Enhanced Recovery After Revisional Bariatric Surgery: a Retrospective Study of 321 Patients with Laparoscopic Conversion of Failed Gastric Banding or Failed Mason Gastroplasty to Roux-en-Y Gastric Bypass.

PURPOSE: With the rising incidence of failed bariatric procedures, the importance of revisional surgery has been increasing. These revisional procedures come with a higher risk of complications leading to longer hospital stays. We believe though that enhanced recovery after revisional bariatric surgery is possible and needs to be advocated. MATERIALS AND METHODS: We retrospectively analyzed our laparoscopic conversions of failed gastric banding and failed Mason gastroplasty to Roux-en-Y gastric bypass. A total of 321 patients was included in the study, from February 2010 until December 2019. The primary endpoints were length of stay (LoS), in-hospital complication rate, and early readmission rate (< 30 days). Logistic regression was used to investigate the impact of several independent variables on complication and readmission rates. RESULTS: Fifty-four patients were male and 267 female. The mean age was 44.2 years and mean BMI at the time of conversion was 37.9 kg/m2. We converted 273 failed adjustable gastric bandings (85,0%) and 48 failed Mason gastroplasties (15.0%). The main reason for conversion was the recurrence of obesity. A mean LoS of 2.10 days was calculated. We had an overall in-hospital complication rate of 3.73% and the overall early readmission rate was 3.43%. The odds ratio for LoS on early readmission is 1.52 (p=0.0079; CI 95% [1.12-2.07]). CONCLUSION: The above data imply that the implementation of advanced ERAS principles for revisional surgery in our center is safe and does not lead to a higher risk of early readmission.

Endoscopic Gastric Plication for Morbid Obesity: a Systematic Review and Meta-analysis of Published Data over Time.

Endoscopic gastric plication or gastroplasty for morbid obesity is gaining worldwide recognition. Data concerning safety and efficacy are rather scarce. Furthermore, clear guidelines are yet to be established. The objective of this meta-analysis is to update the data and investigate the efficacy and safety of the procedure. An online comprehensive search using Cochrane, Google Scholar, PubMed, Web of Science, and Embase on endoscopic gastric plication was completed. The primary outcome was defined as weight loss at 6 months or more after the procedure. Secondary outcomes were defined as the occurrence of adverse events or complications including insufficient weight loss or regain. I2 statistic was used to define the heterogeneity across studies. Twenty-two cohort studies on 7 different devices met the inclusion criteria, with a total of 2475 patients. The mean baseline BMI was 37.8 ± 4.1 kg/m2 (median 37.9; range 28.0-60.2). Either a transoral endoluminal stapling or (suction based) (full-thickness) stitching and/or anchor device was used to obtain gastric volume reduction and/or alter gastric outlet. The mean follow-up was 13 months (median 12; range 6-24) for the specified outcomes of each study. Two active, FDA-approved devices were taken into account for meta-analysis: Endoscopic sleeve gastroplasty (ESG) and the primary obesity surgery endolumenal (POSE™). Average pooled %EWL at 6 months (p = 0.02) and 12 months (p = 0.04) in favor of ESG was 57.9 ± 3.8% (50.5-65.5, I2 = 0.0), 44.4 ± 2.1% (40.2-48.5, I2 = 0.0), and 68.3 ± 3.8% (60.9-75.7, I2 = 5.8), 44.9 ± 2.1% (40.9-49.0, I2 = N/A) for ESG and POSE respectively. Major adverse events without mortality were described in 25 patients (9 studies, p = 0.63). ESG and POSE are both safe and feasible procedures with good short-term weight loss. ESG seems to be superior in terms of weight loss at this point. Few major adverse events are reported and long-term results are awaited.

Heterogeneity in the Definition and Clinical Characteristics of Dumping Syndrome: a Review of the Literature.

BACKGROUND: No real consensus regarding the definition of dumping syndrome (DS) seems to exist and few subtyping is used in clinical practice. Knowledge is needed for correct design of trials and establishment of uniform treatment strategies. The aim of this study is to explore the distribution of clinical characteristics related to the subtypes of DS. METHODS: A comprehensive search was performed in Cochrane, Google Scholar, PubMed, and ResearchGate. Data were collected on the definition and diagnostics of DS used in each study. RESULTS: Twenty-seven clinical trials were included. Seventeen articles clearly provided a definition of DS and ten of these differentiated between early and late DS. Diagnose of DS was based on clinical symptoms (24 articles), hemodynamic parameters (e.g., tachycardia, hypotension; 9 articles), and biochemical analysis (e.g., blood sugar level; 12 articles). Questionnaires were used in 13 articles. A total of 67 different symptoms were correlated with dumping syndrome. Two symptoms were exclusively correlated with early and nine with late DS. Nine articles differentiated between early and late dumping based on timing since the last meal. Hypoglycemia was correlated with late DS in ten articles. CONCLUSIONS: This study reveals a vast heterogeneity in the definition and clinical characteristics of DS after RYGB. We feel that a standardized definition is required to provide a firm parameter in the evaluation and setup of clinical trials. A better understanding and description of the definition and diagnostic criteria of DS after RYGB is crucial to improve scientific reporting.

Laparoscopic Linear Stapled Running Enterotomy Closure in Roux-en-Y Gastric Bypass Using Absorbable Unidirectional Barbed Suture (Stratafix® 2/0).

BACKGROUND: Laparoscopic running enterotomy closure for linear stapled Roux-en-Y gastric bypass (RYGB) may be enhanced by using unidirectional barbed sutures (Stratafix™ 2/0, Ethicon) as it eliminates the need for knot tying and assistance from a third hand. OBJECTIVES: The objective of this paper is to present our technique using unidirectional barbed sutures (Stratafix™ 2/0, Ethicon). METHODS: After stapling the gastrojejunostomy, we start the closure of the residual enterotomy unidirectional from left to right (single, full-thickness layer) which is cut without a knot. For the jejunojejunostomy, the residual enterotomy is closed perpendicular from top to bottom in order to avoid iatrogenic stricture formation (single, full-thickness layer). No backstitches are performed. CONCLUSIONS: We feel strongly that this technique might enhance running enterotomy closure for linear stapled RYGB.

The Use of Unidirectional Knotless Barbed Suture for Enterotomy Closure in Roux-en-Y Gastric Bypass: a Randomized Comparative Study.

PURPOSE: In this study, we assessed feasibility, safety, and time efficiency of laparoscopic running enterotomy closure for linear stapled Roux-en-Y Gastric Bypass (RYGB) using unidirectional barbed sutures (Stratafix™ 2/0- Ethicon). MATERIALS AND METHODS: Two hundred patients undergoing laparoscopic RYGB were prospectively randomized regarding running enterotomy closure of the linear stapled gastrojejunal (GJA) and jejunojejunal anastomosis (JJA). Two groups were created: V-group (Vicryl® 2/0-Ethicon) and S-group (Stratafix™ 2/0-Ethicon). Time spent on closing the enterotomies was measured from first needle in until knot and cut (V-group) or last stitch and cut (S-group). If needed, a nonabsorbable "correction" ("c"; in order to close a small hiatus at the anastomosis) or hemostatic ("h") stitch was made (using a single Prolene® 2/0-Ethicon). RESULTS: Average total procedure time was similar (S-group 1:01:22, V-group 1:00:44, P = 0.340). Closure of the enterotomy (GJA) was significantly shorter in the S-group (07:41 min versus 08:13 min in the V-group, P = 0.005). Extra stitches (GJA) were performed in 33 patients (16.5%): 3 (h) and 20 (c) in the V-group and 1 (h) and 9 (c) in the S-group. Four patients in the V-group suffered from postoperative intraluminal bleeding (3 self-limiting, 1 underwent endoscopic clipping). In the S-group, 1 patient suffered from leakage at the vertical transected staple line of the stomach. CONCLUSIONS: The use of unidirectional barbed sutures for running enterotomy closure after linear stapled RYGB is feasible and safe. Significant time benefit was seen regarding the closure of the GJA. Fewer additional stitches were necessary and postoperative intraluminal bleeding was less encountered.

Linitis plastica of the bypassed stomach 7 years after Roux-en-Y gastric bypass: a case report.

Laparoscopic Roux-en-Y gastric bypass (RYGB) is currently the preferred surgical procedure to treat morbid obesity. It has proven its effects on excess weight loss and its positive effect on comorbidities. One of the main issues, however, is the post-operative evaluation of the bypassed gastric remnant. In literature, cancer of the excluded stomach after RYGB is rare. We describe the case of a 52-year-old woman with gastric linitis plastica in the bypassed stomach after Roux-en-Y gastric bypass, diagnosed by means of laparoscopy and Single-Balloon enteroscopy, and it is clinical importance. Linitis plastica of the excluded stomach after RYGB is a very rare entity. This case report shows the importance of long-term post-operative follow-up, and the importance of single-balloon enteroscopy for visualization of the bypassed stomach remnant, when other investigations remain without results. This case report is only the second report of a linitis plastica in the bypassed stomach after Roux-en-Y gastric bypass.

Roux-en-Y gastric bypass for obesity after Belsey-Mark IV for large hiatus hernia and intrathoracic stomach, in combination with gastroesophageal reflux disease.

BACKGROUND: Obesity is an increasing problem worldwide; patients who remain obese after non-surgical interventions are potential candidates for surgical intervention. Laparoscopic Roux-en-Y gastric bypass (RYGB) has proven its effects on excess weight loss and its positive effect on comorbidities and also, on reflux correction. CASE REPORT: Our patient, a 53-year-old male, with a BMI of 45 kg/m2 and type 2 diabetes, underwent a Belsey-Mark IV procedure in another center because of a large hiatus hernia and intrathoracic stomach, in combination with gastroesophageal reflux disease (GERD). He consulted at our center concerning his morbid obesity. After a positive preoperative evaluation a RYGB was performed with an uneventful postoperative course. CONCLUSION: RYGB is a safe and feasible procedure to perform after a Belsey-Mark IV procedure. To our knowledge, this is the first and only report of a RYGB after a Belsey-Mark IV procedure. There were no intra-operative complications and 18 months follow-up was unremarkable, with a 78.10% excess weight loss (EWL), at 86 kg, and no remaining symptoms of GERD. We also mention resolution of the patient's diabetes mellitus type 2 measured by the cessation of the glucophage, which is an added health benefit.

Conversion of Open Vertical Banded Gastroplasty to Roux-en-Y Gastric Bypass: a Single-Center, Single-Surgeon Experience with 6 Years of Follow-up.

BACKGROUND: The aim of this study is to assess feasibility, relief of complications and mid- and long-term weight loss results following the conversion of open vertical banded gastroplasty (VBG) to Roux-en-Y gastric bypass (RYGB). MATERIALS AND METHODS: Retrospective analysis of patients undergoing conversion of open VBG to RYGB (open and laparoscopic) between 1 April 2000 and 1 January 2015 was performed. (Post)operative complications were listed. Weight loss was assessed using excess weight (EW), percentage excess weight loss (%EWL) and body mass index (BMI) at 1-year intervals after surgery. Ideal weight was determined by recalculating individual lengths to a BMI of 25 kg/m(2). Application of polynomial regression models was used to quantify weight loss over time. RESULTS: Ninety patients were identified in the database. Mean time between bariatric interventions was 9.6 years. Reasons for conversion were insufficient weight loss (82.2%) and outlet obstruction (17.8%). Early complications were encountered in eight patients of which three were reoperated. Patients who underwent conversion for inadequate weight loss after VBG were retrospectively analyzed regarding weight loss: 78.0% EWL after 1 year, 71.4% after 2 years, 62.1% after 3 years, 64.1% after 4 years, 70.2% after 5 years, and 68.9% after 6 years. Outlet obstruction was relieved in 94%. Patient satisfaction was assessed by telephone: 86.4% would repeat the conversion. CONCLUSIONS: Conversion of open VBG to RYGB is feasible and safe and can be performed with an acceptable complication rate. It gives excellent weight loss results and relief of outlet obstruction.