREGUT SOCIETY 2021; 1:357-366. [DOI: 10.1177/26345161211069050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
Abstract
With the growing prevalence of obesity and its association with gastro-esophageal reflux disease (GERD), the thoracic, foregut, and bariatric surgeons will be ever more commonly facing the challenge to treat GERD in patients with obesity, albeit having the opportunity to treat GERD and obesity simultaneously. In this review, we outline the outcomes of laparoscopic antireflux surgery (LARS) in patients with Class 1, 2, and 3 obesity, as well as GERD outcomes of Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG). We also discuss the revisional surgical options for patients with obesity and failed LARS, or with GERD after LRYGB and LSG.
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21
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Faul A, Naudot C, Rebibo L, Msika S. Surgical technique: Laparoscopic conversion of sleeve gastrectomy to Roux-en-Y gastric bypass. J Visc Surg 2021; 159:150-157. [PMID: 34840122 DOI: 10.1016/j.jviscsurg.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A Faul
- Department of Gastric and Bariatic Digestive Surgery, Bichat-Claude-Bernard Hospital, 46, rue Henri-Huchard, 75018 Paris, France
| | - C Naudot
- Department of Gastric and Bariatic Digestive Surgery, Bichat-Claude-Bernard Hospital, 46, rue Henri-Huchard, 75018 Paris, France
| | - L Rebibo
- Université de Paris, Inserm UMR 1149, 75018 Paris, France
| | - S Msika
- Université de Paris, Inserm UMR 1149, 75018 Paris, France.
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22
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Vilallonga R, Nedelcu A, Cirera de Tudela A, Palermo M, Pérez-Aguirre E, Josa-Martínez BM, Armengol Carrasco M, Noel P, Torres A, Nedelcu M. Single Anastomosis Duodeno-ileal Bypass As a Revisional Procedure Following Sleeve Gastrectomy: Review of the Literature. J Laparoendosc Adv Surg Tech A 2021. [PMID: 34569824 DOI: 10.1089/lap.2021.0511] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Laparoscopic sleeve gastrectomies (LSGs) can experience weight-loss failure and conversion to another bariatric procedure. An analysis of the bariatric literature concerning the single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) as revisional surgery after LSG in terms of safety and efficacy identified 607 studies. Fifty-nine studies were analyzed for full content review and 9 primary studies (398 patients) were included. Revisional single anastomosis duodeno-ileal bypass (SADI) was performed in 294 patients at a mean interval of 37.7 months (range 11-179). Total weight loss (%) varies from 20.5% to 46.2%. Early complications after surgery occurred in 4.1% surgeries including leak (7 cases -1.9%). Mortality was nil. SADI after LSG, after failed sleeve gastrectomy or as a sequential procedure, offers a satisfactory weight loss result. Both early and late term complications are acceptable.
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Affiliation(s)
- Ramon Vilallonga
- General Surgery Department and Universitat Autònoma de Barcelona, General Surgery and Advanced Laparoscopy Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Anamaria Nedelcu
- General Surgery Department, Clinique Saint-Michel, Toulon, France
| | - Arturo Cirera de Tudela
- Universitat Autònoma de Barcelona, Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Mariano Palermo
- Department of Surgery, University of Buenos Aires, Centro CIEN-Diagnomed, Buenos Aires, Argentina
| | - Elia Pérez-Aguirre
- Department of Surgery, Health Research Institute of the Hospital Clínico San Carlos (IdISSC), Complutense University of Madrid, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Benito Miguel Josa-Martínez
- Department of Surgery, Health Research Institute of the Hospital Clínico San Carlos (IdISSC), Complutense University of Madrid, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Manuel Armengol Carrasco
- Universitat Autònoma de Barcelona, Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Patrick Noel
- Department of Surgery, Centre Chirurgical de l'Obesite, Clinique Saint-Michel, Toulon, France
| | - Antonio Torres
- Department of Surgery, Health Research Institute of the Hospital Clínico San Carlos (IdISSC), Complutense University of Madrid, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Marius Nedelcu
- Department of Surgery, Centre Chirurgical de l'Obesite, Clinique Saint-Michel, Toulon, France
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Curell A, Beisani M, García Ruiz de Gordejuela A, Vilallonga R, Verdaguer Tremolosa M, González López Ó, Caubet Busquet E, Fort López-Barajas JM. Outcomes of Conversion from Sleeve Gastrectomy to Roux-en-Y Gastric Bypass Due to GERD-a Retrospective Analysis of 35 Patients. Obes Surg 2021; 31:4100-4106. [PMID: 34227017 DOI: 10.1007/s11695-021-05541-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Sleeve gastrectomy (SG) has become one of the most performed bariatric procedures worldwide. Its main weaknesses are weight regain and gastroesophageal reflux disease (GERD). Conversion to Roux-en-Y gastric bypass (RYGB) is considered the gold standard to manage GERD and related symptoms. METHODS Retrospective evaluation from a prospective bariatric surgery database of all our institution's patients converted from SG to RYGB due to GERD between January 2010 and December 2018. Clinical characteristics and workups before SG and before and after RYGB were analyzed. RESULTS During the study period, 35 patients needed a conversion to RYGB, due to GERD or GERD-related symptoms. Mean age was 48.6 years, 85.7% were women, and mean BMI was 31.4 kg/m2. The interval between SG and RYGB was in a range 7 to 70 months (mean 33 months). All conversions were completed laparoscopically, associating a hiatoplasty in 45.7% of cases. A complete remission of symptoms was observed in 74% of patients, some improvement in 20%, and no relief in 6%. There were 3 cases of hiatal hernia persistence and 2 of recidivism. Only 1 patient presented pathological pHmetry, while moderate esophagitis was demonstrated in 2 patients. CONCLUSIONS Conversion to RYGB was effective in almost all patients. Pathological acid exposure and hiatal hernias seem to be the main findings prior to conversion, justifying an exhaustive examination and aggressive approach to the hiatus. Due to the insufficient correlation between symptoms and findings on morphological and functional tests, actively searching for signs of GERD is advisable.
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Affiliation(s)
- Anna Curell
- General and Digestive Surgery Department, Vall d'Hebron Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain.,Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Marc Beisani
- Bariatric Surgery Unit, General and Digestive Surgery Department, Moises Broggi Hospital, CSI, Sant Joan Despi, Barcelona, Spain
| | - Amador García Ruiz de Gordejuela
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Vall d'Hebron Hospital Campus, Universitat Autònoma de Barcelona, Center of Excellence for the EAC-BC, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Ramon Vilallonga
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Vall d'Hebron Hospital Campus, Universitat Autònoma de Barcelona, Center of Excellence for the EAC-BC, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Mireia Verdaguer Tremolosa
- General and Digestive Surgery Department, Vall d'Hebron Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Óscar González López
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Vall d'Hebron Hospital Campus, Universitat Autònoma de Barcelona, Center of Excellence for the EAC-BC, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Enric Caubet Busquet
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Vall d'Hebron Hospital Campus, Universitat Autònoma de Barcelona, Center of Excellence for the EAC-BC, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - José Manuel Fort López-Barajas
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Vall d'Hebron Hospital Campus, Universitat Autònoma de Barcelona, Center of Excellence for the EAC-BC, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
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Matar R, Monzer N, Jaruvongvanich V, Abusaleh R, Vargas EJ, Maselli DB, Beran A, Kellogg T, Ghanem O, Abu Dayyeh BK. Indications and Outcomes of Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass: a Systematic Review and a Meta-analysis. Obes Surg 2021; 31:3936-3946. [PMID: 34218416 DOI: 10.1007/s11695-021-05463-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 05/05/2021] [Accepted: 05/05/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE Sleeve gastrectomy (SG) is the most performed bariatric procedure. Conversion to Roux-en-Y gastric bypass (RYGB) for SG-related complications such as gastroesophageal reflux disease (GERD), insufficient weight loss (ISWL), and weight regain (WR) is increasing. Our aim was to investigate the safety, efficacy, and outcomes of conversion from SG to RYGB. METHODS A literature search was performed from database inception to May 2020. Eligible studies must report indications for conversion, %total body weight loss (%TWL), and/or complications. The pooled mean or proportion were analyzed using a random-effects model. RESULTS Seventeen unique studies (n = 556, 68.7% female, average age at time of conversion 42.6 ± 10.29 years) were included. The pooled conversion rate due to GERD was 30.4% (95% CI 23.5, 38.3%; I2 = 63.9%), compared to 52.0% (95% CI 37.0, 66.6%; I2 = 85.89%) due to ISWL/WR. The pooled baseline BMI at conversion was 38.5 kg/m2 (95% CI 36.49, 40.6 kg/m2; I2 = 92.1%) and after 1 year was 32.1 kg/m2 (95% CI 25.50, 38.7 kg/m2; I2 = 94.53%). The pooled %TWL after 1 year was 22.8% (95% CI 13.5, 32.1%; I2 = 98.05%). Complication rate within 30 days was 16.4% (95% CI 11.1, 23.6%; I2 = 57.17%), and after 30 days was 11.4% (95% CI 7.7, 16.7%; I2 = 0%). CONCLUSION This meta-analysis showed that conversion from SG to RYGB is an option for conversion at a bariatric care center that produces sufficient weight loss outcomes, and potential resolution of symptoms of GERD. Further indication-based studies are required to obtain a clearer consensus on the surgical management of patients seeking RYGB following SG.
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Affiliation(s)
- Reem Matar
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Nasser Monzer
- Department of Medicine, Royal College of Surgeons Ireland, Dublin, Ireland
| | - Veeravich Jaruvongvanich
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Rami Abusaleh
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Eric J Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Daniel B Maselli
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Azizullah Beran
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Todd Kellogg
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Omar Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
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Huynh D, Mazer L, Tung R, Cunneen S, Shouhed D, Burch M. Conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass: patterns predicting persistent symptoms after revision. Surg Obes Relat Dis 2021; 17:1681-1688. [PMID: 34127398 DOI: 10.1016/j.soard.2021.05.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 04/22/2021] [Accepted: 05/14/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric operation performed. However, it is not without its drawbacks and patients may develop gastroesophageal reflux (GERD) after LSG. There are limited data available to guide treatment choice for patients suffering these sequelae. OBJECTIVE This study was undertaken to evaluate the success of conversion to Roux-en-Y gastric bypass (RYGB) in treating GERD symptoms after LSG. SETTING Single bariatric center, United States. METHODS Analysis of a prospectively maintained clinical database was performed. Outcomes studied included heartburn-related quality of life score (GERD-HRQL), anti-secretory usage, and body mass index (BMI). RESULTS A total of 54 patients met inclusion criteria during the review period. Of these, 41 patients (76%) underwent conversion for indication including GERD. Mean BMI at conversion was 33.8 ± 5.61 and was found to be significantly reduced at 12 months after conversion (n = 26; 63%; P < .001) and at long-term follow-up (n = 37; 90%) (P ≤ .001; mean follow-up period: 33.3 mo). Mean GERD-HRQL at time of conversion was 31.5 ± 11.4. Conversion to RYGB produced a significant reduction of HRQL at 6 months after conversion (n = 30; 73%) (mean: 5.6, P < .001) and long-term follow-up (n = 38; 93%) (mean: 7.3, P < .001. mean follow-up period: 15.1 mo). Prior to conversion, 32 patients (78%) required antisecretory therapy for GERD and after conversion, 12 of these patients (38%) required antisecretory therapy (P < .001). These 12 patients were found to exhibit a significantly (P = .005) smaller decrease in GERD-HRQL after revision compared with their peers who were liberated from antisecretory therapy. Preoperative symptoms were compared between these 2 groups. Delayed onset of GERD symptoms after LSG (>3 mo) was found to be a significant risk factor for continued antisecretory dependence after conversion to RYGB. CONCLUSION Conversion of LSG to RYGB quantitatively reduces GERD symptoms, and results in a modest but significant amount of weight loss. While there was a significant improvement in HRQL after revision, a subgroup of patients continued to be antisecretory-dependent and showed a limited improvement in HRQL. This limited response was predicted by a gradual onset of GERD symptoms prior to revision. An interval of 3 months or greater between LSG and onset of symptoms was found to be a significant risk factor for limited response to conversion.
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Affiliation(s)
- Desmond Huynh
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Laura Mazer
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Robert Tung
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Scott Cunneen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel Shouhed
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Miguel Burch
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
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Indications and Long-Term Outcomes of Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass. Obes Surg 2021; 31:3410-3418. [PMID: 33932190 DOI: 10.1007/s11695-021-05444-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/20/2021] [Accepted: 04/21/2021] [Indexed: 12/22/2022]
Abstract
PURPOSE Long-term results on sleeve gastrectomy (SG) with more than 10 years report patients needing sleeve revision for weight loss failure, de novo gastroesophageal reflux (GERD), or sleeve complications. The aim of this study was to analyze the results of laparoscopic conversion of failed SG to Roux-en-Y gastric bypass (RYGB). MATERIALS AND METHODS Retrospective review of a prospectively institutional maintained database to identify patients who underwent conversion of SG to RYGB between 2012 and June 2020. RESULTS Sixty patients(50 females) underwent conversion to RYGB. Average time to conversion was 5.6 years (2-11). Mean %WL and TWL after SG were respectively 26±8.8% and 33.2±14.1kg. Mean BMI at the time of RYGB was 38.1±7.1 kg/m2. Mean follow-up was 30.4±16.8 months (6-84). Available patients at each time of follow-up: 1 year 59 (98.3%); 2 years 47 (78.3%); 3 years 39 (71.6%); and 5 years 33 (55%). Patients were divided according to indication for revision in weight regain/insufficient weight loss (30 patients) group 1 and GERD/complications (25 patients) group 2. Percentage of excess weight loss at 1, 3, and 5 years follow-up after bypass was for group 1 40.3±17.6, 34.3±19.5, and 23.2±19.4 and for group 2 90.4±37, 62.6±28.2, and 56±35.02. Total weight loss at last follow-up since sleeve was respectively 31kg in group 1 and 46.7kg in group 2 (p=0.002). No mortality was observed. Thirty-day complication rate was 3.3%. CONCLUSION RYGB after SG is a safe and effective revisional procedure to manage weight regain and de novo GERD, to address complications, and to improve comorbidities.
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Clapp B, Liggett E, Barrientes A, Aguirre K, Marwaha V, Tyroch A. Concomitant Hiatal Hernia Repair with Sleeve Gastrectomy: A 5-Year Analysis. JSLS 2021; 24:JSLS.2020.00066. [PMID: 33414611 PMCID: PMC7732366 DOI: 10.4293/jsls.2020.00066] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: The sleeve gastrectomy (SG) can be associated with postoperative gastroesophageal reflux and when a hiatal hernia (HH) is present, it should be fixed. Earlier studies have shown that 20% of SG have a concomitant hiatal hernia repair (SG+HHR). The aim of this project is to determine the rate of SG+HHR in a large state administrative database. Methods: The Texas Inpatient Public Use Data File (IPUDF) and Outpatient Public Use Data File (OPUDF) for the years 2013-2017 were examined for patients that underwent SG+HHR at the same time. Patient demographics, diagnosis, and charge data were also examined. A t-test was performed between groups and P was considered significant at < 0.05. Results: In the OPUDF, there were 6,193 (33.7%) patients who underwent SG+HHR out of 18,403 patients who underwent SG. Mean charges were $94,741 [standard deviation (SD) = $87,284]. Length of stay (LOS) was 2.1 (SD = 3.5) vs 2.3 days (SD = 3.3) with a shorter stay for SG+HHR vs SG alone (P < 0.001). In the IPUDF, there were 11,536 (21.1%) patients who underwent SG+HHR out of 54,545 patients who underwent SG. Mean charges were $69,006 (SD = $46,365). LOS was 1.59 days (SD = 3.7) for SG+HHR vs 1.63 days (SD = 1.6) for SG (P = .043). The rate of SG+HHR increased over the study period. Conclusions: SG+HHR is common in both the outpatient and inpatient setting. There is a yearly trend of increasing rates of SG+HHR.
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Affiliation(s)
- Benjamin Clapp
- Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, TX
| | - Evan Liggett
- Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, TX
| | - Ashtyn Barrientes
- Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, TX
| | - Katherine Aguirre
- Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, TX
| | - Vidur Marwaha
- Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, TX
| | - Alan Tyroch
- Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, TX
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Guzman-Pruneda FA, Brethauer SA. Gastroesophageal Reflux After Sleeve Gastrectomy. J Gastrointest Surg 2021; 25:542-550. [PMID: 32935271 DOI: 10.1007/s11605-020-04786-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/03/2020] [Indexed: 01/31/2023]
Abstract
Sleeve gastrectomy continues to be the most commonly performed bariatric operation worldwide. Development or worsening of pre-existing GERD has been recognized as a significant issue postoperatively. There is a paucity of information concerning the most appropriate preoperative workup and the technical and anatomical factors that may or may not contribute to the occurrence of reflux symptoms. Contemporary data quality is deficient given the predominantly retrospective nature, limited follow-up time, and heterogeneous outcome measures across studies. This has produced mixed results regarding the postoperative incidence and severity of GERD. Ultimately, better-constructed investigations are needed in order to offer evidence-based recommendations that may guide preoperative workup and improved patient selection criteria.
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Affiliation(s)
- Francisco A Guzman-Pruneda
- Department of Surgery, Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Stacy A Brethauer
- Department of Surgery, Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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30
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Braghetto I, Korn O, Burgos A, Figueroa M. WHEN SHOULD BE CONVERTED LAPAROSCOPIC SLEEVE GASTRECTOMY TO LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS DUE TO GASTROESOPHAGEAL REFLUX? ACTA ACUST UNITED AC 2021; 33:e1553. [PMID: 33503113 PMCID: PMC7836073 DOI: 10.1590/0102-672020200004e1553] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/24/2020] [Indexed: 02/08/2023]
Abstract
Background: Gastroesophageal reflux (GER) is one of the most common indications for conversion of sleeve gastrectomy (LSG) to laparoscopic Roux-en-Y gastric bypass (LRYGBP). Objective evaluations are necessary in order to choose the best definitive treatment for these patients. Aim: To present and describe the findings of the objective studies for gastroesophageal reflux disease performed before LSG conversion to LRYGBP in order to support the indication for surgery. Method: Thirty-nine non-responder patients to proton pump inhibitors treatment after LSG were included in this prospective study. They did not present GER symptoms, esophagitis or hiatal hernia before LSG. Endoscopy, radiology, manometry, 24 h pH monitoring were performed. Results: The mean time of appearance of reflux symptoms was 26.8+24.08 months (8-71). Erosive esophagitis was found in 33/39 symptomatic patients (84.6%) and Barrett´s esophagus in five. (12.8%). Manometry and acid reflux test were performed in 38/39 patients. Defective lower esophageal sphincter function was observed independent the grade of esophagitis or Barrett´s esophagus. Pathologic acid reflux with elevated DeMeester´s scores and % of time pH<4 was detected in all these patients. more significant in those with severe esophagitis and Barrett´s esophagus. Radiologic sleeve abnormalities were observed in 35 patients, mainly cardia dilatation (n=18) and hiatal hernia (n=11). Middle gastric stricture was observed in only six patients. Conclusion: Patients with reflux symptoms and esophagitis or Barrett´s esophagus after SG present defective lower esophageal sphincter function and increased acid reflux. These conditions support the indication of conversion to LRYGBP.
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Affiliation(s)
- Italo Braghetto
- Department of Surgery, University Hospital "Dr José J. Aguirre", Faculty of Medicine, University of Chile, Santiago, Chile
| | - Owen Korn
- Department of Surgery, University Hospital "Dr José J. Aguirre", Faculty of Medicine, University of Chile, Santiago, Chile
| | - Anamaría Burgos
- Department of Surgery, University Hospital "Dr José J. Aguirre", Faculty of Medicine, University of Chile, Santiago, Chile
| | - Manuel Figueroa
- Department of Surgery, University Hospital "Dr José J. Aguirre", Faculty of Medicine, University of Chile, Santiago, Chile
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Maselli DB, Alqahtani AR, Abu Dayyeh BK, Elahmedi M, Storm AC, Matar R, Nieto J, Teixeira A, Al Khatry M, Neto MG, Kumbhari V, Vargas EJ, Jaruvongvanich V, Mundi MS, Deshmukh A, Itani MI, Farha J, Chapman CG, Sharaiha R. Revisional endoscopic sleeve gastroplasty of laparoscopic sleeve gastrectomy: an international, multicenter study. Gastrointest Endosc 2021; 93:122-130. [PMID: 32473252 DOI: 10.1016/j.gie.2020.05.028] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 05/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Laparoscopic sleeve gastrectomy (LSG) facilitates significant and durable weight loss; however, weight recidivism and need for revisional surgery occur in a subset of patients. Reduction of a dilated LSG using the revisional endoscopic sleeve gastroplasty (R-ESG) approach is an appealing and minimally invasive alternative to surgical revision that is congruent with obesity as a chronic relapsing disease model. In this study, we examine the safety and efficacy of the technique in a large multicenter international cohort. METHODS Prospectively collected data from 9 centers for 82 consecutive adults who underwent R-ESG for weight regain after LSG using the OverStitch device (Apollo Endosurgery, Austin, Tex, USA) from March 2014 to November 2019 were reviewed. Total body weight loss (TBWL) and adverse events were reported up to 12 months. Univariable logistic regression was used to identify predictors of response at 12 months. RESULTS Eighty-two adults (92.7% female) experienced 27.9 ± 20.7 kg weight regain from post-LSG nadir weight, prompting R-ESG (mean age, 42.8 ± 10.4 years) at a mean weight of 128.2 ± 57.5 kg. Mean R-ESG procedure duration was 48.3 ± 20.5 minutes, and the median number of sutures used was 4 (interquartile range, 3-4). After R-ESG, TBWL (follow-up %) was 6.6% ± 3.2% at 1 month (81.7%), 10.6% ± 4.4% at 3 months (74.4%), 13.2% ± 10.1% at 6 months (63.4%), and 15.7% ± 7.6% at 12 months (51.2%). In a per-protocol analysis, ≥10% TBWL was achieved by 37 of 51 patients (72.5%) at 6 months and 34 of 42 patients (81.0%) at 12 months; ≥15% TBWL was achieved by 20 of 46 patients (43.5%) at 6 months and 22 of 42 patients (52.4%) at 12 months. Only 1 moderate adverse event occurred in the form of a narrowed gastroesophageal junction, which resolved after a single endoscopic dilation. CONCLUSIONS R-ESG is a safe and effective means of facilitating weight loss for weight recidivism after LSG, with sustained results at 1 year. R-ESG should be considered before pursuing more-invasive surgical revisional options.
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Affiliation(s)
- Daniel B Maselli
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Aayed R Alqahtani
- Department of Surgery, College of Medicine, King Saud University, and New You Medical Center, Riyadh, Saudi Arabia
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamed Elahmedi
- Department of Surgery, College of Medicine, King Saud University, and New You Medical Center, Riyadh, Saudi Arabia
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Reem Matar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jose Nieto
- Borland Groover Clinic, Jacksonville, Florida
| | - Andre Teixeira
- Orlando Regional Medical Center, Orlando Health, Orlando, Florida, USA
| | - Maryam Al Khatry
- Department of Gastroenterology, Obaidulla Hospital, Ras Al Khaimah, United Arab Emirates
| | | | - Vivek Kumbhari
- Division of Gastroenterology, Johns Hopkins Medicine, Baltimore, Maryland
| | - Eric J Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Mohamad I Itani
- Division of Gastroenterology, Johns Hopkins Medicine, Baltimore, Maryland
| | - Jad Farha
- Division of Gastroenterology, Johns Hopkins Medicine, Baltimore, Maryland
| | - Christopher G Chapman
- University of Chicago Medicine, Center for Endoscopic Research and Therapeutics, Chicago, Illinois
| | - Reem Sharaiha
- Department of Gastroenterology, Weill Cornell Medicine, New York, New York, USA
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Lee Bion A, Le Roux Y, Alves A, Menahem B. Bariatric revisional surgery: What are the challenges for the patient and the practitioner? J Visc Surg 2020; 158:38-50. [PMID: 32958433 DOI: 10.1016/j.jviscsurg.2020.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Bariatric revisional surgery represents an important new issue for obese patients because of the considerable rate of failure and complications following bariatric surgery. As the frequency of bariatric procedures increases, so too does the incidence of revisional surgery, which has become becoming increasingly important. The surgeon must know the indications and the results of the various revisional procedures in order to best guide the therapeutic decision. The current challenge is to correctly select the patients for revisional surgery and to choose the appropriate procedure in each case. Multidisciplinary management is essential to patient re-assessment and to prepare the patient for a re- intervention. The objective of this update, based on data from all the most recent studies concerning revisional surgery, is to guide the surgeon in the choice of the revisional procedure, depending on patient characteristics, co-morbidities, the previously performed procedure, the type of failure or complication observed, but also on the surgeon's own habits and the center's expertise. The collected results show that revisional surgery is difficult, with higher complication rates and weight-loss results that are often lower than those of first-intent surgery. For these reasons, patient selection must be rigorous and multidisciplinary and the management in expert centers of these difficult situations must be encouraged.
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Affiliation(s)
- A Lee Bion
- Digestive surgery department, university hospital of Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France.
| | - Y Le Roux
- Digestive surgery department, university hospital of Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France
| | - A Alves
- Digestive surgery department, university hospital of Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France; Unicaen, Inserm, Anticipe, université de Normandie, 14000 Caen, France
| | - B Menahem
- Digestive surgery department, university hospital of Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France; Unicaen, Inserm, Anticipe, université de Normandie, 14000 Caen, France
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Noel P, Nedelcu A, Eddbali I, Gagner M, Danan M, Nedelcu M. Five-year results after resleeve gastrectomy. Surg Obes Relat Dis 2020; 16:1186-1191. [PMID: 32580923 DOI: 10.1016/j.soard.2020.04.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 04/04/2020] [Accepted: 04/16/2020] [Indexed: 12/19/2022]
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Outcomes of reoperative surgery in severely obese patients after sleeve gastrectomy: a single-institution experience. Surg Obes Relat Dis 2020; 16:983-990. [DOI: 10.1016/j.soard.2020.04.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 04/10/2020] [Accepted: 04/16/2020] [Indexed: 11/20/2022]
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Martínez-Ortega AJ, Olveira G, Pereira-Cunill JL, Arraiza-Irigoyen C, García-Almeida JM, Irles Rocamora JA, Molina-Puerta MJ, Molina Soria JB, Rabat-Restrepo JM, Rebollo-Pérez MI, Serrano-Aguayo MP, Tenorio-Jiménez C, Vílches-López FJ, García-Luna PP. Recommendations Based on Evidence by the Andalusian Group for Nutrition Reflection and Investigation (GARIN) for the Pre- and Postoperative Management of Patients Undergoing Obesity Surgery. Nutrients 2020; 12:E2002. [PMID: 32640531 PMCID: PMC7400832 DOI: 10.3390/nu12072002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/24/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022] Open
Abstract
In order to develop evidence-based recommendations and expert consensus for nutrition management of patients undergoing bariatric surgery and postoperative follow-up, we conducted a systematic literature search using PRISMA methodology plus critical appraisal following the SIGN and AGREE-II procedures. The results were discussed among all members of the GARIN group, and all members answered a Likert scale questionnaire to assess the degree of support for every recommendation. Patients undergoing bariatric surgery should be screened preoperatively for some micronutrient deficiencies and treated accordingly. A VLCD (Very Low-Calorie Diet) should be used for 4-8 weeks prior to surgery. Postoperatively, a liquid diet should be maintained for a month, followed by a semi-solid diet also for one month. Protein requirements (1-1.5 g/kg) should be estimated using adjusted weight. Systematic use of specific multivitamin supplements is encouraged. Calcium citrate and vitamin D supplements should be used at higher doses than are currently recommended. The use of proton-pump inhibitors should be individualised, and vitamin B12 and iron should be supplemented in case of deficit. All patients, especially pregnant women, teenagers, and elderly patients require a multidisciplinary approach and specialised follow-up. These recommendations and suggestions regarding nutrition management when undergoing bariatric surgery and postoperative follow-up have direct clinical applicability.
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Affiliation(s)
- Antonio J. Martínez-Ortega
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain; (A.J.M.-O.); (J.L.P.-C.); (M.P.S.-A.); (P.P.G.-L.)
- Endocrine Diseases Research Group, Institute of Biomedicine of Seville (IBiS), 41007 Sevilla, Spain
| | - Gabriel Olveira
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Regional Universitario de Málaga/Universidad de Málaga, 29010 Málaga, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain;
- CIBERDEM (CB07/08/0019), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - José L. Pereira-Cunill
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain; (A.J.M.-O.); (J.L.P.-C.); (M.P.S.-A.); (P.P.G.-L.)
- Endocrine Diseases Research Group, Institute of Biomedicine of Seville (IBiS), 41007 Sevilla, Spain
| | | | - José M. García-Almeida
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain;
- Unidad de gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain
| | | | - María J. Molina-Puerta
- UGC Endocrinología y Nutrición, Hospital Universitario Reina Sofía, 14004 Córdoba, Spain;
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Córdoba, Spain
| | | | | | - María I. Rebollo-Pérez
- Servicio de Endocrinología y Nutrición, Hospital Juan Ramón Jiménez, 21005 Huelva, Spain;
| | - María P. Serrano-Aguayo
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain; (A.J.M.-O.); (J.L.P.-C.); (M.P.S.-A.); (P.P.G.-L.)
- Endocrine Diseases Research Group, Institute of Biomedicine of Seville (IBiS), 41007 Sevilla, Spain
| | - Carmen Tenorio-Jiménez
- Endocrinology and Nutrition Clinical Management Unit, University Hospital Virgen de las Nieves, 18014 Granada, Spain;
| | | | - Pedro P. García-Luna
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain; (A.J.M.-O.); (J.L.P.-C.); (M.P.S.-A.); (P.P.G.-L.)
- Endocrine Diseases Research Group, Institute of Biomedicine of Seville (IBiS), 41007 Sevilla, Spain
- GARIN Group Coordinator, 41007 Seville, Spain
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Brunaldi VO, Galvao Neto M, Zundel N, Abu Dayyeh BK. Isolated sleeve gastrectomy stricture: a systematic review on reporting, workup, and treatment. Surg Obes Relat Dis 2020; 16:955-966. [PMID: 32331996 DOI: 10.1016/j.soard.2020.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/24/2020] [Accepted: 03/06/2020] [Indexed: 12/11/2022]
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Gastroesophageal reflux disease complicating laparoscopic sleeve gastrectomy: current knowledge and surgical therapies. Surg Obes Relat Dis 2020; 16:1145-1155. [PMID: 32576511 DOI: 10.1016/j.soard.2020.04.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/28/2020] [Accepted: 04/14/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is currently the most commonly performed bariatric procedure worldwide. However, the incidence of gastroesophageal reflux disease (GERD) after LSG is high. OBJECTIVES The aim of this systematic review was to identify the optimal surgical strategy for treating GERD after LSG. SETTING West China Hospital, Sichuan University, Chengdu, China. METHODS A systematic literature search was performed to identify studies on surgical treatments for GERD after LSG. The effectiveness and safety profile of surgical management on GERD after LSG were analyzed. RESULTS A total of 40 articles enrolling 2049 patients were included in this review. Surgical strategies to prevent GERD after LSG were mainly of 2 types: concomitant LSG + antireflux procedures (hiatal hernia repair or fundoplication) and secondary procedures (conversion to Roux-en-Y gastric bypass [RYGB] or repeat sleeve gastrectomy). The short-term remission or improvement rate of GERD was 34.6%-100% after concomitant LSG + antireflux procedures. The postoperative complication rate was the same (3.0%) for both LSG + antireflux procedures and LSG alone. The remission or improvement rate of GERD was 57.1%-100% after conversion to RYGB and 100% after repeat sleeve gastrectomy. CONCLUSIONS The effectiveness and safety profile of concomitant LSG + antireflux procedures is uncertain. However, secondary operations after LSG, such as conversion to RYGB, appear to provide good results. The data overall are heterogeneous, with imprecise methods of documenting and defining GERD complicating LSG. More cohort studies or RCT studies of high quality with long-term follow-up are needed in the future.
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Debs T, Petrucciani N, Kassir R, Juglard G, Gugenheim J, Iannelli A, Martini F, Liagre A. Laparoscopic Conversion of Sleeve Gastrectomy to One Anastomosis Gastric Bypass for Weight Loss Failure: Mid-Term Results. Obes Surg 2020; 30:2259-2265. [PMID: 32036496 DOI: 10.1007/s11695-020-04461-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (SG) became the most performed surgical intervention for treating population with morbid obesity. However, revisional surgery after SG has been increasingly performed due to weight loss failure. We describe the results of a single surgeon's experience with conversion of SG to one anastomosis gastric bypass (OAGB) in patients with previous SG and weight loss failure. The aim of the study is to analyze the short- and mid-term results of conversion of SG to OAGB for failure of weight loss. METHODS Conversion of SG to OAGB was performed in 77 patients from May 2010 to June 2018. Vertical resleeving of the gastric tube was done in all patients. A chart review was conducted to determine the weight loss mid-term results and the occurrence of postoperative complications. RESULTS Revisional surgery was completed by laparoscopy in all cases. The mean operative time was 42.0 ± 8.0 min, and mean blood loss was 56.8 ± 56.7 mL. A total complication rate of 3.9% was observed. Ninety-day mortality rate was 0%. Patients mean %EWL was 80.2 (36-128) at 12-month follow-up, mean percent total weight loss (%TWL) was 0.74 (range 0.03-1.8), and mean percent excess BMI loss (%EBMIL) was 70.7%. At 24-month follow-up, mean %EWL was 84.1 (41-128), mean %TWL 0.79 (range 0.32-1.6), and mean %EBMIL 79.9%. CONCLUSION In patients with history of SG and weight loss failure, conversion from SG to OAGB is effective in terms of weight loss and has a low risk of surgical complications.
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Affiliation(s)
- Tarek Debs
- Digestive Surgery and Liver Transplantation Unit, Centre Hospitalier Universitaire de Nice, Archet 2 Hospital, Nice, France
| | - Niccolò Petrucciani
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea Hospital, via di Grottarossa 1035-1039, 00189, Rome, Italy.
| | - Radwan Kassir
- Department of Digestive Surgery, CHU Félix Guyon, Saint Denis, La Réunion, France
| | - Gildas Juglard
- Digestive and Bariatric Surgery Unit, Clinique des Cedres, Cornebarrieu, France
| | - Jean Gugenheim
- Digestive Surgery and Liver Transplantation Unit, Centre Hospitalier Universitaire de Nice, Archet 2 Hospital, Nice, France
| | - Antonio Iannelli
- Digestive Surgery and Liver Transplantation Unit, Centre Hospitalier Universitaire de Nice, Archet 2 Hospital, Nice, France
| | - Francesco Martini
- Digestive and Bariatric Surgery Unit, Clinique des Cedres, Cornebarrieu, France
| | - Arnaud Liagre
- Digestive and Bariatric Surgery Unit, Clinique des Cedres, Cornebarrieu, France
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A Multi-institutional Study on the Mid-Term Outcomes of Single Anastomosis Duodeno-Ileal Bypass as a Surgical Revision Option After Sleeve Gastrectomy. Obes Surg 2020; 29:3165-3173. [PMID: 31388962 DOI: 10.1007/s11695-019-03917-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Recently, a single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) has become increasingly popular for patients with BMI > 50 as a primary or staged surgery. Staging allows surgeons to do the sleeve gastrectomy (SG) first with the conversion only happening when a failure or technical challenge is identified. PURPOSE We present the mid-term outcomes of SADI bypass surgery after SG. METHOD A retrospective analysis was performed on a prospective database from four institutions. Ninety-six patients were identified from 2013 to 2018. Patients were divided into two groups: one had two-stage SADI because of insufficient weight loss, the second had planned two-stage SADI because of super obesity (BMI > 50 kg/m2). Incidence of complications was divided into < 30 days and > 30 days. RESULT Of 96 patients, 3 patients were completely lost to follow-up. The mean age was 44.8 ± 11.3 years. There were no deaths or conversion to open surgery. The postoperative early complication and late complication rate was 5.3% and 6.4% respectively. At 24 months, group 2 had higher %weight loss (WL) and change in BMI units compared to group 1 with statistically significant difference. The average WL and change in BMI for entire patient's population at 24 months after 2nd stage SADI was 20.5% and 9.4 units respectively. The remission rate for DM was 93.7% with or without the use of medication. CONCLUSION The two-stage approach to SADI-S appears technically simpler than a single compromised operation. However, this approach needs more patients to understand its limitations.
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Aguilar-Espinosa F, Montoya-Ramírez J, Gutiérrez Salinas J, Blas-Azotla R, Aguilar-Soto O, Becerra-Gutiérrez L. Conversion to Roux-en-Y gastric bypass surgery through a robotic-assisted hybrid technique after failed sleeve gastrectomy: Short-term results. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2020. [DOI: 10.1016/j.rgmxen.2019.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Aguilar-Espinosa F, Montoya-Ramírez J, Gutiérrez Salinas J, Blas-Azotla R, Aguilar-Soto O, Becerra-Gutiérrez L. Conversión por técnica híbrida robótica a bypass gástrico en Y de Roux posterior a falla de manga gástrica: resultados a corto plazo. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020; 85:160-172. [DOI: 10.1016/j.rgmx.2019.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 04/29/2019] [Accepted: 04/30/2019] [Indexed: 01/04/2023]
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Chiappetta S, Stier C, Scheffel O, Squillante S, Weiner RA. Mini/One Anastomosis Gastric Bypass Versus Roux-en-Y Gastric Bypass as a Second Step Procedure After Sleeve Gastrectomy-a Retrospective Cohort Study. Obes Surg 2020; 29:819-827. [PMID: 30542828 DOI: 10.1007/s11695-018-03629-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Whether one anastomosis gastric bypass (OAGB) or Roux-en-Y gastric bypass (RYGB) is a better revisional bariatric surgery (RBS) after sleeve gastrectomy (SG) is still under debate. The aim is to compare short-term outcomes of RYGB and OAGB as a RBS after SG, pertaining to their effects on weight loss, resolution of comorbidities, and complications. METHODS We performed a single-center analysis of 55 patients (n = 34 OAGB, n = 21 RYGB). Indications for revisional surgery included weight regain/loss failure (67%) and intractable gastroesophageal reflux disease (33%). Data were collected up to 1-year follow-up (FU) and included time of revisional surgery, operation time, weight, body mass index, excess weight loss, and total weight loss (TWL), both in percent, complications and resolution of comorbidities. RESULTS Operation time was 79 ± 36 (OAGB-MGB) and 98 ± 24 min (RYGB) (p = 0.03). In the first 30 postoperative days, three patients in the RYGB group, and no patient in the OAGB group, had postoperative complications. FU was 100%. Minor complication rates at 12 months were 33.3% (RYGB) and 35.3% (OAGB). At 12 months, mean % TWL was 10.3 ± 7.6% (RYGB) and 15.8 ± 7.8% (OAGB) (p = 0.0132). CONCLUSIONS OAGB after failed SG was found to be a quicker procedure with less perioperative complications. At 1-year FU, no significant differences were seen between RYGB and OAGB regarding readmission and minor complications. Still long-term FU including the risk of malnutrition is needed to have a complete evaluation of OAGB as a RBS for the future.
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Affiliation(s)
- Sonja Chiappetta
- Department of Obesity and Metabolic Surgery, Sana Klinikum Offenbach, 63069, Offenbach am Main, Germany.
| | - Christine Stier
- Adipositaszentrum, University Hospital of Würzburg, Würzburg, Germany
| | - Oliver Scheffel
- Department of Obesity and Metabolic Surgery, Sana Klinikum Offenbach, 63069, Offenbach am Main, Germany
| | | | - Rudolf A Weiner
- Department of Obesity and Metabolic Surgery, Sana Klinikum Offenbach, 63069, Offenbach am Main, Germany
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Axer S, Szabo E, Agerskov S, Näslund I. Predictive factors of complications in revisional gastric bypass surgery: results from the Scandinavian Obesity Surgery Registry. Surg Obes Relat Dis 2019; 15:2094-2100. [DOI: 10.1016/j.soard.2019.09.071] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 09/02/2019] [Accepted: 09/16/2019] [Indexed: 11/25/2022]
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Revisional But Not Conversional Gastric Bypass Surgery Increases the Risk of Leaks: Review of 176 Redo out of 932 Consecutive Cases. Obes Surg 2019; 28:2903-2911. [PMID: 29804282 DOI: 10.1007/s11695-018-3311-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Nowadays, surgeons are dealing more and more with patients experiencing failure of a previous bariatric procedure after the worldwide exponential increase of bariatric surgery. Only a few and contradictory studies investigated both outcomes and complications risk factors in this subset population of bariatric patients. We aimed to study a homogeneous population of patients undergoing redo bariatric surgery (REDO-BS) resulting in bypass anatomy to evaluate early postoperative outcomes and identify risk factors of postoperative complications and mortality. MATERIAL AND METHODS In this study, we compared the outcomes of patients undergoing REDO-BS from another former bariatric procedure into Roux-en-Y gastric bypass (RYGP) to those undergoing primary RYGP. Data were extracted from a prospectively maintained database. RESULTS One hundred thirty-eight conversional bariatric surgery (CBS) cases resulting in RYGP anatomy and 38 RBS cases of pouch resizing (PR) were compared with 756 primary RYGP. There were no statistical significant difference in outcomes between the primary and CBS groups but patients undergoing PR had a significant higher risk of developing a leak than others. CBS complication risk factors were age (OR = 1.05; p = 0.04), operative time, and T2DM (OR = 4.11; p = 0.03). CONCLUSIONS CBS is safe and leads to similar early postoperative outcomes as primary RYGP whereas the indication for revisional surgery such as PR should be carefully evaluated as it is associated with an increased risk of leak.
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Esophagitis After Bariatric Surgery: Large Cross-sectional Assessment of an Endoscopic Database. Obes Surg 2019; 30:161-168. [DOI: 10.1007/s11695-019-04164-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass for complications: outcomes from a tertiary referral center in the Middle East. Surg Obes Relat Dis 2019; 15:1690-1695. [PMID: 31611183 DOI: 10.1016/j.soard.2019.07.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 06/26/2019] [Accepted: 07/29/2019] [Indexed: 01/17/2023]
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Antonopulos C, Rebibo L, Calabrese D, Ribeiro-Parenti L, Arapis K, Dhahri A, Coupaye M, Hansel B, Marmuse JP, Regimbeau JM, Msika S. Comparison of Repeat Sleeve Gastrectomy and Roux-en-Y Gastric Bypass in Case of Weight Loss Failure After Sleeve Gastrectomy. Obes Surg 2019; 29:3919-3927. [PMID: 31388964 DOI: 10.1007/s11695-019-04123-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Few series are available on the results of repeat sleeve gastrectomy (re-SG) and Roux-en-Y gastric bypass (RYGB) performed to manage the failure of primary sleeve gastrectomy (SG). The objective of this study was to compare the short- and medium-term outcomes of re-SG and RYGB after SG. MATERIAL & METHODS Between January 2010 and December 2017, patients undergoing re-SG (n = 61) and RYGB (n = 83) for failure of primary SG were included in this study. Revisional surgery was proposed for patients with insufficient excess weight loss (EWL ≤ 50%) or weight regain. The primary endpoint was the comparison of weight loss in the re-SG group and the RYGB group at the 1-year follow-up. The secondary endpoints were overall mortality and morbidity, specific morbidity, length of stay, weight loss, and correction of comorbidities. RESULTS The mean interval between SG and re-SG was 41.5 vs. 43.2 months between SG and RYGB (p = 0.32). The mean operative time was 103 min (re-SG group) vs. 129.4 min (RYGB group). One death (1.7%; re-SG group) and 25 complications (17.4%; 9 in the re-SG group, 16 in the RYGB group) were observed. At the 1 year, mean body mass index was 31.6 in the re-SG group and 32.5 in the RYGB group (p = 0.61) and excess weight loss was 69.5 vs. 61.2, respectively (p = 0.05). CONCLUSION Re-SG and RYGB as revisional surgery for SG are feasible with acceptable outcomes and similar results on weight loss on the first postoperative year.
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Affiliation(s)
- Christos Antonopulos
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, F-75018, Paris, France.,Department of Medical and Oral Sciences and Biotechnologies, "G.d'Annunzio" University, Via dei Vestini 31, 66100, Chieti, Italy
| | - Lionel Rebibo
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, F-75018, Paris, France.,SSPC (Simplification des Soins des Patients Complexes) - Clinical Research Unit, University of Picardie Jules Verne, 80054, Amiens Cedex 01, France.,Department of Digestive Surgery, Amiens University Medical Center, Avenue René Laennec, F-80054, Amiens Cedex 01, France
| | - Daniela Calabrese
- Department of Digestive and General Surgery, Louis Mourier University Hospital, 178 rue des Renouillers, F-92700, Colombes, France
| | - Lara Ribeiro-Parenti
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, F-75018, Paris, France
| | - Konstantinos Arapis
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, F-75018, Paris, France
| | - Abdennaceur Dhahri
- Department of Digestive Surgery, Amiens University Medical Center, Avenue René Laennec, F-80054, Amiens Cedex 01, France
| | - Muriel Coupaye
- Explorations Fonctionnelles Department, Louis Mourier Hospital, 178 rue des Renouillers, F-92700, Colombes, France
| | - Boris Hansel
- Department of Diabetes and Nutrition, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, F-75018, Paris, France
| | - Jean-Pierre Marmuse
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, F-75018, Paris, France
| | - Jean-Marc Regimbeau
- SSPC (Simplification des Soins des Patients Complexes) - Clinical Research Unit, University of Picardie Jules Verne, 80054, Amiens Cedex 01, France.,Department of Digestive Surgery, Amiens University Medical Center, Avenue René Laennec, F-80054, Amiens Cedex 01, France
| | - Simon Msika
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, F-75018, Paris, France. .,Department of Digestive and General Surgery, Louis Mourier University Hospital, 178 rue des Renouillers, F-92700, Colombes, France.
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Guan B, Chong TH, Peng J, Chen Y, Wang C, Yang J. Mid-long-term Revisional Surgery After Sleeve Gastrectomy: a Systematic Review and Meta-analysis. Obes Surg 2019; 29:1965-1975. [PMID: 30903425 DOI: 10.1007/s11695-019-03842-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This study aimed to make a meta-analysis regarding mid-long-term outcomes (≥ 3-year follow-up) after sleeve gastrectomy (SG), focusing on incidence, reasons, and results of revisional surgery. PubMed, EMBASE, and CENTRAL were searched and 32 studies were included. The overall revision rate was 10.4%, but for patients with ≥ 10-year follow-up, the rate was 22.6%. European studies had a higher revision rate (14.4%) than other studies. The most common reason for revision was failure in weight loss, and the most frequent revisional procedure was gastric bypass. Revisional surgery was favorable for weight reduction and comorbidity resolution. In conclusion, revision rate is not rare after SG, especially when looking at long-term follow-up. Bariatric surgeons and patients need to fully understand and deal with the need for revision after SG.
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Affiliation(s)
- Bingsheng Guan
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Jinan University, Guangzhou, 510630, China
| | - Tsz Hong Chong
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Jinan University, Guangzhou, 510630, China
| | - Juzheng Peng
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Jinan University, Guangzhou, 510630, China
| | - Yanya Chen
- Department of Nursing Science, School of Nursing, Jinan University, Guangzhou, 510632, China
| | - Cunchuan Wang
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Jinan University, Guangzhou, 510630, China
| | - Jingge Yang
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Jinan University, Guangzhou, 510630, China.
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Elshaer M, Hamaoui K, Rezai P, Ahmed K, Mothojakan N, Al-Taan O. Secondary Bariatric Procedures in a High-Volume Centre: Prevalence, Indications and Outcomes. Obes Surg 2019; 29:2255-2262. [DOI: 10.1007/s11695-019-03838-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Dijkhorst PJ, Boerboom AB, Janssen IMC, Swank DJ, Wiezer RMJ, Hazebroek EJ, Berends FJ, Aarts EO. Failed Sleeve Gastrectomy: Single Anastomosis Duodenoileal Bypass or Roux-en-Y Gastric Bypass? A Multicenter Cohort Study. Obes Surg 2018; 28:3834-3842. [PMID: 30066245 PMCID: PMC6223754 DOI: 10.1007/s11695-018-3429-z] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Sleeve gastrectomy (SG) has become the most performed bariatric procedure to induce weight loss worldwide. Unfortunately, a significant portion of patients show insufficient weight loss or weight regain after a few years. OBJECTIVE To investigate the effectiveness of the single anastomosis duodenoileal (SADI) bypass versus the Roux-en-Y gastric bypass (RYGB) on health outcomes in morbid obese patients who had undergone SG previously, with up to 2 years of follow-up. METHODS From 2007 to 2017, 140 patients received revisional laparoscopic surgery after SG in four specialized Dutch bariatric hospitals. Data was analyzed retrospectively and included comparisons for indication of surgery, vitamin/mineral deficiencies, and complications; divided into short-, medium-term. To compare weight loss, linear regression and linear mixed models were used. RESULTS Conversion of a SG to SADI was performed in 66 patients and to RYGB in 74 patients. For patients in which additional weight loss was the main indication for surgery, SADI achieved 8.7%, 12.4%, and 19.4% more total body weight loss at 6, 12, and 24 months compared to RYGB (all p < .001). When a RYGB was indicated in case of gastroesophageal reflux or dysphagia, it greatly reduced complaints almost directly after surgery. Furthermore, a similar amount of complications and nutritional deficiencies was observed for both groups. There was no intra- or post-operative mortality. CONCLUSION Conversion into a SADI resulted in significantly more weight loss while complications rates and nutritional deficiencies were similar and may therefore be considered the recommended operation for patients in which only additional weight loss is required.
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Affiliation(s)
- Phillip J. Dijkhorst
- Dutch Obesity Clinic, Huis ter Heide, Netherlands
- Department of Surgery, Rijnstate Hospital/Vitalys Clinics, Arnhem, Netherlands
| | - Abel B. Boerboom
- Department of Surgery, Rijnstate Hospital/Vitalys Clinics, Arnhem, Netherlands
| | | | - Dingeman J. Swank
- Department of Surgery, NOK-West/HMC and Groene Hart, The Hague and Gouda, Netherlands
| | - René M. J. Wiezer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Eric J. Hazebroek
- Department of Surgery, Rijnstate Hospital/Vitalys Clinics, Arnhem, Netherlands
| | - Frits J. Berends
- Department of Surgery, Rijnstate Hospital/Vitalys Clinics, Arnhem, Netherlands
| | - Edo O. Aarts
- Department of Surgery, Rijnstate Hospital/Vitalys Clinics, Arnhem, Netherlands
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