Esophageal function and non-acid reflux evaluated by impedance-24 h-pH-metry, high-resolution manometry, and gastroscopy after one-anastomosis gastric bypass-outcomes of a prospective mid-term study.

BACKGROUND: One-Anastomosis Gastric Bypass (OAGB) is the third most common bariatric operation for patients with obesity worldwide. One concern about OAGB is the presence of acid and non-acid reflux in a mid- and long-term follow-up. The aim of this study was to objectively evaluate reflux and esophagus motility by comparing preoperative and postoperative mid-term outcomes. SETTING: Cross-sectional study; University-hospital based. METHODS: This study includes primary OAGB patients (preoperative gastroscopy, high-resolution manometry (HRM), and impedance-24 h-pH-metry) operated at Medical University of Vienna before 31st December 2017. After a mean follow-up of 5.1 ± 2.3 years, these examinations were repeated. In addition, history of weight, remission of associated medical problems (AMP), and quality of life (QOL) were evaluated. RESULTS: A total of 21 patients were included in this study and went through all examinations. Preoperative weight was 124.4 ± 17.3 kg with a BMI of 44.7 ± 5.6 kg/m2, total weight loss after 5.1 ± 2.3 years was 34.4 ± 8.3%. In addition, remission of AMP and QOL outcomes were very satisfactory in this study. In gastroscopy, anastomositis, esophagitis, Barrett´s esophagus, and bile in the pouch were found in: 38.1%, 28.3%, 9.5%, and 42.9%. Results of HRM of the lower esophageal sphincter pressure were 28.0 ± 15.6 mmHg, which are unchanged compared to preoperative values. Nevertheless, in the impedance-24 h-pH-metry, acid exposure time and DeMeester score decreased significantly to 1.2 ± 1.2% (p = 0.004) and 7.5 ± 8.9 (p = 0.017). Further, the total number of refluxes were equal to preoperative; however, the decreased acid refluxes were replaced by non-acid refluxes. CONCLUSION: This study has shown decreased rates of acid reflux and increased non-acid reflux after a mid-term outcome of primary OAGB patients. Gastroscopy showed signs of chronic irritation of the gastrojejunostomy, pouch, and distal esophagus, even in asymptomatic patients. Follow-up gastroscopies in OAGB patients after 5 years may be considered.

Endoluminal Vacuum Therapy as Effective Treatment for Patients with Postoperative Leakage After Metabolic Bariatric Surgery-A Single-Center Experience.

BACKGROUND: Metabolic bariatric surgery (MBS) is standardized and safe. Nevertheless, complications such as anastomotic leakage (AL) or staple-line leakage (SLL) can occur. In upper GI or colorectal surgery, endoluminal vacuum therapy (EVT) offers a therapeutic alternative to revisional surgery. Data on EVT in patients with leakage after MBS remain scarce. The aim of this study is to evaluate the efficacy of EVT and its potential as endoscopic alternative to revisional surgery. MATERIAL AND METHODS: All patients treated for AL or SLL with EVT after MBS between 01/2016 and 08/2023 at the Department for General Surgery, Medical University Vienna, were included in this retrospective, single-center study. Therapeutic value of EVT as management option for acute postoperative leakage after MBS in daily practice was evaluated. Statistical analyses were performed descriptively. RESULTS: Twenty-one patients were treated with EVT within the observational period of 7 years. In 11 cases (52.4%), the index surgery was a primary bariatric intervention; in 10 cases (47.6%), a secondary surgery after initial MBS was performed. Favored approach was a combination of revisional surgery and EVT (n = 18; 85.7%), intermediate self-expanding metal stent (SEMS) in 16 (76.2%) cases. EVT was changed six times (0-33) every 3-4 days. Mean EVT time was 25.1 days (3-97). No severe associated complications were detected and EVT showed an efficacy of 95.2%. CONCLUSION: This small case series supports the trend to establish EVT in daily clinical practice when revisional surgery after MBS is needed, thus preventing further reoperation and reducing associated morbidity and mortality in critically ill patients.

Outcome and complications of long-term self-expanding esophageal stenting.

Esophageal stenting with self-expanding plastic or covered metal stents is believed to be safe and effective. As data on the outcome of patients with long-term stenting are not available, this study was conducted to evaluate the safety and efficacy of long-term esophageal stenting. From 2002 to 2008, 70 patients with long-term esophageal stenting for various indications from a prospective database were included into further analysis. The median stent period was 297 (124-1980) days during a mean follow-up time of 55 ± 52.4 months. Overall complication rate was 30% with a primary success rate of 97.2%. The stent-related total reintervention rate was 17.1%. There were no correlations between stent characteristics and the risk of complication or migration. No stent-related death was observed. Our data provide evidence that long-period esophageal stenting is safe and effective for various indications.

Outcome of Sleeve Gastrectomy Converted to Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass.

PURPOSE: Sleeve gastrectomy (SG) is the commonest bariatric procedure worldwide but there is also a high conversion rate mainly due to weight regain and gastroesophageal reflux disease (GERD) reported in studies with long-term follow-up. The aim of this study is to highlight benefits and limitations of converting SG patients to Roux-en-Y gastric bypass (RYGB) and one-anastomosis gastric bypass (OAGB). SETTING: Retrospective cross-sectional-study, medical university clinic setting. METHODS: This study includes all patients converted from primary SG to RYGB or OAGB by 12/2018 at the Medical University of Vienna. Patients were examined using gastroscopy, esophageal manometry, 24-h pH-metry, and questionnaires. RESULTS: Fifty-eight patients were converted from SG to RYGB (n = 45) or OAGB (n = 13). Total weight loss of patients converted to RYGB and OAGB was 41.5% and 44.8%, respectively, at nadir. Six patients had Barrett's esophagus (BE) after SG. In four out of these six patients, a complete remission of BE after conversion to RYGB was observed; nevertheless, two patients after RYGB and one after OABG newly developed BE. Clinical GERD improved at a higher rate after RYGB than after OAGB. Both revisional procedures improved associated medical problems. CONCLUSION: Conversion to RYGB is probably the best option for patients with GERD after SG. OAGB has shown a low potential to cure patients from GERD symptoms after SG. In terms of additional weight loss and remission of associated medical problems, both procedures studied were equal. Surveillance gastroscopies every 5 years after SG revisions are recommended.

HER-2 status in primary oesophageal cancer, lymph nodes and distant metastases.

BACKGROUND: Some 10-15 per cent of patients with oesophageal cancer overexpress human epidermal growth factor receptor (HER) 2 at the primary tumour site, leading to the hope that specific targeted systemic therapy might favourably influence clinical and subclinical disease at locoregional and distant sites. This approach is based on primary tumour characteristics, without knowledge of expression patterns at metastatic sites. In oesophageal cancer, concordance between HER-2 status at the primary tumour and other sites is unknown. METHODS: The HER-2 status of primary tumours and corresponding metastatic sites (lymph node and distant) and local recurrence were evaluated in a series of patients with oesophageal cancer, using immunohistochemistry and dual colorimetric in situ hybridization. RESULTS: There were 97 adenocarcinomas (ACs) and 79 squamous cell carcinomas (SCCs). Some 14 per cent of primary ACs and 1 per cent of primary SCCs were staged as HER-2-positive. The HER-2 status was identical in the primary tumour and lymph node metastases in 95 per cent of ACs and 99 per cent of SCCs respectively (P = 0·375, sign test). Nineteen of 22 distant metastases from AC and all from SCC had identical HER-2 status to the primary tumour. In two of 22 patients with AC the primary tumour was classed as negative but distant metastases were HER-2-positive. CONCLUSION: With over 85 per cent concordance in HER-2 status between primary tumours and distant metastases in oesophageal cancer, routine HER-2 testing of metastases to confirm HER-2 positivity is not warranted. Assessment of HER-2 status at metastatic sites may be worthwhile in some patients with easily accessible metastases and negative HER-2 status at the primary tumour, or if adequate material cannot be obtained from the primary site.

Outcome of hepaticojejunostomy for biliary tract obstruction following liver transplantation.

BACKGROUND: Strictures and concrements are the most common biliary complications following liver transplantation. Endoscopic treatment might not lead to a definitive cure in all patients, especially in strictures involving the biliary bifurcation. The aim of this study was to determine the efficacy and the long-term outcome of hepaticojejunostomy (HJS) for post-transplant biliary tract obstruction. MATERIAL AND METHODS: Thirty-seven patients were retrospectively studied for resolving of cholestasis and the incidence of recurring biliary obstruction. RESULTS: Surgery was performed because of anastomotic strictures in 11, ischemic strictures at the donor common bile duct in seven, strictures involving the bile duct bifurcation in 10, hepatolithiasis without strictures in one and biliary cast formation diagnosed by endoscopic retrograde cholangiography or T-tube cholangiography in eight patients. Cholestasis instantly improved in 82% of the patients. After a long-term follow-up of median 33 months (range 3-149), 28 of the patients (76%) required no further intervention for recurring biliary obstruction following HJS. Anastomotic strictures were observed in six (16%), recurring biliary concrements in two patients (5%). CONCLUSION: HJS did prevent recurrent biliary obstruction in the majority of the patients. We therefore recommend early HJS for complicated post-transplant biliary tract obstruction not treatable by a limited number of endoscopic interventions.

Weight Loss and Resolution of Comorbidities After Sleeve Gastrectomy: A Review of Long-Term Results.

BACKGROUND AND AIMS:: Laparoscopic sleeve gastrectomy (SG) has massively increased in numbers over the last decade and is the most frequently performed bariatric procedure worldwide today. The aim of this review is to evaluate SG in terms of weight loss and resolution of comorbidities, based on data gained from the latest long-term studies available. MATERIAL AND METHODS:: This review includes the results of any long-term studies on SG available at this point as well as a selection of short- and mid-term studies. RESULTS:: There are only a handful of studies on sleeve gastrectomy with long-term follow-up available at this point. Conversion rates in these long-term studies amount to up to one-third of their cohorts; however, excess weight loss in patients maintaining their sleeve is over 50%. Results on the resolution of comorbidities vary among the studies available today. SUMMARY:: Sleeve gastrectomy is a valid bariatric method but one has to be aware of its limitations.

Inadequate weight loss vs secondary weight regain: laparoscopic conversion from gastric banding to Roux-en-Y gastric bypass.

BACKGROUND: Beside complications like band migration, pouch-enlargement, esophageal dilation, or port-site infections, laparoscopic adjustable gastric banding (LAGB) has shown poor long-term outcome in a growing number of patients, due to primary inadequate weight loss or secondary weight regain. The aim of this study was to assess the safety and efficacy of laparoscopic conversion to Roux-en-Y gastric bypass (RYGBP) in these two indications. METHODS: A total of 25 patients, who underwent laparoscopic conversion to RYGBP due to inadequate weight loss (n = 10) or uncontrollable weight regain (n = 15) following LAGB, were included to this prospective study analyzing weight loss and postoperative complications. RESULTS: All procedures were completed laparoscopically within a mean duration of 219 +/- 52 (135-375) min. Mean body weight was reduced from 131 +/- 22 kg (range 95-194) at time of the RYGBP to 113 +/- 25, 107 +/- 22, and 100 +/- 21 kg at 3, 6, and 12 months, respectively, which results in excess weight losses (EWL) of 28.3 +/- 9.9%, 40.5 +/- 12.3%, and 50.8 +/- 15.2%. No statistically significant differences were found comparing weight loss within these two groups. CONCLUSION: RYGBP was able to achieve EWLs of 37.6 +/- 16.1%, 48.5 +/- 15.1%, and 56.9 +/- 15.0% at 3, 6, and 12 months following conversion, respectively, based on the body weight at LAGB.

Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels.

BACKGROUND: Different changes of plasma ghrelin levels have been reported following gastric banding, Roux-en-Y gastric bypass, and biliopancreatic diversion. METHODS: This prospective study compares plasma ghrelin levels and weight loss following laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) in 20 patients. RESULTS: Patients who underwent LSG (n=10) showed a significant decrease of plasma ghrelin at day 1 compared to preoperative values (35.8 +/- 12.3 fmol/ml vs 109.6 +/- 32.6 fmol/ml, P=0.005). Plasma ghrelin remained low and stable at 1 and 6 months postoperatively. In contrast, no change of plasma ghrelin at day 1 (71.8 +/- 35.3 fmol/ml vs 73.7 +/- 24.8 fmol/ml, P=0.441) was found in patients after LAGB (n=10). Increased plasma ghrelin levels compared with the preoperative levels at 1 (101.9 +/- 30.3 fmol/ml vs 73.7 +/- 24.8 fmol/ml, P=0.028) and 6 months (104.9 +/- 51.1 fmol/ml vs 73.7 +/- 24.8 fmol/ml, P=0.012) after surgery were observed. Mean excess weight loss was higher in the LSG group at 1 (30 +/- 13% vs 17 +/- 7%, P=0.005) and 6 months (61 +/- 16% vs 29 +/- 11%, P=0.001) compared with the LAGB group. CONCLUSIONS: As a consequence of resection of the gastric fundus, the predominant area of human ghrelin production, ghrelin is significantly reduced after LSG but not after LAGB. This reduction remains stable at follow-up 6 months postoperatively, which may contribute to the superior weight loss when compared with LAGB.

Weight loss and weight regain-5-year follow-up for circular- vs. linear-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Weight regain (WR) occurs in some patients after laparoscopic Roux-en-Y gastric bypass (LRYGBP). Loss of restriction due to dilation of the gastrojejunostomy (GJS) or the gastric pouch might be the main cause for WR. With different techniques available for the establishment of the GJS, the surgical technique might influence long-term success. METHODS: We present a 5-year follow-up for weight loss and WR of a matched-pair study comparing circular stapled (CSA) to linear stapled (LSA) GJS in a series of 150 patients who underwent primary antecolic antegastric LRYGBP. Complete 5-year follow-up was obtained for 79 % of the patients. RESULTS: Excess BMI loss (EBL) at 3 months was better with the CSA (p = 0.02) and comparable thereafter. The 5-year %EBL was 67.3 ± 23.2 vs. 73.3 ± 24.3 % (CSA vs. LSA, p = 0.19) WR of > 10 kg from nadir was found in 24 patients (16 %) with higher incidence in CSA than in LSA patients (20 % vs. 12 %). The %WR was comparable for both groups, 16 ± 13 vs. 15 ± 19 % (CSA vs. LSA, p = 0.345). Eleven patients underwent surgical re-intervention for WR by placement of a non-adjustable band (n = 2), adjustable band (n = 7) and conversion to distal gastric bypass (n = 2). CONCLUSIONS: CSA and LSA lead to comparable weight loss in this 5-year follow-up. More patients in the CSA group had WR. Weight regain of more than 10 kg was found in one out of seven patients within 5 years postoperatively.