Defining Global Benchmarks in Elective Secondary Bariatric Surgery Comprising Conversional, Revisional, and Reversal Procedures.

OBJECTIVE: To define "best possible" outcomes for secondary bariatric surgery (BS). BACKGROUND: Management of poor response and of long-term complications after BS is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. METHODS: Out of 44,884 BS performed in 18 high-volume centers from 4 continents between 06/2013-05/2019, 5,349 (12%) secondary BS cases were identified. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of centers. Benchmark cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, thromboembolic events, BMI> 50 kg/m2 or age> 65 years. RESULTS: The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8 ±â€Š10 years, 8.4 ±â€Š5.3 years after primary BS, with a BMI 35.2 ±â€Š7 kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.6% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.37) and after conversional/reversal or revisional procedures with gastrointestinal suture/stapling (OR 1.84). Benchmark cutoffs for conversional BS were ≤4.5% re-intervention, ≤8.3% re-operation 90-days postoperatively. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation. CONCLUSION: Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.

The first consensus statement on revisional bariatric surgery using a modified Delphi approach.

BACKGROUND: Revisional bariatric surgery (RBS) constitutes a possible solution for patients who experience an inadequate response following bariatric surgery or significant weight regain following an initial satisfactory response. This paper reports results from the first modified Delphi consensus-building exercise on RBS. METHODS: We created a committee of 22 recognised opinion-makers with a special interest in RBS. The committee invited 70 RBS experts from 27 countries to vote on 39 statements concerning RBS. An agreement amongst ≥ 70.0% experts was regarded as a consensus. RESULTS: Seventy experts from twenty-seven countries took part. There was a consensus that the decision for RBS should be individualised (100.0%) and multi-disciplinary (92.8%). Experts recommended a preoperative nutritional (95.7%) and psychological evaluation (85.7%), endoscopy (97.1%), and a contrast series (94.3%). Experts agreed that Roux-Y gastric bypass (RYGB) (94.3%), One anastomosis gastric bypass (OAGB) (82.8%), and single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) (71.4%) were acceptable RBS options after gastric banding (84.3%). OAGB (84.3%), bilio-pancreatic diversion/duodenal switch (BPD/DS) (81.4%), and SADI-S (88.5%) were agreed as consensus RBS options after sleeve gastrectomy. lengthening of bilio-pancreatic limb was the only consensus RBS option after RYGB (94.3%) and OAGB (72.8%). CONCLUSION: Experts achieved consensus on a number of aspects of RBS. Though expert opinion can only be regarded as low-quality evidence, the findings of this exercise should help improve the outcomes of RBS while we develop robust evidence to inform future practice.

Hypermetabolic lesion in the prevascular mediastinum - always a thymoma/lymphoma?

Cholesterol granuloma is a foreign-body giant cell reaction that can occur in response to the presence of cholesterol crystals. They are usually found in the middle ear, paranasal sinuses or mastoid process due to chronic inflammation. Presentation in the prevascular mediastinum is a rare finding. We describe a case of a cholesterol granuloma located in the prevascular mediastinum in a symptomatic 57-year-old male patient.

Surgical treatment of therapy-resistant reflux after Roux-en-Y gastric bypass. A case series of the modified Nissen fundoplication.

Introduction: Patients with intractable reflux after RYGB have limited treatment options. Here a modified Nissen fundoplication (MNF) as described by N. Kawahara might be the answer.Methods: In this retrospective case study we identified six patients with therapy-resistant GERD after RYGB. All six were treated with a MNF, using the remnant stomach to construct the fundoplication. Short term follow-up 1 month and 6-12 months postoperatively was conducted to inquire about GERD symptoms.Results: Six patients underwent a MNF. Three out of six patients had had a gastric band in their medical history. Upper GI barium swallow test revealed herniation of the gastric pouch in 4/6 patients. After surgery all patients were symptom free and 4/6 completely stopped PPI treatment.Discussion: Mechanisms of new onset or deteriorating GERD after RYGB are herniation of gastric pouch and destruction of the lower esophageal sphincter after banding. Both problems are tackled when constructing a MNF.Conclusion: Complete symptom relief was seen 1 month after MNF. The procedure seems safe, feasible and effective. The study is limited by small sample size and short follow-up yet shows clear improvement of symptoms. Larger trials are needed to establish validity of the MNF.

Defining Global Benchmarks in Bariatric Surgery: A Retrospective Multicenter Analysis of Minimally Invasive Roux-en-Y Gastric Bypass and Sleeve Gastrectomy.

OBJECTIVE: To define "best possible" outcomes for bariatric surgery (BS)(Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]). BACKGROUND: Reference values for optimal surgical outcomes in well-defined low-risk bariatric patients have not been established so far. Consequently, outcome comparison across centers and over time is impeded by heterogeneity in case-mix. METHODS: Out of 39,424 elective BS performed in 19 high-volume academic centers from 3 continents between June 2012 and May 2017, we identified 4120 RYGB and 1457 SG low-risk cases defined by absence of previous abdominal surgery, concomitant procedures, diabetes mellitus, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, anticoagulation, BMI>50 kg/m and age>65 years. We chose clinically relevant endpoints covering the intra- and postoperative course. Complications were graded by severity using the comprehensive complication index. Benchmark values were defined as the 75th percentile of the participating centers' median values for respective quality indicators. RESULTS: Patients were mainly females (78%), aged 38±11 years, with a baseline BMI 40.8 ±â€Š5.8 kg/m. Over 90 days, 7.2% of RYGB and 6.2% of SG patients presented at least 1 complication and no patients died (mortality in nonbenchmark cases: 0.06%). The most frequent reasons for readmission after 90-days following both procedures were symptomatic cholelithiasis and abdominal pain of unknown origin. Benchmark values for both RYGB and SG at 90-days postoperatively were 5.5% Clavien-Dindo grade ≥IIIa complication rate, 5.5% readmission rate, and comprehensive complication index ≤33.73 in the subgroup of patients presenting at least 1 grade ≥II complication. CONCLUSION: Benchmark cutoffs targeting perioperative outcomes in BS offer a new tool in surgical quality-metrics and may be implemented in quality-improvement cycle.ClinicalTrials.gov Identifier NCT03440138.

AURORA: bariatric surgery registration in women of reproductive age - a multicenter prospective cohort study.

BACKGROUND: The expansion of the obesity epidemic is accompanied with an increase in bariatric procedures, in particular in women of reproductive age. The weight loss induced by the surgery is believed to reverse the negative impact of overweight and obesity on female reproduction, however, research is limited to in particular retrospective cohort studies and a growing number of small case-series and case-(control) studies. METHODS/DESIGN: AURORA is a multicenter prospective cohort study. The main objective is to collect long-term data on reproductive outcomes before and after bariatric surgery and in a subsequent pregnancy. Women aged 18-45 years are invited to participate at 4 possible inclusion moments: 1) before surgery, 2) after surgery, 3) before 15 weeks of pregnancy and 4) in the immediate postpartum period (day 3-4). Depending on the time of inclusion, data are collected before surgery (T1), 3 weeks and 3, 6, 12 or x months after surgery (T2-T5) and during the first, second and third trimester of pregnancy (T6-T8), at delivery (T9) and 6 weeks and 6 months after delivery (T10-T11). Online questionnaires are send on the different measuring moments. Data are collected on contraception, menstrual cycle, sexuality, intention of becoming pregnant, diet, physical activity, lifestyle, psycho-social characteristics and dietary supplement intake. Fasting blood samples determine levels of vitamin A, D, E, K, B-1, B-12 and folate, albumin, total protein, coagulation parameters, magnesium, calcium, zinc and glucose. Participants are weighted every measuring moment. Fetal ultrasounds and pregnancy course and complications are reported every trimester of pregnancy. Breastfeeding is recorded and breast milk composition in the postpartum period is studied. DISCUSSION: AURORA is a multicenter prospective cohort study extensively monitoring women before undergoing bariatric surgery until a subsequent pregnancy and postpartum period. TRIAL REGISTRATION: Retrospectively registered (July 2015 - NCT02515214 ).

A one-step conversion from gastric banding to laparoscopic Roux-en-Y gastric bypass is as safe as a two-step conversion: A comparative analysis of 885 patients.

AIMS: To achieve additional weight loss or to resolve band-related problems, a laparoscopic adjustable gastric banding (LAGB) can be converted to a laparoscopic Roux-en-Y gastric bypass (RYGB). There is limited data on the feasibility and safety of routinely performing a single-step conversion. We assessed the efficacy of this revisional approach in a large cohort of patients operated in a high-volume bariatric institution. METHODS: Between October 2004 and December 2015, a total of 885 patients who underwent LAGB removal with RYGB were identified from a prospectively collected database. In all cases, a single-stage conversion procedure was planned. The feasibility of this approach and peri-operative outcomes of these patients were evaluated and analyzed. RESULTS: A single-step approach was successfully achieved in 738 (83.4%) of the 885 patients. During the study period, there was a significant increase in performing the conversion from LAGB to RYGB single-staged. No mortality or anastomotic leakage was observed in both groups. Only 45 patients (5.1%) had a 30-d complication: most commonly hemorrhage (N = 20/45), with no significant difference between the groups. CONCLUSION: Converting a LAGB to RYGB can be performed with a very low morbidity and zero-mortality in a high-volume revisional bariatric center. With increasing experience and full standardization of the conversion, the vast majority of operations can be performed as a single-stage procedure. Only a migrated band remains a formal contraindication for a one-step approach.

Laparoscopic Roux-en-Y gastric bypass in the elderly: feasibility, short-term safety, and impact on comorbidity and weight in 250 cases.

INTRODUCTION: In the elderly obese population, frequently suffering from multiple comorbidities, laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered a high-risk procedure. The aim of this study was to evaluate short-term safety (30-day hospital morbidity and mortality) of this procedure and its impact on weight and associated comorbidities in the medium term (type-two diabetes, hypertension, sleep apnea, hypercholesterolemia, and joint pain). METHODS: This study represents a retrospective analysis of all our Belgian patients older than 60 years of age who underwent a LRYGB between October 2004 and October 2012. Patient files were reviewed and patients were contacted by formal consultation or by phone for an update of their clinical status. Demographics, operative details, postoperative course, and the evolution of weight and associated comorbidities were registered. RESULTS: A total of 280 patients were included. A complete follow-up was available for 250 patients (89 %), of whom 161 were female and 89 male. Mean age, BMI, and hospital stay were 64.1 years (60-78 years), 41.9 kg/m(2) (27.4-68 kg/m(2)), and 4.3 days (2-19 days), respectively. There was no in-hospital mortality, 27 (10.8 %) patients suffered from early postoperative complications and 5 (2 %) patients needed to be readmitted. After a mean follow-up of 31.5 months, the mean excess weight loss was 59.3 % (range 21.9-120.1 %). Resolution or improvement of diabetes, hypertension, sleep apnea, hypercholesterolemia, and joint pain was seen in 94.6, 77.6, 88.0, 77.1 and 57.6 % respectively. CONCLUSION: LRYGB has an acceptable complication rate in the elderly. Since all obesity-related comorbidities improved during follow-up, there is a plea not to exclude this subgroup of patients from the well-known benefits of gastric bypass surgery.

Nissen Sleeve as a Redo Surgery Post Gastric Banding for Non-responders to Weight Loss and Therapy-Resistant Reflux.

Roux-en-Y gastric bypass (LRYGB) would be the procedure of choice for non-responders of weight loss and patients with reflux symptoms (GERD). However, not every patient is a candidate for RYGB, and sometimes, the patient can insist only on alternatives other than malabsorption procedures, as was the case with our patient. We report a case with symptomatic GERD who underwent a successful Nissen sleeve gastrectomy after band removal. To our knowledge, this is the first case using Nissen sleeve as a redo surgery after a previous bariatric procedure.

The Management of Biliary Disease in Patients with Severe Obesity Undergoing Metabolic and Bariatric Surgery-An International Expert Survey.

OBJECTIVE: This study aimed to survey international experts in metabolic and bariatric surgery (MBS) to improve and consolidate the management of biliary disease in patients with severe obesity undergoing MBS. BACKGROUND: Obesity and rapid weight loss after MBS are risk factors for the development of gallstones. Complications, such as cholecystitis, acute cholangitis, and biliary pancreatitis, are potentially life-threatening, and no guidelines for the proper management of gallstone disease exist. METHODS: An international scientific team designed an online confidential questionnaire with 26 multiple-choice questions. The survey was answered by 86 invited experts (from 38 different countries), who participated from August 1, 2023, to September 9, 2023. RESULTS: Two-thirds of experts (67.4%) perform concomitant cholecystectomy in symptomatic gallstones during MBS. Half of experts (50%) would wait 6-12 weeks between both surgeries with an interval approach. Approximately 57% of the experts prescribe ursodeoxycholic acid (UDCA) prophylactically after MBS, and most recommend a 6-month course. More than the half of the experts (59.3%/53.5%) preferred laparoscopic assisted transgastric ERCP as the approach for treating CBD stones in patients who previously had RYGB/OAGB. CONCLUSION: Concomitant cholecystectomy is preferred by the experts, although evidence in the literature reports an increased complication rate. Prophylactic UDCA should be recommended to every MBS patient, even though the current survey demonstrated that not all experts are recommending it. The preferred approach for treating common bile duct stones is a laparoscopic assisted transgastric ERCP after gastric bypass. The conflicting responses will need more scientific work and clarity in the future.

Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus.

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

30-day morbidity and mortality of revisional bariatric surgery - An international multi-centre collaborative (BROAD) study.

INTRODUCTION: Revisional bariatric surgery (RBS) for insufficient weight loss/weight regain or metabolic relapse is increasing worldwide. There is currently no large multinational, prospective data on 30-day morbidity and mortality of RBS. In this study, we aimed to evaluate the 30-day morbidity and mortality of RBS at participating centres. METHODS: An international steering group was formed to oversee the study. The steering group members invited bariatric surgeons worldwide to participate in this study. Ethical approval was obtained at the lead centre. Data were collected prospectively on all consecutive RBS patients operated between 15th May 2021 to 31st December 2021. Revisions for complications were excluded. RESULTS: A total of 65 global centres submitted data on 750 patients. Sleeve gastrectomy (n = 369, 49.2 %) was the most common primary surgery for which revision was performed. Revisional procedures performed included Roux-en-Y gastric bypass (RYGB) in 41.1 % (n = 308) patients, One anastomosis gastric bypass (OAGB) in 19.3 % (n = 145), Sleeve Gastrectomy (SG) in 16.7 % (n = 125) and other procedures in 22.9 % (n = 172) patients. Indications for revision included weight regain in 615(81.8 %) patients, inadequate weight loss in 127(16.9 %), inadequate diabetes control in 47(6.3 %) and diabetes relapse in 27(3.6 %). 30-day complications were seen in 80(10.7 %) patients. Forty-nine (6.5 %) complications were Clavien Dindo grade 3 or higher. Two patients (0.3 %) died within 30 days of RBS. CONCLUSION: RBS for insufficient weight loss/weight regain or metabolic relapse is associated with 10.7 % morbidity and 0.3 % mortality. Sleeve gastrectomy is the most common primary procedure to undergo revisional bariatric surgery, while Roux-en-Y gastric bypass is the most commonly performed revision.

Revision/Conversion Surgeries After One Anastomosis Gastric Bypass-An Experts' Modified Delphi Consensus.

PURPOSE: There is a lack of evidence for treatment of some conditions including complication management, suboptimal initial weight loss, recurrent weight gain, or worsening of a significant obesity complication after one anastomosis gastric bypass (OAGB). This study was designed to respond to the existing lack of agreement and to provide a valuable resource for clinicians by employing an expert-modified Delphi consensus method. METHODS: Forty-eight recognized bariatric surgeons from 28 countries participated in the modified Delphi consensus to vote on 64 statements in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was regarded to indicate a consensus. RESULTS: A consensus was achieved for 46 statements. For recurrent weight gain or worsening of a significant obesity complication after OAGB, more than 85% of experts reached a consensus that elongation of the biliopancreatic limb (BPL) is an acceptable option and the total bowel length measurement is mandatory during BPL elongation to preserve at least 300-400 cm of common channel limb length to avoid nutritional deficiencies. Also, more than 85% of experts reached a consensus on conversion to Roux-en-Y gastric bypass (RYGB) with or without pouch downsizing as an acceptable option for the treatment of persistent bile reflux after OAGB and recommend detecting and repairing any size of hiatal hernia during conversion to RYGB. CONCLUSION: While the experts reached a consensus on several aspects regarding revision/conversion surgeries after OAGB, there are still lingering areas of disagreement. This highlights the importance of conducting further studies in the future to address these unresolved issues.

Roux-en-Y Gastric Bypass as Conversion Procedure of Failed Gastric Banding: Short-Term Outcomes of 1295 Patients in One Single Center.

PURPOSE: Laparoscopic adjustable gastric band (LAGB) has high technical and weight loss failure rates. We evaluate here the 1-year morbidity, mortality, and weight loss of laparoscopic Roux-en-Y-gastric bypass (LRYGB) as a feasible conversion strategy. METHODS: Patients with a failed primary LAGB who underwent LRYGB from July 2004 to December 2019 were selected from an electronic database at our center. Patients had a conversion to LRYGB at the same time (one-stage approach) or with a minimum of 3 months in between (two-stage approach). Primary outcomes included 30-day morbidity and mortality. Secondary outcomes were body mass index (BMI), percent excess weight loss (%EWL), and percent excess BMI lost (%EBMIL) at 1 year postoperatively. RESULTS: A total of 1295 patients underwent a conversion from LAGB to LRYGB at our center: 1167 patients (90.1%) in one stage and 128 patients (9.9%) in two stages. There was no mortality. An early (30-day) postoperative complication occurred in 93 patients (7.2%), with no significant difference found between groups. Hemorrhage was the most common complication in 39 patients (3.0%), and the reoperation was required in 19 patients (1.4%). At 1 year postoperatively, the mean BMI was 28.0 kg/m2, the mean %EWL 72.8%, and the mean %EBMIL 87.0%. No statistically significant difference was found between the groups. CONCLUSION: Conversion to LRYGB can be considered as a safe and effective option with low complication rate and good weight loss outcomes at 1 year. One-stage conversion provides the same early outcome as two-step surgery with a competent surgeon.

Gastric pouch sero-myotomy for persistent dysphagia after roux-en-Y gastric bypass: Video report.

Laparoscopic Sleeve Gastrectomy (LSG) is one of the most common bariatric operations done worldwide [1]. About 6.6% of the LSG is being converted to laparoscopic roux-en-Y gastric bypass (LRYGB), most commonly due to inadequate weight loss (65%) and severe reflux (26%) [2]. The most common late complications after LRYGB are dumping, small bowel obstruction, internal hernia, weight regain, marginal ulcer, strictures of the gastro-jejunostomy [3] and rarely proximal stricture at the gastric pouch as our presented case. Treatment options for such a case may start with endoscopic dilatation and if not succeeded it may warrant surgical intervention as shortening of the pouch and redo of the gastrojejunostomy proximal to the stricture or even total gastrectomy and esophago-jejunal anastomosis. Sero-myotomy of the gastric pouch can be done as the same technique which can be used in sero-myotomy of sleeved stomach with stricture [4] and spare resection of the pouch. This report aims to present a new option of surgical management for proximal stricture of the gastric pouch after LRYGB which to our knowledge was never published in the literature.

Shortening and Plication of Entero-enterostomy for Intussusception in Roux-en-Y Gastric Bypass: Video Report.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered by a large percentage of bariatric surgeons' the operation of choice for obesity surgery as reported by Melvin (J Gastrointest Surg. 4:398-400, 2004). It is considered a generally safe procedure with a low percentage of complications. One of these complications is small bowel obstruction which has different etiologies. A rare cause of intestinal obstruction is intussusception at the entero-enterostomy as reported by Arapis et al. (Surg Obes Relat Dis. 1:23-33, 2019) and Sneineh et al. (OBES SURG 30:846-850, 2020). The accurate incidence of intussusception after LRYGB is unknown but Simper et al. (Surg Obes Relat Dis. 4:77-83, 2008) found a 0.15% incidence in their study. Diagnosis of intussusception requires a high index of suspicion because neither physical examination nor imaging is sensitive. CT scan might identify the problem, but a negative CT scan image does not rule out intussusception. Treatment of intussusception varies according to the clinical picture of the patient at the presentation. These variations may include conservative treatment up to resection of the entero-enterostomy and do a re-anastomosis as discussed by Daellenbach et al. (OBES SURG 21:253-263, 2011). The video aims to present an alternative option for surgical management of intussusception of the entero-enterostomy following LRYGB which to our knowledge was not published before.

Sometimes the Best Solution Is Transit Bipartition: Video Case Report.

The simplest definition of Santoro's operation is a sleeve gastrectomy with transit bipartition. Santoro et al. reported long-term data regarding sleeve gastrectomy with transit bipartition, which is a similar operation to duodenal switch but without complete exclusion of the duodenum to minimize nutritional complications and to allow endoscopic management of obstructive jaundice. Afterward, several studies proved the efficacy and safety of transit bipartition; the real benefit of this operation is the reduction of side effects and protein malnutrition compared with the bilio-pancreatic diversion with duodenal switch or Roux-en-Y gastric bypass. One of the well-known complications of sleeve gastrectomy is reflux which usually responds well to medical treatment, but in few cases, the reflux is refractory to conservative management and warrants surgical intervention as a conversion of the sleeve gastrectomy to other bariatric procedures. There are many theories concerning the increased incidence of gastro-esophageal reflux disease after sleeve gastrectomy which included reduction of lower esophageal sphincter pressure due to the division of ligaments and blunting of the angle of His, reduction in gastric compliance, increased sleeve pressure with an intact pylorus due to the use of Bougie < 40 Fr, decreased sleeve volume and distensibility, and dilated upper part of the final shape with a relative narrowing of the mid-stomach without complete obstruction. Our video report aims to present a unique surgical case and to show the surgical technique in this patient despite the complex surgical history.

Post-bariatric Abdominoplasty: Identification of Risk Factors for Complications.

PURPOSE: The aim was to evaluate the complication rate after abdominoplasty procedures performed in a high volume post-bariatric center and to identify predictors of complications. MATERIAL AND METHODS: A retrospective analysis was performed and included all abdominoplasty procedures performed between January 2011 and December 2019. Complications classified according to the Clavien-Dindo classification were documented and potential risk factors were statistically evaluated. RESULTS: A total of 898 patients were included. Overall complication rate was 29.8%. Type I complications (minor wound problems) occurred in 15.8% (n = 140). Type II complications requiring medical intervention occurred in 10% (n = 90). Five patients had deep venous thrombosis or pulmonary embolism; others received antibiotic treatment for wound infections. In total 42 type III complications occurred in 36 patients, with re-intervention for wound problems (n = 16), seroma (n = 16), umbilical necrosis (n = 4), and bleeding (n = 6). The weight of tissue resected (p < 0.001), the interval between bariatric and body contouring surgery (p < 0.05), preoperative BMI (p < 0.05), male gender (p < 0.05), diabetes mellitus type 2 (p = 0.05), and smoking (p < 0.05) were important predictors for developing complications. CONCLUSION: In this large retrospective post-bariatric abdominoplasty series, the overall complication rate is low compared to other published series as a consequence of our completely standardized approach and technique. Our analysis shows a significant linear correlation between the amount of skin tissue resected and postoperative complications. Moreover, the longer the interval between bariatric surgery and abdominoplasty, the higher the complication rate. High preoperative BMI, diabetes mellitus type 2, smoking, and male gender were identified as independent significant risk factors for complications.

Laparoscopic Adjustable Gastric Banding with the Adhesix® Bioring® for Weight Regain or Insufficient Weight Loss After a Roux-en-Y Gastric Bypass: Midterm Data from the Pronto Registry.

PURPOSE: Although Roux-en-Y gastric bypass (RYGB) is one of the most common bariatric procedures, insufficient weight loss is described to be as high as 20-35%. To treat weight regain/inadequate weight loss, laparoscopic adjustable gastric banding (LAGB) could be a feasible revisional strategy. MATERIALS AND METHODS: We report on a prospective study which included 35 patients who presented inadequate weight loss or significant weight regain after primary RYGB (percentage excess weight loss [%EWL] at revision < 50%). All patients underwent revisional LAGB with the placement of an Adhesix® Bioring® adjustable gastric band (Cousin Biotech, Wervicq-Sud, France). Patients' weight loss, complications, frequency of revisions and quality of life were evaluated. RESULTS: Follow-up data at 24 months are available for 80% of the included patients. The mean BMI before RYGB was 43.6 ± 5.4 kg/m2 and before revisional LAGB was 38.8 ± 4.3kg/m2. The %EWL before revisional surgery was 23.3 ± 24.8%. The average time between both procedures was 6.7 (mean) ± 3.6 (SD) years. Twenty-four months after revisional LAGB, the average BMI calculated from the weight at RYGB dropped to 32.0 ± 4.5 kg/m2, with an additional %EWL of 49.9 ± 30.3% resulting in a total %EWL of 60.7 ± 28%. The reoperation rate for complications related to LAGB was 21.2%. No band erosions occurred, but two bands needed to be removed during the study. CONCLUSION: Revisional LAGB may be considered a valid salvage procedure in patients with weight regain or inadequate weight loss after RYGB, though band- and port-related complications remain a notable concern.

Modified Nissen Fundoplication for Late Dumping Syndrome After Roux-en-Y Gastric Bypass.

INTRODUCTION: Postoperative dumping syndrome (DS) is a common complication after Roux-en-y gastric bypass (RYGB) for morbid obesity. DS is mostly treated conservatively through dietary or pharmacologic measures. In case of non-responding to or contraindication for conservative treatment, surgical intervention may be considered. Various procedures have been described, as there is currently no gold standard technique. We present a new approach by performing a modified Nissen fundoplication. CASE: A 34-year-old female consulted at our outpatient clinic. In her history, she had a laparoscopic RYGB 6 years earlier because of morbid obesity (BMI 37.6 kg/m2). Two years postoperatively, she developed a late DS, for which she was successfully treated with long-acting octreotide. Because of pregnancy wish, octreotide needed to be halted. A laparoscopic modified Nissen fundoplication was performed, creating a cuff around the oesophageal-gastric junction with the fundus of the remnant stomach. This slows down the passage of food through the gastric pouch. Postoperatively, the octreotide treatment was halted without any problems. At 6 months, the patient is still free of dumping complaints. DISCUSSION: Postoperative DS is a common complication after bariatric surgery. Dietary measures form the first treatment of DS, followed by pharmacologic treatment. Since octreotide is contraindicated in pregnancy, a surgical intervention was opted for. Our case is the first documented modified Nissen fundoplication to treat late postoperative DS after RYGB for morbid obesity. CONCLUSION: A laparoscopic modified Nissen fundoplication could be a promising surgical alternative in the treatment of late dumping syndrome after RYGB for morbid obesity.