Hypoabsorptive surgeries cause limb-dependent changes in the gut endocannabinoidome and microbiome in association with beneficial metabolic effects.

OBJECTIVE: To determine whether the metabolic benefits of hypoabsorptive surgeries are associated with changes in the gut endocannabinoidome (eCBome) and microbiome. METHODS: Biliopancreatic diversion with duodenal switch (BPD-DS) and single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) were performed in diet-induced obese (DIO) male Wistar rats. Control groups fed a high-fat diet (HF) included sham-operated (SHAM HF) and SHAM HF-pair-weighed to BPD-DS (SHAM HF-PW). Body weight, fat mass gain, fecal energy loss, HOMA-IR, and gut-secreted hormone levels were measured. The levels of eCBome lipid mediators and prostaglandins were quantified in different intestinal segments by LC-MS/MS, while expression levels of genes encoding eCBome metabolic enzymes and receptors were determined by RT-qPCR. Metataxonomic (16S rRNA) analysis was performed on residual distal jejunum, proximal jejunum, and ileum contents. RESULTS: BPD-DS and SADI-S reduced fat gain and HOMA-IR, while increasing glucagon-like peptide-1 (GLP-1) and peptide tyrosine tyrosine (PYY) levels in HF-fed rats. Both surgeries induced potent limb-dependent alterations in eCBome mediators and in gut microbial ecology. In response to BPD-DS and SADI-S, changes in gut microbiota were significantly correlated with those of eCBome mediators. Principal component analyses revealed connections between PYY, N-oleoylethanolamine (OEA), N-linoleoylethanolamine (LEA), Clostridium, and Enterobacteriaceae_g_2 in the proximal and distal jejunum and in the ileum. CONCLUSIONS: BPD-DS and SADI-S caused limb-dependent changes in the gut eCBome and microbiome. The present results indicate that these variables could significantly influence the beneficial metabolic outcome of hypoabsorptive bariatric surgeries.

Duodenal switch without versus with laparoscopic cholecystectomy: a perioperative risk comparative analysis of the MBSAQIP database (2015-2019).

BACKGROUND: The results of concurrent cholecystectomy with Roux-en Y gastric bypass and sleeve gastrectomy have been well elucidated. Large-scale data on the outcomes of concomitant cholecystectomy during biliopancreatic diversion with duodenal switch (BPD-DS) are still lacking. Our study aimed to explore whether simultaneous cholecystectomy with BPD-DS alters the 30-day postoperative outcomes. METHODS: We conducted a retrospective analysis of the MBSAQIP database between 2015 and 2019. Propensity-score matching (PSM) in BPD-DS with cholecystectomy (Group 1) and BPD-DS without cholecystectomy (Group 2) cohorts was performed (PSM ratio 1:2). The two groups were matched for a total of 21 baseline variables including age, gender, BMI, ASA class, and other medical comorbidities and conditions. The 30-day postoperative morbidity, mortality, reoperation, reintervention, and readmissions were obtained. RESULTS: Initially, 568 patients in Group 1 and 5079 in Group 2 were identified. After performing PSM, 564 and 1128 patients respectively were compared. The BPD-DS with cholecystectomy group reported a higher rate of reoperation and reintervention compared to BPD-DS alone (3.9% versus 2.4% and 3.2% versus 2%, respectively), even though it did not reach statistical significance. The intervention time was significantly higher in Group 1 compared to Group 2 (192.4 ± 77.6 versus 126.4 ± 61.4 min). Clavien-Dindo complications (1-5) were similar between these two PSM cohorts. CONCLUSION: Concomitant cholecystectomy during BPD-DS increases operative times but does not affect the other outcomes. Based on our results, the decision of cholecystectomy at the time of BPD-DS should be left to the surgeon's judgment.

Ten year comparative analysis of sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch in patients with BMI ≥ 50 kg/m2.

INTRODUCTION: Bariatric surgery is the most effective modality to stably reduce weight and related comorbidities in patients suffering from class II and III obesity. Data comparing long-term safety and efficacy of the three most effective bariatric operations are limited in patients with BMI ≥ 50 kg/m2, which complicate shared surgeon-patient decision making regarding optimal procedure selection. METHODS: A retrospective analysis was performed on all patients with BMI ≥ 50 kg/m2 who underwent biliopancreatic diversion with duodenal switch (BPD/DS), Roux-en-Y gastric bypass (RYGB), or sleeve gastrectomy (SG) at our institution between 2009 and 2019. Data collected from patients' electronic medical records included operative details as well as BMI and presence and resolution of obesity-related comorbidities at 0, 6, 12, 24, 48, and 60 months post-operatively. RESULTS: Among 537 patients with BMI ≥ 50 kg/m2 who had a primary bariatric procedure, 93 patients underwent BPD/DS (17.3%), 341 patients underwent RYGB (63.5%), and 103 patients underwent SG (19.2%). BMI decreased by 23.7 kg/m2 in BPD/DS, 14.7 kg/m2 in RYGB, and 13.6 kg/m2 in SG cohorts at 60 months post-operatively (p < 0.0001). The greatest %TWL occurred in BPD/DS cohort (38.4%) followed by the RYGB (26.3%) and SG (23.6%) cohorts (p < 0.0001). The thirty-day complication rate was 12.9% for BPD/DS, 4.7% for RYGB, and 8.7% for SG (p = 0.015). CONCLUSIONS: Our study demonstrated that the BPD/DS is the most effective operation at long-term reduction of BMI and achieved highest %TWL while SG and RYGB had similar results at 60 months post-op. BPD/DS is associated with increased early and late surgical complications compared to RYGB and SG.

Long-term comparative study on open versus laparoscopic biliopancreatic diversion.

BACKGROUND: To date, bariatric surgery has been proposed as the most effective treatment to resolve morbid obesity, a multifactorial chronic disease with an epidemic and increasing tendency. The purpose of this study was to determinate the impact of the laparoscopy on weight loss parameters in morbid obese patients who underwent surgery according to Scopinaro's biliopancreatic diversion (BPD) and evaluate early and late complications related to the open and laparoscopic approach of this technique. MATERIALS AND METHODS: This is a longitudinal retrospective study in consecutive patients undergoing BPD due to morbid obesity between 1999 and 2015. From 2006 the laparoscopic technique was introduced in our group for obesity surgery. In both approaches, open and laparoscopic surgery, the procedure performed consists of a proximal gastric section with a long Roux-en-Y reconstruction. The following variables were assessed in the two groups: intervention duration (min), estimated blood loss (mL), conversions to open approach (%), preoperative stay, postoperative and global stay (days). Complications were divided into early and late postoperative complications. The early surgical complications were catalogued according to the Clavien-Dindo classification. RESULTS: Two hundred seventy-seven patients were consecutively enrolled and divided in two groups: open BPD and laparoscopic BPD. There were no significant differences in the comparison of the two groups and the mean age was 43.9 years (19-60) with a mean BMI of 52.5 kg/m2. A statistically significant reduction was observed in favor of the laparoscopic group with respect to the reduction in hospital stay and in the incidence of incisional hernia as a late complication. No statistically significant difference were found with respect to early postoperative complications. CONCLUSIONS: Laparoscopic BPD is a safe technique that allows a shorter hospital stay compared to open surgery and that allows a drastic reduction in the incidence of incisional hernias.

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.

Pancreatobiliary Diversion in the Mouse.

The gut hormone cholecystokinin (CCK) is primarily secreted from I-cells in the duodenum and proximal jejunum. CCK secretion is stimulated by food digests and inhibited by proteases from pancreatic juice. CCK regulates digestion and appetite, stimulates pancreatic growth, and participates in pancreatic carcinogenesis. The molecular mechanisms of CCK-induced effects are not fully understood. When the mechanisms are studied in animals, the surgical model of pancreatobiliary diversion (PBD) is frequently used. After animals have had PBD, their CCK secretion is no longer inhibited by pancreas-derived proteases, so circulating CCK is increased. PBD is established in rats and hamsters, but not in mice. In this study, we modified PBD procedures and established the model in the mouse. In an experiment, we performed PBD and sham operation (SO) in two groups of mice (20 mice per group). Twenty days after operation, 75% of the PBD mice and all SO mice survived. When plasma CCK was determined by radioimmunoassay, the PBD group had higher levels than the SO group (p < 0.001). To assess pancreatic growth, we determined pancreatic weight and pancreatic contents of protein and DNA. We also stained pancreatic sections by immunohistochemistry to show the proliferating cells that either expressed the proliferating cell nuclear antigen or were labeled with 5-bromo-2'-deoxyuridine. As a result, the pancreases of the PBD mice were heavier (p < 0.001) and had more protein (p < 0.001), DNA (p < 0.01), and proliferating cells (p < 0.01) than those of the SO counterparts. Thus, pancreatic growth was increased as a result of PBD-induced hypercholecystokininemia. The plasma and pancreatic data demonstrated that the PBD model was a success. This model may be used in CCK-related research. For instance, pancreatic cancer is frequently studied in transgenic mice. PBD may be combined with the cancer model to study the role of CCK in the molecular biology of pancreatic cancer.

Biliopancreatic diversion with duodenal switch (BPD-DS) and single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) result in distinct post-prandial hormone profiles.

BACKGROUND/OBJECTIVE: Biliopancreatic diversion with duodenal switch (BPD-DS) is the most effective bariatric intervention to treat morbid obesity and related disorders. Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a new bariatric procedure devised with the purpose of simplifying the complexity of the BPD-DS technique while maintaining its efficacy. However, whether BPD-DS and SADI-S result in similar fasting and post-prandial hormone profiles has not yet been studied. Therefore, the purpose of this study was to assess and compare the hormone response to a standardized mixed meal in subjects operated with BPD-DS or SADI-S. SUBJECTS/METHODS: Subjects submitted to BPD-DS (n = 9) or SADI-S (n = 9) 1.5 years earlier on average, with no past nor current diabetes diagnosis underwent a liquid mixed-meal tolerance test (MMTT) to assess the baseline and post-prandial profile of glucose, enteropancreatic hormones and total bile acids. RESULTS: Fasting glucose, enteropancreatic hormones and total bile acids levels after BPD-DS and SADI-S were similar. After the MMTT, the response of subjects who underwent SADI-S was characterized by higher glucose (t = 30 min: p < 0.05; iAUC: 156.1 ± 46.2 vs. 103.4 ± 35.8 mmol/L × min, p = 0.02), GLP-1 (t = 30 min: p < 0.05; iAUC: 5388 ± 3010 vs. 2959.0 ± 2146 pmol/L × min, p = 0.02), glucagon (t = 30 min: p < 0.05; iAUC: 678.7 ± 295.2 vs. 376.9 ± 215.7 pmol/L × min, p = 0.02), insulin (t = 30 and 45 min: p < 0.05); and C-peptide levels (t = 30 and 45 min: p < 0.05), when compared to BPD-DS. CONCLUSIONS: The post-prandial hormone secretion profile after SADI-S is characterized by increased GLP-1, glucagon and insulin secretion, when compared to BPD-DS, which suggests the existence of different endocrine driven mechanisms leading to weight loss and metabolic improvement after the two procedures.

Duodenal intussusception of the remnant stomach after biliopancreatic diversion: a case report.

BACKGROUND: We present a rare case of an antegrade intussusception of the remnant stomach four years after a biliopancreatic diversion. CASE PRESENTATION: A 55-year-old female patient presented with epigastric pain in our emergency room. Laboratory parameters showed an anemia as well as elevated transaminases and hyperbilirubinemia. The CT scan showed an intussusception of the remnant stomach into the duodenum followed by cholestasis. At laparotomy the remnant stomach was resected. CONCLUSION: Bowel obstruction and intussusception after bariatric surgery are a rare but often unrecognized complication. Sonography as well as a CT scan should be performed. The exploratory laparoscopy however is the most valuable diagnostic tool in patients with suspected intussusception, due to the high rate of non-specific symptoms and misinterpreted radiographic investigations.

Long-term (>10 Yrs) Outcome of the Laparoscopic Biliopancreatic Diversion With Duodenal Switch.

OBJECTIVE: The aim of the study was to report 10+ year outcome of laparoscopic biliopancreatic diversion with duodenal switch (LDS), with special focus on quality of life. BACKGROUND:: Reports on long-term morbidity and quality of life after LDS are rare. METHODS: Records of all patients who underwent LDS 10+ years ago were analyzed. Patients were contacted to answer a questionnaire based on Bariatric Analysis and Reporting Outcome System. Blood work was reported when performed within the past year. RESULTS: Of the 153 patients who underwent LDS, follow-up was available for 113 patients (78.5%). Mean follow-up was 130.2 ±â€Š4.6 months. Percentage total weight loss was 40.7 ±â€Š10.8%. Weight loss was greatest in the super obese category (BMI > 50 kg/m). Remission rate for type 2 diabetes was 87.5% (21/24) and for arterial hypertension 80.9% (38/47). Dyslipidemia remission rates were 93.3% (28/30) for total cholesterol, 89.7% (26/29) for triglycerides, and 95.0% (19/20) for low-density lipoprotein cholesterol. However, 42.5% of the patients needed reoperation, including 10.6% for correction of protein malnutrition, the latter exclusively in non-super obese individuals. Most common deficiencies concerned vitamin A and D, iron, and zinc. De novo gastroesophageal reflux disease was reported in 43.8%. The Bariatric Analysis and Reporting Outcome System score was good at 4.9 ±â€Š2.2, and 82.3% of participants would choose the procedure again. CONCLUSIONS: LDS is a very effective metabolic procedure, at the cost of occasional protein and other nutritional deficiencies. Outcome in the long term is best in super obese patients. Overall quality of life is good. The high reoperation rate and incidence of gastroesophageal reflux disease are concerning.

[Incretin secretion and glucose metabolism in morbidly obese patients in the early and late periods after biliopancreatic diversion]. / Produktsiya inkretinov i obmen glyukozy u bol'nykh patologicheskim ozhireniem v rannem i otdalennom periode posle biliopankreaticheskogo shuntirovaniya.

AIM: To estimate the parameters of glucose metabolism and to assess the secretion of incretins in patients after biliopancreatic diversion (BPD) for morbid obesity (MO) in the early and late postoperative periods. SUBJECTS AND METHODS: The prospective part of the investigation included 22 patients with a body mass index of 35.8 to 68.4 kg/m2 and type 2 diabetes mellitus (T2DM). All the patients were examined before, 3 weeks and 3 months after BPD. The retrospective part covered 23 patients who were examined after BPD for MO; the postoperative period was 4.7 [2.3; 7.2] years. A control group consisted of 22 healthy, normal weight volunteers. A 75-g oral glucose tolerance test was carried out in all the groups to study the levels of glucose, immunoreactive insulin (IRI), glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP) and glucagon at 0, 30, 60, and 120 min. RESULTS: T2DM patients showed improvement in glucose metabolism just 3 weeks after BPD; following 3 months, they had normalized fasting blood glucose levels (5.6 [5.0; 6.0] mmol/l). During 3 months, glycated hemoglobin decreased from 7.5 [6.6; 8.5] to 5.7 [5.3; 5.9]%. In the early period following BPD, there was an increase in basal and postprandial GLP-1 levels associated with the peak IRI concentration. In the late period after BPD, the enhanced secretion of IRI and GLP-1 persisted, which was followed by a reduction in postprandial glucose levels in 4 of the 23 patients. CONCLUSION: T2DM remission does not depend on weight loss in the early period after BPD. In this period, the significant improvement of glucose metabolic parameters in patients with obesity and T2DM is associated with elevated GLP-1 levels. The altered incretin response is a stable effect of BPD and remains in its late period.

Totally robot-assisted biliary pancreatic diversion with duodenal switch: single dock technique and technical outcomes.

BACKGROUND: The biliopancreatic diversion with duodenal switch (BPD/DS) requires operating in three different abdominal quadrants. Previous techniques have used either two docks or a hybrid technique in which the robot is used only to suture the duodeno-ileal anastomosis, while the rest of the operation was performed laparoscopically. Recently, a modification in technique has allowed all operative steps to be completed robotically with a single dock. The operative technique and its technical results are described. METHODS: Operative technique is described. Baseline demographics, operative duration, length of stay, and adverse events (intraoperative, 30-days, and 1-year) of all primary totally robot BPD/DS cases are reported. RESULTS: From Nov. 2011 to Jan. 2014, 59 totally robotic BPD/DS operations were attempted. One was completed hybrid, and the rest were totally robotic. No robotic operation was converted to an open operation. Five trocars were placed, the small bowel was anchored to the anterior abdominal wall, and the robot was docked. Mean age was 44 ± 10 years with a mean preoperative BMI of 56 ± 9 kg/m(2). 69 % was female, and 71 % was Caucasian. Mean operative duration was 306 ± 80 min (60 min less than the hybrid technique). There were no mortality, leaks, venous thromboembolism, or bleeding requiring transfusion. Mean length of stay was 4.6 ± 4.3 days. Three patients were readmitted for nausea and vomiting. There was one superficial wound infection, and three patients needed reoperations in the first year, two for strictures, and one for debriding a suture abscess. CONCLUSIONS: All key technical components of the BPD/DS were performed with low morbidity and mortality with a single dock. Since the surgeon performed all key parts of the operation from the console, the need for experienced bedside assistance was minimized, resulting in shorter operative duration compared to the hybrid technique.

The Prevalence of Small Intestinal Bacterial Overgrowth After Roux-en-Y Gastric Bypass (RYGB): a Systematic Review and Meta-analysis.

We reviewed the literature on the prevalence of small intestinal bacterial overgrowth (SIBO) after Roux-en-Y gastric bypass (RYGB). Eight studies examining 893 patients were included. The mean age of the patients was 48.11 ± 4.89 years. The mean BMI before surgery and at the time of SIBO diagnosis was 44.57 ± 2.89 kg/m2 and 31.53 ± 2.29 kg/m2, respectively. Moreover, the results showed a 29% and 53% prevalence of SIBO at < 3-year and > 3-year follow-up after RYGB, respectively. Symptoms included abdominal pain, diarrhea, bloating, nausea, vomiting, constipation, soft stool, frequent defecation, flatulence, rumpling, dumping syndrome, and irritable bowel syndrome. SIBO is prevalent after RYGB; digestive symptoms should prompt the consideration of SIBO as a potential etiology. Antibiotic therapy has proven to be therapeutic.

Ten-Year Outcomes Following Roux-en-Y Gastric Bypass vs Duodenal Switch for High Body Mass Index: A Randomized Clinical Trial.

Importance: Results from long-term follow-up after biliopancreatic diversion with duodenal switch (DS) are scarce. Objective: To compare weight loss, health outcomes, and quality of life 10 years or more after Roux-en-Y-gastric bypass (RYGB) and DS surgery in patients with severe obesity-that is, a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 50 to 60. Design, Setting, and Participants: This open-label randomized clinical trial was conducted at 2 academic bariatric centers in Sweden and Norway. Sixty patients with a BMI of 50 to 60 were included from March 1, 2006, to August 31, 2007. Data were analyzed from August 12, 2022, to January 25, 2023. Interventions: Laparoscopic RYGB or laparoscopic DS. Main Outcomes and Measures: The main outcome was change in BMI after 10 or more years. Secondary outcomes included anthropometric measures, lipid and glycemic profiles, bone mass density, adverse events, gastrointestinal tract symptoms, and health-related quality of life. Results: Forty-eight of the original 60 patients (80%) were assessed after a median of 12 (range, 9-13) years (mean [SD] age, 48.0 [6.0] years; 35 women [73%]). At follow-up, the mean BMI reductions were 11.0 (95% CI, 8.3-13.7) for RYGB and 20.3 (95% CI, 17.6-23.0) for DS, with a mean between-group difference of 9.3 (95% CI, 5.4-13.1; P < .001). Total weight loss was 20.0% (95% CI, 15.3%-24.7%) for RYGB and 33.9% (95% CI, 27.8%-40.0%) for DS (P = .001). Mean serum lipid levels, except high-density lipoprotein cholesterol and hemoglobin A1c, improved more in the DS group during follow-up. Bone mass was reduced for both groups from 5 to 10 years, with lower bone mass after DS at 10 years. Quality-of-life scores (Obesity-Related Problem Scale and the 36-Item Short Form Health Survey) were comparable across groups at 10 years. The total number of adverse events was higher after DS (135 vs 97 for RYGB; P = .02). More patients in the DS group developed vitamin deficiencies (21 vs 11 for RYGB; P = .008) including 25-hydroxyvitamin D deficiency (19 for DS vs 9 for RYGB; P = .005). Four of 29 patients in the DS group (14%) developed severe protein-caloric malnutrition, of whom 3 (10%) underwent revisional surgery. Conclusions and Relevance: In this randomized clinical trial, BMI reduction was greater after DS, but RYGB had a better risk profile over 10 years. Biliopancreatic diversion with DS may not be a better surgical strategy than RYGB for patients with a BMI of 50 to 60. Trial Registration: ClinicalTrials.gov Identifier: NCT00327912.

Preoperative predictors of type 2 diabetes remission after bilio-pancreatic diversion with duodenal switch.

BACKGROUND: Many patients achieve short-term type 2 diabetes (T2D) remission after bariatric surgery, but relapses are common. Diabetes outcomes after bariatric surgery vary across procedures and populations. T2D remission scores are simple clinical tools developed to predict remission after bariatric surgery. However, they have never been tested after Biliopancreatic diversion with duodenal switch (BPD-DS). OBJECTIVES: The aim of this study was to compare the predictive value of T2D remission scores and preoperative diabetes characteristics in predicting T2D remission after BPD-DS. SETTING: Quebec Heart and Lung Institute - Laval University. METHODS: We retrospectively identified 918 patients with preoperative T2D who had undergone BPD-DS. Retrospective chart review was performed and variables used to calculate predictive scores were captured. T2D status was assessed annually for up to 10 years postop. Predictive values for each score (DiarRem, Ad Diarem, and Diabetter) and single preoperative diabetes characteristics used to construct these algorithms were evaluated by area under receiver operating characteristic curves (AUC). RESULTS: Diabetter showed greater performance for prediction of durable diabetes remission than other algorithms with acceptable discriminative ability (AUC between .69 and .79), but was not superior to T2D duration as a single predictor (P = .24 and P = .18). At 10 years, T2D duration had a better discriminative ability for the prediction of T2D remission than all 3 predictive models (AUC = .85, P < .05). CONCLUSIONS: Better chances for T2D remission following BPD-DS are associated with a shorter duration or T2D before surgery. Duration of T2D alone offers an excellent predictive ability and is a convenient alternative to diabetes remission scores to estimate chances of long-term diabetes remission after BPD-DS.

Long-term results of conversion of Roux-en-Y to biliopancreatic diversion with duodenal switch.

BACKGROUND: Despite the fact Roux-en-Y gastric bypass (RYGB) is one of the most efficient bariatric procedures, postoperative weight regain still can be seen. OBJECTIVES: To retrospectively assess the early outcomes and up to 10-year weight results of the conversion of RYGB to biliopancreatic diversion with duodenal switch (BPD-DS). SETTING: French private hospital, 2-surgeon practice in a bariatric surgery center with an experience of >20 RYGB procedures. METHODS: Analysis was conducted on patients who had a conversion of RYGB to BPD-DS performed since 2010 for a percentage of excess weight loss (%EWL) <50% with a small gastric pouch. RESULTS: A total of 65 females and 9 males aged 46.8 ± 8.8 years had an RYGB procedure done 110.6 ± 38.8 months earlier for a body mass index of 47.4 ± 7.8 kg/m2. Conversion was always performed in 1 stage and laparoscopically for 93% of the patients. The 30-day complication rate was 25.7%, with 14.8% of patients undergoing reoperation. Maximum results were seen 2 years after conversion, outranging RYGB: %EWL of 78.3% ± 24% with percent total weight loss (%TWL) of 35.9% ± 11.9% and %EWL of 72% ± 24.1% with %TWL of 32.6% ± 11%, respectively. The 5-year weight of all the patients (85.7% follow-up) remained lower than the pre-conversion weight. Over time, 1 reversal and 4 revisions were required, and frequent stools and gastroesophageal reflux were the most frequent complaints. CONCLUSION: Despite its complexity, conversion of RYGB to BPD-DS can be performed in 1 stage, although the use of an unconventional technique could not reduce the high complication rate. BPD-DS remains an efficient procedure after RYGB in selected patients, comparable to distalization of RYGB, which can be less risky.

Management of Malnutrition and Hepatic Impairment After Duodenal Switch.

BACKGROUND: Malnutrition and liver impairment after duodenal switch (DS) are possible and undesired complications, often conservatively treated. However, in specific cases, surgical revision may be necessary. This study aims to describe outcomes achieved by two bariatric surgery centers and address effectiveness and safety of revisional surgical procedures to resolve these complications. METHODS: A retrospective chart review was performed in two bariatric surgery centers from 2008 to 2022. Patients who required revisional surgery to treat malnutrition and/or liver impairment refractory to nutritional and total parenteral nutrition intervention (TPN) after duodenal switch were included. No comparisons were performed due to the descriptive nature of this study. RESULTS: Thirteen patients underwent revisional surgery, the mean age was 44.7, the 53.8% were females, and the mean preoperative BMI was 54.7 kg/m2; the mean time between DS and revisional procedure was 26.5 months, and 69.1% of patients were placed on TPN. One patient developed hepatic encephalopathy; one patient presented with ascites, pleural effusion, and renal insufficiency, undergoing reoperation after revisional procedure due to a perforated ileal loop. Mortality rate was 0%; all patients regained weight after the revisional procedure, and the mean total protein and albumin blood levels 12 months after surgery were 6.3 and 3.6 g/dl, respectively. CONCLUSIONS: While refractory malnutrition and/or liver failure are rare among patients post-DS, if underdiagnosed and untreated, this can lead to irreversible outcomes and death. All revisional procedures included in this study resulted in improvement of the nutritional status and reversal of liver impairment, with low complication rates.

Revisional surgery after failed laparoscopic adjustable gastric banding: a systematic review.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has emerged as one of the most commonly performed bariatric procedures worldwide. Unfortunately, revisional surgery is required in 20-30 % of cases. Several revisional strategies have been proposed, but there is no consensus regarding the best surgical option. This systematic review was designed to determine which revisional surgery (laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, or laparoscopic biliopancreatic diversion with duodenal switch) is best suited to enhance weight loss following failed LAGB due to complications or inadequate weight loss. METHODS: EMBASE, MEDLINE, PsycINFO, and Cochrane Clinical Trials were searched using the most comprehensive timeline for each database. A total of 24 relevant articles were identified. Two investigators independently extracted data, and differences were resolved by consensus. The weighted means were calculated for weight loss measurements. RESULTS: A total of 106, 514, and 71 patients underwent conversion from LAGB to laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), and laparoscopic biliopancreatic diversion and duodenal switch (BPDDS), respectively. Before revisional surgery, the weighted mean body mass index (BMI) was 38.8 (6.9), 43.3 (8.1), and 41.3 (7.2) kg/m(2) for the LSG, LRYGB, and BPDDS groups, respectively. The majority of data was reported at 12-24 months follow-up. The mean BMI within this interval was 28 (10.5), 32.2 (6.4), and 33 (5.7) kg/m(2) for the LSG, LRYGB, and BPDDS groups, respectively. In addition, the mean excess weight loss (EWL) was 22 % (2.8), 57.8 % (11.7), 47.1 % (14) for the LSG, LRYGB, and BPDDS groups, respectively. The EWL reached 78.4 % (35) in the BPPDS group after 2-year follow-up. CONCLUSIONS: Failed LAGB is best managed with conversion to another bariatric procedure. Stable weight loss occurs with salvage LRYGB. Although results for revisional BPPDS appear promising, additional research, with higher methodological quality, is needed.

Long-term Follow-up 15 Years After Duodenal Switch or Gastric Bypass for Super Obesity: a Randomized Controlled Trial.

BACKGROUND: In super obesity, Roux-en-Y gastric bypass (RYGB) may be insufficient why some surgeons advocate biliopancreatic diversion with duodenal switch (BPD/DS), a more malabsorptive procedure. There is a paucity of evidence regarding results beyond 10 years, especially after BPD/DS. The aim of this randomized controlled trial was to compare the long-term outcome of BPD/DS, and RYGB in patients with super obesity, i.e., body mass index (BMI) > 50 kg/m2. METHODS: This is a 13- to 17-year follow-up study of a single-center, single-blinded randomized trial in which 47 patients (BMI > 48 and eligible for bariatric surgery) were randomized 1:1 to BPD/DS and RYGB (25 men, 24 BPD/DS, 39.1 ± 9.9 years, BMI 54.5 ± 6.1 kg/m2). The primary outcome was weight loss. The study was financed by Swedish governmental funding of clinical research (ALF). TRIAL REGISTRATION NUMBER: ISRCTN10940791. RESULTS: Thirty-four (18 BPD/DS) of the living 42 patients (81.0%) participated. BPD/DS resulted in higher BMI loss (20.4 ± 7.9 vs. 12.4 ± 8.6, p = .008) and higher percent of total body weight loss (37.5% ± 12.2 vs. 22.8% ± 14.8, p = .004). BPD/DS was associated with lower fasting glucose, glycated hemoglobin (HbA1c), and low-density lipoprotein (LDL) as well as lower hemoglobin. Adverse events were more common after BPD/DS (2.7 vs. 0.9 per patient, p = .004). The global assessment tool BAROS (Bariatric Analysis and Reporting Outcome System) demonstrated superior scores for BPD/DS (p = .047). CONCLUSION: When compared to RYGB, BPD/DS results in superior weight loss and metabolic control as well as superior BAROS score, however, at the cost of more adverse events.

Impact on Mid-Term Health-Related Quality of Life after Duodenal Switch: a Systematic Review and Meta-Analysis.

PURPOSE: Metabolic and bariatric surgery (MBS) could improve health-related quality of life (HrQoL) for selected patients with obesity. Although biliopancreatic diversion with duodenal switch (BPD-DS) is regarded as the most effective MBS technique in achieving weight loss, no consensus has been reached on the impact of BPD-DS on HrQoL. The aim of this meta-analysis is to assess the mid-term HrQoL after BPD-DS in the management of patients with obesity. MATERIALS AND METHODS: Cochrane, Embase, APA PsycInfo, PubMed, Scopus, and Web of Science were searched for articles from their inception to August 2022 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42022352073). RESULTS: From 223 studies screened, twelve studies met the eligibility criteria, with a total of 937 patients with obesity undergoing BPD-DS. Minimal clinically important differences (MCID) were reached for the physical component summary score (PCS) of the 36-Item Short-Form Health Survey (SF-36) (MD = 13.4) and impact of weight on quality of life (IWQOL)-Lite total score (MD = 48.7). Similarly, MCIDs were attained in the Laval questionnaire and SF-36 subscales. CONCLUSION: Our meta-analysis demonstrated an improvement in mid-term HrQoL after BPD-DS. Despite the promising trends demonstrated in this meta-analysis, further studies with large sample sizes are needed to evaluate the impact of HrQoL on patients with obesity after BPD-DS.