Safety and efficacy of LA-ERCP procedure following Roux-en-Y gastric bypass: a systematic review and meta-analysis.

INTRODUCTION: Rapid weight loss following Roux-en-Y gastric bypass surgery (RYGB) translates to an increased need for endoscopic retrograde cholangiopancreatography (ERCP) intervention. Laparoscopically Assisted Transgastric ERCP (LA-ERCP) has emerged to address the issue of accessing the excluded stomach. This study aims to evaluate the safety and efficacy of LA-ERCP procedure following RYGB. METHODS: The Cochrane, EMBASE, SCOPUS, MEDLINE, Daily and Epub databases were searched from inception to May 2022 using the PRISMA guidelines. Eligible studies reported participants older than 18 years who underwent the LA-ERCP procedure, following RYGB, and outcomes of patients. RESULTS: 27 unique studies met the inclusion criteria with 1283 patients undergoing 1303 LA-ERCP procedures. 81.9% of the patients were female and the mean age was 52.18 ± 13.38 years. The rate of concurrent cholecystectomy was 33.6%. 90.9% of procedures were undertaken for a biliary indication. The mean time between RYGB and LA-ERCP was 89.19 months. The most common intervention performed during the LA-ERCP was a sphincterotomy (94.3%). Mean total operative time was 130.48 min. Mean hospital length of stay was 2.697 days. Technical success was 95.3%, while clinical success was 93.8%. 294 complications were recorded with a 20.6% complication rate. The most frequent complications encountered were pancreatitis (6.8%), infection (6.1%), bleeding (3.4%), and perforation (2.5%). Rate of conversion to open laparotomy was 7%. CONCLUSION: This meta-analysis presents preliminary evidence to suggest the safety and efficacy of LA-ERCP procedure following RYGB. Further investigations are warranted to evaluate the long-term efficacy of this procedure using studies with long-term patient follow-up.

Predictors of marginal ulcer after gastric bypass: a systematic review and meta-analysis.

INTRODUCTION: Marginal ulcer (MU) is a common complication following Roux-en-Y gastric bypass (RYGB) with an incidence rate of up to 25%. Several studies have evaluated different risk factors associated with MU with inconsistent findings. In this meta-analysis, we aimed to identify the predictors of MU after RYGB. METHODS: A comprehensive literature search of PubMed, Embase, and Web of Science databases was conducted through April 2022. All studies that used a multivariate model to assess risk factors for MU after RYGB were included. Pooled odds ratios (OR) with 95% confidence intervals (CI) for risk factors reported in ≥ 3 studies were obtained within a random-effects model. RESULTS: Fourteen studies with 344,829 patients who underwent RYGB were included. Eleven different risk factors were analyzed. Meta-analysis demonstrated that Helicobacter pylori (HP) infection (OR 4.97 [2.24-10.99]), smoking (OR 2.50 [1.76-3.54]), and diabetes mellitus (OR 1.80 [1.15-2.80]), were significant predictors of MU. Increased age, body mass index, female gender, obstructive sleep apnea, hypertension, and alcohol use were not predictors of MU. There was a trend of an increased risk of MU associated with nonsteroidal anti-inflammatory drugs (OR 2.43 [0.72-8.21]) and a lower risk of MU with proton pump inhibitors use (OR 0.44 [0.11-2.11]). CONCLUSIONS: Smoking cessation, optimizing glycemic control, and eradication of HP infection reduce the risk of MU following RYGB. Recognition of predictors of MU after RYGB will allow physicians to identify high-risk patients, improve surgical outcomes, and reduce the risk of MU.

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.

Prospective Multicenter Study of the Primary Obesity Surgery Endoluminal (POSE 2.0) Procedure for Treatment of Obesity.

BACKGROUND & AIMS: The Primary Obesity Surgery Endoluminal (POSE) 2.0 procedure involves a novel pattern of full-thickness gastric body plications to shorten and narrow the stomach using durable suture anchor pairs. Our prospective, multicenter trial examined the safety, efficacy, durability, and physiologic effects of POSE 2.0 in adults with obesity. METHODS: Adults with obesity underwent POSE 2.0 at 3 centers. Primary outcomes were percent total body weight loss (%TBWL) and proportion of patients achieving >5% TBWL at 12 months. Secondary outcomes included change in obesity comorbidities, satiety, quality of life at 6 months, and durability of plications at 12 and 24 months. Subjects were followed for adverse events throughout the study duration. RESULTS: 44 patients (61% female; mean age, 45 ± 9.7 years; mean body mass index, 37 ± 2.1 kg/m2) were enrolled. This procedure used an average of 19 suture anchor pairs, with a mean duration of 37 ± 11 minutes, and was technically successful in all subjects. Mean %TBWL at 12 months was 15.7% ± 6.8%. At 12 months, %TBWL >5%, >10%, and >15% was achieved in 98%, 86%, and 58% of patients, respectively. Improvements in lipid profile, liver biochemistries, and hepatic steatosis were seen at 6 months. Improvements in hepatic steatosis persisted for 24 months in a subgroup of patients (P < .01). POSE 2.0 reduced maximum tolerated meal volume (P = .03) and was associated with increased fullness (P < .01) and improved eating behavior (P < .01) at 6 months. Impact of weight on quality-of-life questionnaire improved at 6 months (2.23 vs 1.23; P < .01). Repeat assessment at 24 months (n = 26) showed fully intact plications. No serious adverse events occurred. CONCLUSION: POSE 2.0 is an effective and durable endoscopic bariatric therapy which may influence physiologic pathways impacting satiety. Larger comparative studies are needed to further elucidate these initial findings. CLINICALTRIALS: gov Identifier: NCT03721731.

Update on the efficacy and safety of intravenous tranexamic acid in hip fracture surgery: a systematic review and meta-analysis.

AIM: The aim of this meta-analysis was to assess the safety and efficacy of tranexamic acid (TXA) in the management of hip fracture surgeries in comparison with placebo. METHODS: A systematic search was conducted from August 6, 2021. Eligible studies included randomized clinical trials and prospective studies comparing the use of intravenous TXA in patients treated for hip fractures, in comparison with placebo. Review Manager was used for the meta-analysis. RESULTS: Eighteen prospective studies including 14 RCTs met the eligibility criteria. The results favored the TXA group in the quantity of total blood loss (MD = - 196.91 mL, 95% CI - 247.59, - 146.23, I2 = 92%), intraoperative blood loss (MD = - 26.86 mL, 95% CI - 36.96, - 16.78, I2 = 62%), and rate of blood transfusion (OR 0.35, 95% CI 0.28, 0.42, I2 = 0%). TXA also exhibited higher hemoglobin level at day 1 (MD = 6.77 g/L, 95% CI 4.30, 9.24, I2 = 83%) and day 3 (MD = 7.02 g/L, 95% CI 3.30, 10.74, I2 = 82%) postoperatively. There was no significant difference found in the incidence of thromboembolic events from occurring between the two groups, such as deep vein thrombosis (OR 1.22, 95% CI 0.73, 2.02, I2 = 0%) and pulmonary embolism (OR 0.82, 95% CI 0.33, 2.05, I2 = 0%). CONCLUSION: Administration of intravenous TXA appears to reduce blood loss, rate of blood transfusions and pose no increased risk of thromboembolic events. Therefore, TXA should be considered by physicians when managing hip fracture patients.

Open Versus Laparoscopic Surgery in the Management of Adrenocortical Carcinoma: A Systematic Review and Meta-analysis.

BACKGROUND: Laparoscopic surgery is considered a standard treatment for benign adrenal tumors; however, no consensus has been reached on the optimal resection technique for adrenocortical carcinomas. This study aims to evaluate the safety and efficacy of laparoscopic surgery and open surgery in the management of adrenocortical carcinoma. METHODS: The Cochrane, Embase, PubMed, Scopus, and Web of Science databases were searched for articles from inception to May 2022, by two independent reviewers using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. The review was registered prospectively on the PROSPERO database (CRD42022316050). RESULTS: From 183 studies screened, 11 studies met the eligibility criteria, with a total of 1617 patients with adrenocortical carcinoma undergoing either laparoscopic surgery (n = 472) or open surgery (n = 1145). Open surgery demonstrated a lower rate of positive resection margin compared with laparoscopic surgery (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.10-2.10; I2 = 0%). Additionally, open surgery had more favorable overall survival (OR 0.56, 95% CI 0.44-0.72; I2 = 0%) and recurrence-free rates (OR 0.60, 95% CI 0.42-0.85; I2 = 38%) than laparoscopic surgery at 3 years. Hospital stay was shorter for laparoscopic surgery than open surgery (mean difference - 2.49 days, 95% CI - 2.95 to - 2.04; I2 = 45%). CONCLUSIONS: Open surgery should still be considered the standard operative approach; however, laparoscopic surgery could be regarded as an effective and safe operation for selected adrenocortical carcinoma cases with appropriate laparoscopic expertise. Further randomized controlled studies with tumor stage- and resection margin-dependent survival analysis are necessary to ascertain the safety and efficacy of the treatment.

Comparative Effectiveness and Safety Between Endoscopic Sleeve Gastroplasty and Laparoscopic Sleeve Gastrectomy: a Meta-analysis of 6775 Individuals with Obesity.

INTRODUCTION: Endoscopic sleeve gastroplasty (ESG) is a novel endoscopic bariatric therapy that complements current medical and surgical therapeutic offerings for weight management and fills an unmet need. Few meta-analyses compared ESG to laparoscopic sleeve gastrectomy (LSG). However, these studies relied on indirect evidence derived from non-comparative studies. Comparative effectiveness data derived from direct comparative studies is needed. We performed a meta-analysis of studies that directly compared ESG with LSG. METHODS: A comprehensive search of PubMed, Embase, and Cochrane databases was conducted. Single-arm studies were excluded. Pooled mean difference (MD) and risk ratio (RR) with 95% confidence intervals (CIs) were obtained within a random-effect model. RESULTS: Seven studies with 6,775 patients (3,413 with ESG vs. 3,362 with LSG) were included. There were significant differences in 6-month (MD - 7.48; 95% CI - 10.44, - 4.52; P < 0.00001), 12-month (MD - 9.90; 95% CI - 10.59, - 9.22; P < 0.00001), and 24-month (MD - 7.63; 95% CI - 11.31, - 3.94; P < 0.0001) TBWL% favoring LSG over ESG. There was a trend toward lower incidence of adverse events with ESG compared to LSG but did not reach statistical significance (RR 0.51, 95% CI 0.23-1.11, P = 0.09). The incidence of new-onset gastroesophageal reflux disease (GERD) was significantly lower after ESG compared to LSG, 1.3% vs. 17.9%, respectively (RR 0.10, 95% CI 0.02-0.53, P = 0.006). CONCLUSIONS: ESG achieved clinically adequate but lower short- and mid-term weight loss when compared to LSG, with fewer adverse events, including GERD. Given the stomach-sparing nature of ESG and acceptable safety profile, it provides an acceptable alternative to LSG for patients with mild-to-moderate obesity.

Single Versus Double Anastomosis Duodenal Switch in the Management of Obesity: A Meta-analysis and Systematic Review.

BACKGROUND: Biliopancreatic diversion with duodenal switch (BPD-DS) is an effective yet technically challenging bariatric surgery with many complications. Alternatively, single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) was recently introduced as a simplified bariatric procedure. This meta-analysis aimed to assess the safety and efficacy of SADI-S compared with BPD-DS in the management of patients with obesity. METHODS: Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to May 2022 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system. The review was registered prospectively with PROSPERO (CRD42022333521). RESULTS: From 123 studies screened, 6 studies met the eligibility criteria, with a total of 1847 patients with obesity undergoing either SADI-S (n=818) or BPD-DS (n=1029). Preoperative body mass index was similar between the 2 groups, and the BPD-DS group had a greater % excess body mass index loss (EBMIL) (MD=-10.16%, 95% confidence interval: -11.80, -8.51, I 2 =0%) at 2 years compared with the SADI-S group. There was no difference observed in preoperative comorbidities and remission, including diabetes, hypertension, and dyslipidemia between SADI-S and BPD-DS cohorts. Compared with BPD-DS, SADI-S had shorter hospital stays (MD=-1.36 d, 95% CI: -2.39, -0.33, I 2 =86%), and fewer long-term (>30 d) complications (OR=0.56, 95% CI: 0.42, 0.74, I 2 =20%). Conversely, among nutritional deficiency outcomes, the SADI-S group had few patients with abnormal vitamin D (OR=0.51, 95% CI: 0.36, 0.72, I 2 =0%) values than the BPD-DS group. CONCLUSIONS: SADI-S has shown to be a possible alternative treatment option to BPD-DS in managing patients with obesity. Despite the promising results, further randomized controlled studies with more extended follow-up periods are necessary to ascertain the safety and efficacy of the treatment.

Outcomes of patients with thromboembolic events following coronavirus disease 2019 AstraZeneca vaccination: a systematic review and meta-analysis.

AstraZeneca coronavirus disease 2019 (COVID-19) vaccinations have recently been implicated in thromboembolism formations. Our aim was to investigate the outcomes of patients with thromboembolic events following the AstraZeneca vaccine (ChAdOx1 nCoV-19, AZD1222). A literature search was performed from December 2019 to September 2021. Eligible studies must report participants older than 18 years vaccinated with AstraZeneca and outcomes of thromboembolic events. Pooled mean or proportion were analyzed using a random-effects model. A total of 45 unique studies (number of patients = 144, 64.6% women, mean age 21-68 years) were included. The most common presenting adverse events were headache (12.1%), intracerebral hemorrhage (7.5%), and hemiparesis (7%). The most common thromboembolic adverse events were cerebral venous sinus thrombosis (38.5%) and deep vein thrombosis/pulmonary embolism (21.1%). The most common radiologic finding were intracerebral hemorrhage and cerebral venous thrombosis. Laboratory findings included thrombocytopenia (75%) and hypofibrinogenemia (41%). On admission, 64 patients tested positive for PF4-Heparin ELISA assay (80%). Seventy-four patients were hospitalized with 22 being admitted to the ICU. A total of 78 patients recovered while 39 patients died. This meta-analysis presents evidence to suggest vaccine-induced immune thrombotic thrombocytopenia (VITT) following AstraZeneca vaccine. Clinical practice must, therefore, account for the possibility of VITT and subsequent embolic events in certain individuals' postvaccination with adenovirus-based COVID-19 vaccines. Serum anti-PF4 suggests diagnostic value for VITT and could subsequently inform treatment choices in such instances.

Endoscopic suturing and plication in the stomach for weight loss.

The prevalence of obesity has been increasing on a global scale. However, less than 1% of patients eligible for bariatric surgery actually undergo weight loss surgery. Endobariatric therapies (EBTs) have emerged to bridge the obesity treatment gap, as they are less invasive, highly effective, and more broadly applicable to patients with mild to moderate obesity. Endoscopic sleeve gastroplasty and primary obesity surgery endoluminal are the two most promising EBTs, altering stomach physiologies mimicking bariatric surgery. This review focuses on these two EBT approaches.

Indications and Outcomes of Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass: a Systematic Review and a Meta-analysis.

PURPOSE: Sleeve gastrectomy (SG) is the most performed bariatric procedure. Conversion to Roux-en-Y gastric bypass (RYGB) for SG-related complications such as gastroesophageal reflux disease (GERD), insufficient weight loss (ISWL), and weight regain (WR) is increasing. Our aim was to investigate the safety, efficacy, and outcomes of conversion from SG to RYGB. METHODS: A literature search was performed from database inception to May 2020. Eligible studies must report indications for conversion, %total body weight loss (%TWL), and/or complications. The pooled mean or proportion were analyzed using a random-effects model. RESULTS: Seventeen unique studies (n = 556, 68.7% female, average age at time of conversion 42.6 ± 10.29 years) were included. The pooled conversion rate due to GERD was 30.4% (95% CI 23.5, 38.3%; I2 = 63.9%), compared to 52.0% (95% CI 37.0, 66.6%; I2 = 85.89%) due to ISWL/WR. The pooled baseline BMI at conversion was 38.5 kg/m2 (95% CI 36.49, 40.6 kg/m2; I2 = 92.1%) and after 1 year was 32.1 kg/m2 (95% CI 25.50, 38.7 kg/m2; I2 = 94.53%). The pooled %TWL after 1 year was 22.8% (95% CI 13.5, 32.1%; I2 = 98.05%). Complication rate within 30 days was 16.4% (95% CI 11.1, 23.6%; I2 = 57.17%), and after 30 days was 11.4% (95% CI 7.7, 16.7%; I2 = 0%). CONCLUSION: This meta-analysis showed that conversion from SG to RYGB is an option for conversion at a bariatric care center that produces sufficient weight loss outcomes, and potential resolution of symptoms of GERD. Further indication-based studies are required to obtain a clearer consensus on the surgical management of patients seeking RYGB following SG.

Impact of bariatric surgery on surveillance and treatment outcomes of Barrett's esophagus: A stage-matched cohort study.

BACKGROUND: Obesity could increase the risk of Barrett's esophagus (BE). Roux-en-Y gastric bypass (RYGB) could alter the natural course of BE. Data on BE progression after RYGB are scarce. OBJECTIVES: To study endoscopic surveillance and endoscopic eradication therapy (EET) outcomes of BE in post-RYGB patients versus controls with obesity. SETTING: Academic referral centers, a retrospective cohort study. METHODS: Patients who underwent RYGB with biopsy-proven BE or intramucosal esophageal adenocarcinoma (IM-EAC) with an endoscopic follow-up of at least 12 months were identified from a prospectively maintained database between January 1992 and February 2019 at 3 tertiary care centers. RYGB patients were matched 1-to-2 to patients with obesity (body mass index > 30 kg/m2) by the initial BE stage at diagnosis. Surveillance and EET outcomes were compared. RESULTS: A total of 147 patients were included (49 RYGB and 98 BE stage-matched controls with obesity). For endoscopic surveillance, the rate of disease progression to high-grade dysplasia /IM-EAC was significantly lower in the RYGB patients than controls (2.6% versus 40.2%, respectively; P < .0001), with a comparable median follow-up time (85 months versus 80 months, respectively). This effect persisted in a multivariate analysis, with a hazard ratio of .09 (95% confidence interval, .01-.69). For EET, no difference in the rate of achieving complete remission of intestinal metaplasia was observed between the RYGB and control groups (71.2% versus 81.3%, respectively; P = .44). CONCLUSION: RYGB appears to be a protective factor for disease progression to neoplastic BE during endoscopic surveillance. However, disease progression was still observed after RYGB, warranting continuing endoscopic surveillance. EET appeared to be equally effective between RYGB patients and controls with obesity.

Endoscopic management of refractory leaks and fistulas after bariatric surgery with long-term follow-up.

BACKGROUND: In selected cases of post-bariatric leaks and fistulas, endoscopy is an initial treatment modality. Management can be complex and require multiple endoscopic sessions with varying degrees of success. Our aim was to describe our tertiary care experience on endoscopy management of refractory post-bariatric leaks and fistulas. METHODS: Patients with post-bariatric leaks and/or fistulas who failed an initial endoscopic intervention were included. Endoscopic treatments were classified into four strategies: (1) closure management, (2) active drainage, (3) passive drainage, and (4) plugging. Clinical success and adverse events were assessed. RESULTS: A total of 25 patients (mean age = 45.3 ± 11.8 years and 56% female) were included. Clinical success was achieved in 20 patients (80%) with a mean of 3.0 ± 1.5 procedures and a median time to healing of 114.5 (53-210.3) days. Closure and plugging were the main successful strategies used for early and acute leaks/fistulas, while drainage was for late and chronic leaks/fistulas. Adverse events were observed in 13 patients (52%) with one serious adverse event. Patients with fistulas had a lower success rate (72.2% vs. 100%, P = 0.052). Of those with clinical failure (n = 5), four underwent reconstructive surgery, eventually led to success in 3 patients. The other one died of septic shock related to a complicated fistula. CONCLUSIONS: Complex multi-modality endoscopic management ultimately achieved clinical success in most cases of refractory leaks/fistulas post-bariatric with an acceptable safety profile. However, a close follow-up to detect the development of long-term failure is warranted. These patients should be referred to a specialized bariatric center with expertise in bariatric endoscopy and surgery.

Revisional endoscopic sleeve gastroplasty of laparoscopic sleeve gastrectomy: an international, multicenter study.

BACKGROUND AND AIMS: Laparoscopic sleeve gastrectomy (LSG) facilitates significant and durable weight loss; however, weight recidivism and need for revisional surgery occur in a subset of patients. Reduction of a dilated LSG using the revisional endoscopic sleeve gastroplasty (R-ESG) approach is an appealing and minimally invasive alternative to surgical revision that is congruent with obesity as a chronic relapsing disease model. In this study, we examine the safety and efficacy of the technique in a large multicenter international cohort. METHODS: Prospectively collected data from 9 centers for 82 consecutive adults who underwent R-ESG for weight regain after LSG using the OverStitch device (Apollo Endosurgery, Austin, Tex, USA) from March 2014 to November 2019 were reviewed. Total body weight loss (TBWL) and adverse events were reported up to 12 months. Univariable logistic regression was used to identify predictors of response at 12 months. RESULTS: Eighty-two adults (92.7% female) experienced 27.9 ± 20.7 kg weight regain from post-LSG nadir weight, prompting R-ESG (mean age, 42.8 ± 10.4 years) at a mean weight of 128.2 ± 57.5 kg. Mean R-ESG procedure duration was 48.3 ± 20.5 minutes, and the median number of sutures used was 4 (interquartile range, 3-4). After R-ESG, TBWL (follow-up %) was 6.6% ± 3.2% at 1 month (81.7%), 10.6% ± 4.4% at 3 months (74.4%), 13.2% ± 10.1% at 6 months (63.4%), and 15.7% ± 7.6% at 12 months (51.2%). In a per-protocol analysis, ≥10% TBWL was achieved by 37 of 51 patients (72.5%) at 6 months and 34 of 42 patients (81.0%) at 12 months; ≥15% TBWL was achieved by 20 of 46 patients (43.5%) at 6 months and 22 of 42 patients (52.4%) at 12 months. Only 1 moderate adverse event occurred in the form of a narrowed gastroesophageal junction, which resolved after a single endoscopic dilation. CONCLUSIONS: R-ESG is a safe and effective means of facilitating weight loss for weight recidivism after LSG, with sustained results at 1 year. R-ESG should be considered before pursuing more-invasive surgical revisional options.

Long-term outcomes of Roux-en-Y gastric diversion after failed surgical fundoplication in a large cohort and a systematic review.

BACKGROUND: Roux-en-Y gastric diversion (RNYG) is an alternative approach for patients with persistent or recurrent gastroesophageal reflux disease (GERD) after surgical fundoplication, especially in patients with esophageal dysmotility or morbid obesity, because redo fundoplication could offer unfavorable outcomes. OBJECTIVE: To evaluate long-term outcomes of RNYG for failed fundoplication and its impact on esophageal function. SETTING: A retrospective cohort study and a systematic review. METHODS: Patients who underwent RNYG after failed fundoplication between 1995 and 2019 were identified. Surgical-related complications, GERD, dysphagia, and endoscopic and esophageal manometric findings were reviewed. A literature search for relevant studies was performed from several databases from database inception to September 2019. RESULTS: A total of 101 patients (mean age, 52.1 yr; 86.1% female; mean body mass index, 35.8 kg/m2) were included. Overall complication rates within and more than 30 days after surgery were 36.3% and 53.5%. GERD symptoms were resolved in 70.1% after RNYG. However, 39.7% had a recurrence during a median follow-up of 56.2 months. In patients with no baseline dysphagia (n = 36), 16 (44%) developed new-onset dysphagia after surgery. In patients with severe baseline dysphagia (n = 9), 5 patients (56%) had persistent dysphagia after surgery. Seven studies involving 381 patients were included in our systematic review. High rates of GERD improvement have been reported across studies; however, long-term GERD, dysphagia, and objective outcomes were infrequently reported. CONCLUSION: RNYG is an effective alternative surgery in a subset of patients with intractable symptoms who failed fundoplication. However, patients should be informed of the risks of postoperative GERD symptoms and dysphagia. Referral for a careful evaluation by a multidisciplinary foregut team is warranted.

A Preclinical Animal Study of Combined Intragastric Balloon and Duodenal-Jejunal Bypass Liner for Obesity and Metabolic Disease.

INTRODUCTION: Endoscopic bariatric and metabolic therapies can potentially reproduce similar gastric and small intestinal anatomic and physiologic manipulations as Roux-en-Y gastric bypass. This proof of concept animal study was aimed to assess the feasibility, safety, efficacy, and impact on gastrointestinal physiology of combined intragastric balloons (IGB) and duodenal-jejunal bypass liner (DJBL) for the treatment of obesity. METHODS: Five Ossabaw pigs were fed a high-calorie diet to develop obesity and were randomly assigned to receive IGB or DJBL in sequence. The weight gain rate was calculated. Fasting and postprandial blood samples were drawn before any intervention (serving as the baseline group) and 1 month after second device insertion (serving as the combination group) to measure gut neurohormonal changes and metabolic parameters. RESULTS: Four pigs successfully received a sequential device insertion. One pig developed duodenal sleeve prolapse that was spontaneously resolved. One pig was early terminated because of developing a central line infection. The rate of weight gain in the combination group (0.63 ± 1.3 kg/wk) was significantly lower than the baseline group (1.96 ± 2.17 kg/wk) and numerically lower than after insertion of the IGB (1.00 ± 1.40 kg/wk) or the DJBL (0.75 ± 2.27 kg/wk) alone. A trend of higher postprandial glucagon-like peptide-1 was observed in the combination group compared with the baseline group. DISCUSSION: A combination of IGB and DJBL is feasible and well tolerated. A strategy of sequential use of these devices might offer a synergistic approach that can enhance weight loss and metabolic outcomes.

Esophageal Pathophysiologic Changes and Adenocarcinoma After Bariatric Surgery: A Systematic Review and Meta-Analysis.

INTRODUCTION: To assess the effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on acid reflux and esophageal motor function and to evaluate the observation of esophageal adenocarcinoma (EAC) after bariatric surgery. METHODS: We searched 5 databases for adults who underwent SG or RYGB and had esophageal pH test and/or esophageal manometry before and after surgery. A separate systemic search of observational studies and a retrospective review at 3 institutions of adults who developed EAC after these surgeries were conducted. Outcomes were changes in manometric and pH parameters and EAC cases after SG and RYGB. RESULTS: A total of 27 nonrandomized studies (SG: 612 patients; RYGB: 470 patients) were included. After SG, lower esophageal sphincter pressure and esophageal body amplitude were decreased and the risk of ineffective esophageal motility was increased. Total and recumbent acid exposure times were increased. After RYGB, an increased risk of ineffective esophageal motility was observed. Total, upright, and recumbent acid exposure times were decreased. The total reflux episodes remained unchanged but with increased nonacid reflux and decreased acid reflux events. Including our largest series, 31 EAC cases have been reported to date after SG and RYGB. DISCUSSION: This systematic review demonstrates increased acid reflux after SG and decreased acid reflux after RYGB. An observed increased nonacid reflux after RYGB might contribute to failure of gastroesophageal reflux disease improvement. This refluxate might be noxious to the esophagus, warranting further studies. RYGB might not entirely preserve esophageal function as previously believed.

A protocolized approach to endoscopic hydrostatic versus pneumatic balloon dilation therapy for gastric sleeve stenosis: a multicenter study and meta-analysis.

BACKGROUND: Gastric sleeve stenosis (GSS) is reported in .7% to 4% of cases after sleeve gastrectomy. Two endoscopic balloon dilation techniques are available with no clear consensus on the therapeutic approach. OBJECTIVES: To compare the treatment efficacy and safety between hydrostatic and pneumatic balloon dilations for GSS. SETTING: Academic referral centers, United States and a meta-analysis. METHODS: Consecutive patients who presented with GSS and underwent endoscopic hydrostatic and/or pneumatic balloon dilations at 3 tertiary care hospitals were included. Clinical success was defined as an improvement of symptoms that allowed the patient to avoid further interventions. A systematic literature search was performed to identify relevant studies for meta-analysis. RESULTS: Of 46 patients, 13 had pneumatic dilation only, 26 had hydrostatic dilation only, and 7 had pneumatic dilation after failed hydrostatic dilation. Clinical success was not significantly different among the 3 groups with the success rates of 30.8%, 57.6%, and 57.1% (P = .25) after single dilation and 61.5%, 63.6%, and 71.4% (P = .90) after serial dilations in the pneumatic group, hydrostatic group, and pneumatic after failed hydrostatic group, respectively. Patients who failed hydrostatic balloon dilation (n = 7) had a success rate of 71.4% with subsequent pneumatic dilation. Two serious adverse events were observed in the pneumatic group, whereas none were observed in the hydrostatic group. A meta-analysis of 16 studies involving 360 patients demonstrated higher clinical success with single pneumatic balloon dilation compared with hydrostatic balloon dilation (62.2% versus 36.4%; P = .007) with higher adverse events (3 versus 0 events). CONCLUSIONS: Hydrostatic balloon dilation should be considered as an initial modality for GSS given its acceptable success rate and high safety profile. In those who fail hydrostatic balloon dilation, a subsequent step-up approach to pneumatic balloon dilation or revisional surgery should be attempted.