Long-term weight loss of distal gastric bypass is moderately superior compared to proximal gastric bypass in patients with a BMI of 37-44 Kg/m2.

PURPOSE: The laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the standard procedures in metabolic surgery. Different limb lengths have been proposed in the past to maximize weight loss (WL) and reduce metabolic complications. Distal gastric bypass surgery with a very short common channel (CC) (up to 100 cm) has been often criticized due to frequent side effects such as malnutrition, bone weakening and short-bowel syndrome. We introduced a modified version of a distal LRYGB with a 50-70 cm long biliopancreatic limb (BPL) and an intermediate short CC (120-150 cm). Our primary goal was to compare the long-term WL between distal and proximal LRYGB in two cohorts of patients. Secondary outcomes were weight regain (WR), insufficient weight loss (IWL), postoperative complications and metabolic changes 5 years after surgery. METHODS: In this retrospective study we collected data from 160 patients operated between 2014 and 2015, with a BMI of 37-44 Kg/m2. 101 patients underwent a distal and 59 patients a proximal LRYGB in two bariatric centers. WL was calculated as percent of excess of BMI loss (%EBMIL), loss of body mass index (Delta-BMI), percent of excess weight loss (%EWL) and percent of total weight loss (%TWL). Data were collected 3, 6, 9, 12, 24, 48 and 60 months after surgery. RESULTS: The distal LRYGB resulted in significantly better 5-year-WL compared to the proximal bypass in terms of %EBMIL (median at 5 years: 83% vs. 65%, p = 0.001), %TWL (median at 5 years: 32% vs. 26%, p = 0.017) and %EWL (median at 5 years: 65% vs. 51%, p = 0.029), with equal major complications and metabolic alterations. In addition, WR was significantly lower in patients with distal bypass (18% vs. 35%, p = 0.032). CONCLUSIONS: Distal LYRGB with a 120-150 long CC results in better WL and WL-maintenance compared to proximal LRYGB without major side effects after five years.

Assessment of liver function by gadoxetic acid avidity in MRI in a model of rapid liver regeneration in rats.

BACKGROUND: This animal study investigates the hypothesis of an immature liver growth following ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) by measuring liver volume and function using gadoxetic acid avidity in magnetic resonance imaging (MRI) in models of ALPPS, major liver resection (LR) and portal vein ligation (PVL). METHODS: Wistar rats were randomly allocated to ALPPS, LR or PVL. In contrast-enhanced MRI scans with gadoxetic acid (Primovist®), liver volume and function of the right median lobe (=future liver remnant, FLR) and the deportalized lobes (DPL) were assessed until post-operative day (POD) 5. Liver functionFLR/DPL was defined as the inverse value of time from injection of gadoxetic acid to the blood pool-corrected maximum signal intensityFLR/DPL multiplied by the volumeFLR/DPL. RESULTS: In ALPPS (n = 6), LR (n = 6) and PVL (n = 6), volumeFLR and functionFLR increased proportionally, except on POD 1. Thereafter, functionFLR exceeded volumeFLR increase in LR and ALPPS, but not in PVL. Total liver function was significantly reduced after LR until POD 3, but never undercuts 60% of its pre-operative value following ALPPS and PVL. DISCUSSION: This study shows for the first time that functional increase is proportional to volume increase in ALPPS using gadoxetic acid avidity in MRI.

Current trends in regenerative liver surgery: Novel clinical strategies and experimental approaches.

Liver resections are performed to cure patients with hepatobiliary malignancies and metastases to the liver. However, only a small proportion of patients is resectable, largely because only up to 70% of liver tissue is expendable in a resection. If larger resections are performed, there is a risk of post-hepatectomy liver failure. Regenerative liver surgery addresses this limitation by increasing the future liver remnant to an appropriate size before resection. Since the 1980s, this surgery has evolved from portal vein embolization (PVE) to a multiplicity of methods. This review presents an overview of the available methods and their advantages and disadvantages. The first use of PVE was in patients with large hepatocellular carcinomas. The increase in liver volume induced by PVE equals that of portal vein ligation, but both result only in a moderate volume increase. While awaiting sufficient liver growth, 20%-40% of patients fail to achieve resection, mostly due to the progression of disease. The MD Anderson Cancer Centre group improved the PVE methodology by adding segment 4 embolization ("high-quality PVE") and demonstrated that oncological results were better than non-surgical approaches in this previously unresectable patient population. In 2012, a novel method of liver regeneration was proposed and called Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS). ALPPS accelerated liver regeneration by a factor of 2-3 and increased the resection rate to 95%-100%. However, ALPPS fell short of expectations due to a high mortality rate and a limited utility only in highly selected patients. Accelerated liver regeneration, however, was there to stay. This is evident in the multiplicity of ALPPS modifications like radiofrequency or partial ALPPS. Overall, rapid liver regeneration allowed an expansion of resectability with increased perioperative risk. But, a standardized low-risk approach to rapid hypertrophy has been missing and the techniques used and in use depend on local expertise and preference. Recently, however, simultaneous portal and hepatic vein embolization (PVE/HVE) appears to offer both rapid hypertrophy and no increased clinical risk. While prospective randomized comparisons are underway, PVE/HVE has the potential to become the future gold standard.

Bouveret's Syndrome - Case Series with Therapeutic Implications.

Bouveret's syndrome is a rare complication resulting from gallstone disease. Both surgical and endoscopical procedures are performed, with the disease to be seen as strictly interdisciplinary. There are no well-established recommendations for this condition. In this paper, we want to describe our experience from 6 cases in 3 Swiss hospitals from 2015 to 2017 with emphasis on the endoscopic technique of electrohydraulic lithotripsy followed by balloon dilatation and propose a treatment algorithm.

[Metabolic surgery in patients with poorly controlled type 2 diabetes and low BMI]. / Metabole Chirurgie zur Behandlung des schwer einstellbaren Diabetes mellitus Typ 2 und tiefem BMI.

Metabolic surgery in patients with poorly controlled type 2 diabetes and low BMI Abstract. Bariatric surgery has been established as an efficient therapy for morbid obesity. Metabolic surgery represents the operative treatment of type 2 diabetes and other metabolic disorders. Metabolic surgery does not focus on weight loss, as many mechanisms, which are responsible for the improvement of the glycemic control are independent from weight loss. There are many studies, which show the efficient effect of metabolic surgery in diabetic patients with class II obesity. Furthermore, there is growing evidence, that metabolic surgery does also work in patients with a BMI below 35 kg / m2. Multiple surgical and endocrinological associations have endorsed these facts and adopted their guidelines. In obese type 2 diabetics with a BMI below 35 kg / m2 and a poor glycemic control metabolic surgery should be considered as a therapeutic option.

Recurrence Patterns and Long-term Results After Induction Chemotherapy, Chemoradiotherapy, and Curative Surgery in Patients With Locally Advanced Esophageal Cancer.

OBJECTIVE: The long-term follow up data of 2 prospective phase II trials is reported (NCT00072033, NCT00445861), which investigated neoadjuvant chemoradiation followed by surgery in patients with esophageal carcinoma. Postoperative complications as well as prognostic factors and patterns of relapse during long-term observation are shown. SUMMARY OF BACKGROUND DATA: Long-term follow-up is often missing in the complex setting of multimodal treatments of esophageal carcinoma; this leads to rather undifferentiated follow-up guidelines for this tumor entity. METHODS: In the first trial, patients received induction chemotherapy followed by chemoradiation and surgery. In the second trial, cetuximab was added to the same neoadjuvant treatment concomitant with induction chemotherapy and chemoradiation. RESULTS: Eighty-two patients underwent surgery; the median follow-up time was 6.8 and 6.4 years, respectively. Fifty-five percent were diagnosed with adenocarcinoma, 80% clinically node-positive, 68% received transthoracic esophagectomy, and 32% transhiatal or transmediastinal resection. Five patients died postoperatively in-hospital due to complications (6%). The median overall survival was 4.3 years, and the median event-free survival was 2.7 years. Patients with adenocarcinoma rarely relapsed after a 3-year event-free survival. Whereas patients with residual tumor cells after neoadjuvant therapy primarily experienced relapse within the first 2 postoperative years, this in contrast to several patients with complete remission who also experienced late relapses 4 years after surgery. CONCLUSION: After curative surgery in a multimodal setting, the histological type and the response to neoadjuvant therapy predicted the time frame of relapse; this knowledge may influence further follow-up guidelines for esophageal carcinoma.

Diagnosis, assessment, and management of surgical complications following esophagectomy.

Despite improvements in operative strategies for esophageal resection, anastomotic leaks, fistula, postoperative pulmonary complications, and chylothorax can occur. Our review seeks to identify potential risk factors, modalities for early diagnosis, and novel interventions that may ameliorate the potential adverse effects of these surgical complications following esophagectomy.

Hand-assisted living-donor nephrectomy: a retrospective comparison of two techniques.

BACKGROUND: Living-donor nephrectomy (LDN) is challenging, as surgery is performed on healthy individuals. Minimally invasive techniques for LDN have become standard in most centers. Nevertheless, numerous techniques have been described with no consensus on which is the superior approach. Both hand-assisted retroperitoneoscopic (HARS) and hand-assisted laparoscopic (HALS) LDNs are performed at Zurich University Hospital. The aim of this study was to compare these two surgical techniques in terms of donor outcome and graft function. METHOD: Retrospective single-center analysis of 60 consecutive LDNs (HARS n = 30; HALS n = 30) from June 2010 to May 2012, including a one-year follow-up of the recipients. RESULTS: There was no mortality in either group and little difference in the overall complication rates. Median warm ischemia time (WIT) was significantly shorter in the HARS group. The use of laxatives and the incidence of postoperative vomiting were significantly greater in the HALS group. There was no difference between right- and left-sided nephrectomies in terms of donor outcome and graft function. CONCLUSIONS: Both techniques appear safe for both donors and donated organs. The HARS technique is associated with a shorter WIT and a reduced incidence of postoperative paralytic ileus. Therefore, we consider HARS LDN a valuable alternative to HALS LDN.

MRI and PET-CT Failed to Differentiate Between Hepatic Malignancy and Brucelloma.

Brucellosis is a common, worldwide zoonosis. Clinical presentation is protean and often goes unrecognized. Hepatic brucelloma is a rare local complication of chronic brucellosis. We report a case in which magnetic resonance imaging and positron emission tomography imaging prompted suspicion of a hepatic malignancy. Diagnosis was ultimately made by serology and polymerase chain reaction of resected liver tissue.

Effect of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Roux-en-Y Gastric Bypass on Weight Loss in Patients With Morbid Obesity: The SM-BOSS Randomized Clinical Trial.

Importance: Sleeve gastrectomy is increasingly used in the treatment of morbid obesity, but its long-term outcome vs the standard Roux-en-Y gastric bypass procedure is unknown. Objective: To determine whether there are differences between sleeve gastrectomy and Roux-en-Y gastric bypass in terms of weight loss, changes in comorbidities, increase in quality of life, and adverse events. Design, Setting, and Participants: The Swiss Multicenter Bypass or Sleeve Study (SM-BOSS), a 2-group randomized trial, was conducted from January 2007 until November 2011 (last follow-up in March 2017). Of 3971 morbidly obese patients evaluated for bariatric surgery at 4 Swiss bariatric centers, 217 patients were enrolled and randomly assigned to sleeve gastrectomy or Roux-en-Y gastric bypass with a 5-year follow-up period. Interventions: Patients were randomly assigned to undergo laparoscopic sleeve gastrectomy (n = 107) or laparoscopic Roux-en-Y gastric bypass (n = 110). Main Outcomes and Measures: The primary end point was weight loss, expressed as percentage excess body mass index (BMI) loss. Exploratory end points were changes in comorbidities and adverse events. Results: Among the 217 patients (mean age, 45.5 years; 72% women; mean BMI, 43.9) 205 (94.5%) completed the trial. Excess BMI loss was not significantly different at 5 years: for sleeve gastrectomy, 61.1%, vs Roux-en-Y gastric bypass, 68.3% (absolute difference, -7.18%; 95% CI, -14.30% to -0.06%; P = .22 after adjustment for multiple comparisons). Gastric reflux remission was observed more frequently after Roux-en-Y gastric bypass (60.4%) than after sleeve gastrectomy (25.0%). Gastric reflux worsened (more symptoms or increase in therapy) more often after sleeve gastrectomy (31.8%) than after Roux-en-Y gastric bypass (6.3%). The number of patients with reoperations or interventions was 16/101 (15.8%) after sleeve gastrectomy and 23/104 (22.1%) after Roux-en-Y gastric bypass. Conclusions and Relevance: Among patients with morbid obesity, there was no significant difference in excess BMI loss between laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass at 5 years of follow-up after surgery. Trial Registration: clinicaltrials.gov Identifier: NCT00356213.

Planned secondary wound closure at the circular stapler insertion site after laparoscopic gastric bypass reduces postoperative morbidity, costs, and hospital stay.

PURPOSE: The aims of the present study were to assess whether planned secondary wound closure at the insertion site of the circular stapler reduces wound infection rate and postoperative morbidity after laparoscopic Roux-en-Y gastric bypass (RYGB) and to identify independent predictive factors increasing the risk for wound infections after RYGB. METHODS: This paper is a retrospective single-center analysis of a prospectively collected database of 1400 patients undergoing RYGB surgery in circular technique between June 2000 and June 2016. Planned secondary wound closure at the circular stapler introduction site was performed at postoperative day 3 in 291 (20.8%) consecutive patients and compared to a historical control of 1109 (79.2%) consecutive patients with primary wound closure. Independent predictive factors for wound infection were assessed by multivariable analysis. RESULTS: Secondary wound closure significantly decreased wound infection rate from 9.3% (103/1109) to 1% (3/291) (p < 0.001) leading to a shorter hospital stay (mean 9 (SD8) vs. 7 days (SD2), p < 0.001), lower costs (p = 0.039), and reduced postoperative morbidity (mean 90-day Comprehensive Complication Index (CCI) 7.4 (SD14.0) vs. 5.1 (SD11.1) p = 0.008) when compared to primary wound closure. Primary wound closure, dyslipidemia, and preoperative gastritis were independent predictive risk factors for developing wound infections both in the univariate (p < 0.001; p = 0.048; p = 0.003) and multivariable analysis (p < 0.001; p = 0.040; p = 0.012). Further, on multivariable analysis, the female gender was a predictive factor (p = 0.034) for wound infection development. CONCLUSIONS: Secondary wound closure at the circular stapler introduction site in laparoscopic RYGB significantly reduces the overall wound infection rate as well as postoperative morbidity, costs, and hospital stay when compared to primary wound closure.

Linear stapled gastrojejunostomy results in fewer strictures compared to circular stapled gastrojejunostomy in laparoscopic gastric bypass surgery.

PURPOSE: Currently, there are two laparoscopic stapling techniques to perform the gastrojejunostomy in gastric bypass surgery: the linear stapling and circular stapling techniques. The aim of the study was to compare the two techniques regarding postoperative morbidity and weight loss at an accredited bariatric reference center in Switzerland. METHODS: We compared two consecutive cohorts at a single institution between November 2012 and June 2014 undergoing laparoscopic gastric bypass surgery. The frequency of complications and weight loss at 1 year was assessed in 109 patients with the 21-mm circular stapling technique (CSA) and 134 patients with the linear stapling technique (LSA). RESULTS: Postoperative complications were more frequent in the CSA group with 23.9 versus 4.5% in the LSA group (p = <0.0001). The main difference was the frequency of strictures, which occurred in 15.6% in the CSA group versus 0% in the LSA group. As a result, endoscopic dilation was required at least once in 15 patients. There was no statistically significant difference in percentage of excessive weight loss (EWL) in both groups; EWL was 74% in the CSA group and 73% in the LSA group (p = 0.68). CONCLUSION: Linear stapled laparoscopic gastric bypass had fewer stenotic strictures with similar weight loss at 1 year compared to circular stapling technique.

Prognostic Value of Negative Coronary CT Angiography in Severely Obese Patients Prior to Bariatric Surgery: a Follow-Up After 6 Years.

BACKGROUND: This study aims to determine the long-term prognostic value of coronary CT angiography (CCTA) prior to bariatric surgery in severely obese patients with a body mass index (BMI) ≥35 kg/m2. MATERIAL AND METHODS: Seventy consecutive patients undergoing cardiac CT for coronary assessment prior to bariatric surgery were prospectively included. Images were analysed for the presence of coronary calcification and for non-obstructive (<50%) or obstructive (>50% stenosis) coronary artery disease (CAD). A median clinical follow-up of 6.1 years in 54 patients was obtained for major adverse cardiovascular events (MACEs), defined as death, non-fatal myocardial infarction or coronary revascularisation. Weight loss and BMI decrease following bariatric surgery were recorded. RESULTS: The median BMI prior to surgery was 46.9 kg/m2. The median percentage of excess BMI loss after surgery was 75%. CT showed coronary calcification in 26 (48%) patients, whereas 28 (52%) patients had no calcification. CCTA revealed normal coronaries in 47 (87%) and non-obstructive CAD in 7 (13%) patients. No obstructive CAD was found. All patients successfully underwent bariatric surgery, and no MACE occurred neither perioperatively nor in the follow-up period. The negative predictive value of CCTA was 100% (95% confidence interval of 90.1-100.0%). CONCLUSIONS: In severely obese patients, the absence of obstructive CAD in cardiac CT prior to bariatric surgery with subsequently marked weight reduction has strong long-term prognostic implications for ruling out major adverse cardiac events in the postoperative period.

The More the Better-Lower Rate of Stage Migration and Better Survival in Patients With Retrieval of 20 or More Regional Lymph Nodes in Pancreatic Cancer: A Population-Based Propensity Score Matched and Trend SEER Analysis.

OBJECTIVE: The aim of this study was to assess the influence of regional lymph node (RLN) retrieval on stage migration and survival in pancreatic cancer. METHODS: A total of 7685 stage I and II pancreatic cancer patients were identified in the Surveillance, Epidemiology, and End Results database in 2004-2011. The impact of RLN was assessed using Cox regression, propensity score methods, and joinpoint regression. RESULTS: In 3079 patients, 1 to 10 RLNs were retrieved; in 2799 patients, 11 to 19 RLNs, and in 1807 patients, 20+ RLNs. The rate of node-positive pancreatic cancer increased with the number of retrieved RLN. This trend continued beyond 10 retrieved RLN (P < 0.001). In unadjusted analysis, retrieval of RLN did not influence survival (P = 0.178). When adjusting for significant bias in staging variables (P < 0.001), retrieval of 20+ RLNs compared to 11 to 19 RLNs was associated with an increased survival in node-negative (hazard ratio, 0.78; 95% confidence interval, 0.62-0.98; P = 0.033) and node-positive cancer (hazard ratio, 0.83; 95% confidence interval, 0.74-0.93; P = 0.002). CONCLUSIONS: This population-based propensity score-adjusted investigation demonstrated that more retrieved RLNs in pancreatic cancer decreases the rate of stage migration and improves the oncological outcome in node-negative and positive cancer. Contradictory results may be explained by a bias in the cancer characteristics for a different extent of RLN retrieval.

Laparoscopic Sleeve Gastrectomy Versus Roux-Y-Gastric Bypass for Morbid Obesity-3-Year Outcomes of the Prospective Randomized Swiss Multicenter Bypass Or Sleeve Study (SM-BOSS).

OBJECTIVE: Laparoscopic sleeve gastrectomy (LSG) is performed almost as often in Europe as laparoscopic Roux-Y-Gastric Bypass (LRYGB). We present the 3-year interim results of the 5-year prospective, randomized trial comparing the 2 procedures (Swiss Multicentre Bypass Or Sleeve Study; SM-BOSS). METHODS: Initially, 217 patients (LSG, n = 107; LRYGB, n = 110) were randomized to receive either LSG or LRYGB at 4 bariatric centers in Switzerland. Mean body mass index of all patients was 44 ±â€Š11 kg/m, mean age was 43 ±â€Š5.3 years, and 72% of patients were female. Minimal follow-up was 3 years with a rate of 97%. Both groups were compared for weight loss, comorbidities, quality of life, and complications. RESULTS: Excessive body mass index loss was similar between LSG and LRYGB at each time point (1 year: 72.3 ±â€Š21.9% vs. 76.6 ±â€Š20.9%, P = 0.139; 2 years: 74.7 ±â€Š29.8% vs. 77.7 ±â€Š30%, P = 0.513; 3 years: 70.9 ±â€Š23.8% vs. 73.8 ±â€Š23.3%, P = 0.316). At this interim 3-year time point, comorbidities were significantly reduced and comparable after both procedures except for gastro-esophageal reflux disease and dyslipidemia, which were more successfully treated by LRYGB. Quality of life increased significantly in both groups after 1, 2, and 3 years postsurgery. There was no statistically significant difference in number of complications treated by reoperation (LSG, n = 9; LRYGB, n = 16, P = 0.15) or number of complications treated conservatively. CONCLUSIONS: In this trial, LSG and LRYGB are equally efficient regarding weight loss, quality of life, and complications up to 3 years postsurgery. Improvement of comorbidities is similar except for gastro-esophageal reflux disease and dyslipidemia that appear to be more successfully treated by LRYGB.

Modest overall survival improvements from 1998 to 2009 in metastatic gastric cancer patients: a population-based SEER analysis.

BACKGROUND: An increasing fraction of gastric cancer patients present with distant metastases at diagnosis. The objective of the present 11-year population-based trend analysis was to assess the survival rates in patients who underwent and in patients who did not undergo palliative gastrectomy. METHODS: Patients with metastatic gastric cancer were identified from the Surveillance, Epidemiology, and End Results (SEER) database between 1998 and 2009. Time trend and impact of palliative gastrectomy on survival were assessed by both a multivariate Cox proportional hazards model and propensity score matching. RESULTS: We identified 8249 patients with stage IV gastric cancer. The rate of metastatic disease increased from 31.0 % in 1998 to 37.5 % in 2009 (P < 0.001). The palliative gastrectomy rate dropped from 18.8 to 10.2 % (P = 0.004). The median survival for patients who underwent palliative gastrectomy (N = 1445, 17.4 %) and for patients who did not undergo palliative gastrectomy (N = 6804, 82.4 %) was 7 and 3 months, respectively. There was an increase in median overall survival from 2 months (1998) to 3 months (2009) in the no-gastrectomy group, and from 6.5 to 8 months in the gastrectomy group. The 3-year cancer-specific survival rates were 2.1 % (95 % confidence interval 1.7-2.5 %) for patients who did not undergo palliative gastrectomy and 9.4 % (95 % confidence interval 7.8-11.2 %) for patients who underwent palliative gastrectomy (P < 0.001). Palliative gastrectomy was associated with an increased cancer-specific survival in propensity-score-adjusted Cox regression analyses (hazard ratio 0.50, 95 % confidence interval 0.46-0.55, P < 0.001). CONCLUSION: On a population-based level, only modest improvements in prognosis for metastatic gastric cancer were observed in patients who underwent and in patients who did not undergo palliative gastrectomy. Considering the low rate of midterm survivors in both groups, only a small subgroup of patients benefits from palliative gastrectomy.

Where to begin and where to end? Preoperative assessment for patients undergoing metabolic surgery.

Bariatric surgery is the most effective treatment of obesity and its associated diseases like type 2 diabetes mellitus. Given the obesity epidemic and the efficacy of surgical treatment, the number of surgical weight loss procedures has grown in recent years. Nevertheless, there is little consensus regarding the extent of preoperative investigations required prior to patients undergoing surgery. This article aims to discuss the available evidence on which preoperative tests are useful for the detection and treatment of conditions such as venous thromboembolism, obstructive sleep apnea syndrome and Helicobacter pylori-positive gastritis prior to an operation. The present literature suggests that only a few preoperative investigations are essential, but that preoperative multidisciplinary care is beneficial.

Gastric bypass: current results and different techniques.

Obesity has been steadily increasing over the last three decades and is one of the leading causes of increased health costs due to its associated comorbidities. Unfortunately, conservative treatment including lifestyle changes did not achieve the desired results. Bariatric surgery, on the other hand, has emerged as an effective and safe treatment for obesity and its related comorbidities such as type 2 diabetes. Much time has passed since the first Roux-en-Y gastric bypass was performed in the 1960s, and the operation technique has since evolved. New variations such as the distal gastric bypass as well as the omega loop bypass have been developed. Today, the laparoscopic gastric bypass is still the most widely applied bariatric operation technique, followed by laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding. The refinement of the surgical technique and the introduction of laparoscopy have resulted in low perioperative morbidity and mortality after gastric bypass surgery. In this article, we will be discussing the history of gastric bypass surgery as well as presenting current data on excessive weight loss and resolution of comorbidities with a focus on diabetes. We will be looking into newer techniques such as omega loop bypass and their efficacy compared to the standard gastric bypass. Furthermore, we will be addressing the most important early and long-term complications, their diagnostic strategies as well as their management.

Operative strategies for patients with failed primary bariatric procedures.

Bariatric surgery is the most effective therapy to treat obesity and its sequelae. With the increasing incidence of obesity, the number of bariatric procedures has dramatically increased in recent years. The perioperative morbidity reached a very low level, and nearly all revisional bariatric procedures are primarily minimally invasive today. About 10-25% of the patients undergoing bariatric surgery require a revision at some point after their initial operation. Consequently, revisional bariatric surgery has emerged as a distinct practice, performed mainly at tertiary centers, to resolve complications caused by the primary operation and to provide satisfactory weight loss. In this review, our personal experience with revisional bariatric surgery is discussed against the background of the available literature. We further attempt to define major indications for revisional bariatric surgery and balance them with perioperative and long-term morbidity as well as the surgical outcome.