Long-term outcomes of magnetic sphincter augmentation in sleeve gastrectomy and Roux-en-Y gastric bypass patients: a comprehensive analysis.

INTRODUCTION: Management of gastroesophageal reflux disease after bariatric procedures can be challenging. There are very few long-term studies in this arena. This study aims to evaluate the long-term outcomes of the magnetic sphincter augmentation (MSA) reflux management system in a cohort of bariatric patients who had previously undergone sleeve gastrectomy and Roux-en-Y gastric bypass, with a focus on assessing gastroesophageal reflux disease (GERD) scores, medication use, and patient-reported symptoms. METHODS: We conducted a retrospective chart review of 16 consecutive bariatric patients who received MSA implants following sleeve gastrectomy (n = 14) or gastric bypass (n = 2) surgeries. Data were collected regarding BMI, GERD quality of life assessments (GERD-HRQL), reflux symptoms, and use of PPIs in the sleeve/RGB patients through an extended period with a mean follow-up of 48 months. RESULTS: Patients were followed up for a range of .5-84 months. Preoperative assessments included upper gastrointestinal imaging (UGI), high-resolution manometry, Bravo pH studies, and esophagogastroduodenoscopy (EGD). Three patients exhibited reflux on UGI, and 13/13 patients had positive Bravo studies preoperatively. Sixteen patients had a lower esophageal sphincter (LES) pressure under 18 mmHg, and eight patients had biopsy-proven esophagitis. Long-term outcomes are as follows. Daily PPI use fell from 88 to 25% at greater than three years. GERD-HRQL scores fell from 50.6 at baseline (range 27-70) and normalized at long-term follow-up. GERD symptom of regurgitation completely resolved. At long term, two patients had dysphagia and two patients had ongoing reflux. No adverse events were noted. CONCLUSION: This is the first long-term outcomes study of magnetic sphincter augmentation placement after bariatric surgery. Our study showed the majority of patients had long-term improvement in GERD-HRQL scores and resolution/ relief of their reflux symptoms, with decreased use of PPIs. MSA is a safe, effective and durable management tool for reflux after bariatric surgery in carefully selected patients.

Five-year outcomes of revisional bariatric surgery: gastric band to sleeve gastrectomy or to Roux-en-Y gastric bypass.

BACKGROUND: Revisional bariatric surgery after an index adjustable gastric band (AGB) may be indicated to remedy weight relapse or band-related complications. We examined outcomes five years following revision from AGB to laparoscopic sleeve gastrectomy (AGB-LSG) or to Roux-en-Y gastric bypass (AGB-RYGB). METHODS: We conducted a retrospective review to identify patients (men and women, age 18-80) who underwent one revisional bariatric procedure with AGB as the index procedure at two medical centers in our healthcare system between January 2012 and February 2017. We only included patients with a pre-revision BMI > 30 kg/m2 for whom 5-year follow-up data were available. We compared 5-year weight loss and remission of comorbidities in patients undergoing AGB-LSG and AGB-RYGB conversion. RESULTS: A total of 114 patients met inclusion criteria (65 AGB-LSG, 49 AGB-RYGB). At 5-year post-revision, percent total weight loss (3.4% vs 19.9%; p < 0.001), percent excess weight loss (7.0% vs 50.8%; p < 0.001) and decrease in BMI (1.5 vs 8.8; p < 0.001) was greater in AGB-RYGB vs. AGB-LSG. No significant difference in remission or development of new comorbidities was observed. CONCLUSION: Conversion of AGB to RYGB is associated with superior intermediate-term weight loss compared to conversion of AGB to LSG. Future multicenter studies with larger sample sizes are necessary to further describe the intermediate-term outcomes of revisional bariatric surgery.

Posterior fixation of gastric tube with fibrin sealant in laparoscopic sleeve gastrectomy: a promising method to prevent revision surgeries.

BACKGROUND: We aim to assess the effects of gastric posterior fixation with fibrin sealant in laparoscopic sleeve gastrectomy in aspects of 12th-month body mass index and gastric volume. METHODS: The patients who underwent laparoscopic sleeve gastrectomy between January 2019 and February 2021 were divided into two groups preoperatively. The first 75 patients were appointed to the posterior fixation group, and the second 75 were to the control group. Changes in gastric volume and body mass index were assessed in the postoperative 12th month. RESULTS: There were 110 patients in the final analysis. Fifty-four patients had posterior fixation, and 56 had only laparoscopic sleeve gastrectomy. The posterior fixation group was superior in terms of total weight loss rate (39.1% vs. 34.5%, p<0.001) and less gastric volume increase rate (39.8% vs. 164.7%, p<0.001) in the postoperative 12th month. CONCLUSION: Our study suggests that posterior fixation with fibrin sealant in laparoscopic sleeve gastrectomy is a promising method for preventing weight regain and creating a need for revision surgery.

Gastric bypass revisional surgery: percentage total body weight loss differences among three different techniques.

INTRODUCTION: Suboptimal weight loss or weight regain may occur after Roux-en-Y gastric bypass (RYGB). For this reason, revisional surgery has gained increasing interest. We aimed to compare the percentage of total body weight loss (%TBWL) at one-year follow-up among three different techniques: Jejuno-jejunostomy distalization (JJD), Sleeve resection of the gastrojejunostomy and gastric pouch (SRGJP), and the combination of both (JJD + SRGJP). METHODS: This retrospective cohort study included all patients who underwent revisional surgery after RYGB (2020-2021). The cohort was stratified by the type of revisional technique performed. Postoperative bariatric outcomes and nutritional deficiencies were compared among groups. RESULTS: A total of 78 patients underwent revisional surgery after RYGB: JJD was performed in 8 (10.3%), SRGJP in 34 (43.6%), and JJD + SRGJP in 36 (46.1%) patients. The most common indication for surgery was weight regain, in 72 (92.3%) patients. The median lengths of the BP limbs before and after distalization, were 50 cm (IQR 40-75 cm) and 175 cm (IQR 150-200 cm), respectively. The median length of the new common limb (NCL) and total alimentary limb length (TALL) were 277 cm (IQR 250-313 cm) and 400 cm (IQR 375-475 cm), respectively. Median percentage of total body weight loss (%TBWL) at one year was 15% (IQR 15-19%) for JJD, 20% (IQR 13-26%) for SRGJP, and 21% (IQR 15- 28%) for JJD + SRGJP (p = 0.40). CONCLUSIONS: In this study, the combined procedure (JJD + SRGJP) exhibited higher %TBWL at one year, however no statistically significant difference was identified among the three techniques.

One-Anastomosis Gastric Bypass (OABG) vs. Single Anastomosis Duodeno-Ileal Bypass (SADI) as revisional procedure following Sleeve Gastrectomy: results of a multicenter study.

PURPOSE: Sleeve Gastrectomy (SG) is the most performed bariatric surgery, but a considerable number of patients may require revisional procedures for suboptimal clinical response/recurrence of weight (SCR/RoW). Conversion options include One-Anastomosis Gastric Bypass (OAGB) and Single Anastomosis Duodeno-Ileal Bypass (SADI). The study aims to compare SADI vs. OAGB as revisional procedures in terms of early and mid-term complications, operative time, postoperative hospital stay and clinical outcomes. METHODS: All patients who underwent OAGB or SADI as revisional procedures following SG for SCR/RoW at three high-volume bariatric centers between January 2014 and April 2021 were included. Propensity score matching (PSM) analysis was performed. Demographic, operative, and postoperative outcomes of the two groups were compared. RESULTS: One hundred and sixty-eight patients were identified. After PSM, the two groups included 42 OAGB and 42 SADI patients. Early (≤ 30 days) postoperative complications rate did not differ significantly between OAGB and SADI groups (3 bleedings vs. 0, p = 0.241). Mid-term (within 2 years) complications rate was significantly higher in the OAGB group (21.4% vs. 2.4%, p = 0.007), mainly anastomotic complications and reflux disease (12% of OAGBs). Seven OAGB patients required conversion to another procedure (Roux-en-Y Gastric Bypass-RYGB) vs. none among the SADI patients (p = 0.006). CONCLUSIONS: SADI and OAGB are both effective as revisional procedures for SCR/RoW after SG. OAGB is associated with a significantly higher rate of mid-term complications and a not negligible rate of conversion (RYGB). Larger studies are necessary to draw definitive conclusions.

Morbidity Associated With Distal Tibial Autograft Harvest.

Distal tibial autograft harvesting has been studied in the past, but morbidity at the level of the donor site is unclear. The purpose of this retrospective review is to assess morbidity in distal tibial autograft harvesting associated with foot and ankle arthrodesis procedures. A retrospective analysis was performed utilizing patients treated in the last 13 years at a large, multicenter, academic, tertiary referral, research institution. Included patients were between the ages of 18 and 80 years old. One-hundred and seven patients (39 male; 68 female) underwent ipsilateral distal tibial bone graft (n = 110) harvesting to augment the index procedure. Patients were followed for an average of 11.2 months after surgery (Range: 1-73 months). The incidence rate of distal tibial stress fractures was 4.5%, with an overall postoperative complication rate of 8.2%. Overall, low complication rates associated with distal tibial autograft harvesting were found, supporting the use of the distal tibia as an appropriate site for autograft harvesting in foot and ankle surgery.

How to address weight regain after bariatric surgery in an individualized way.

Bariatric surgery is the most effective obesity treatment. As a chronic and progressive disease, weight loss response to surgery will vary individually. Thus, insufficient weight loss or regain can happen after surgery, but they lack a standard definition. There are different mechanisms underlying weight regain and/or insufficient weight loss, such as genetics, maladaptive eating behaviors, and the inadequate choice of index operations, among others. Patients with weight regain or insufficient weight loss should be submitted to an individualized and comprehensive evaluation by a multidisciplinary team. This may help identify the causes and direct the appropriate treatment individually. Options for patients with insufficient weight loss and/or weight regain following bariatric surgery include repair of postoperative complications, conversion into another operation, endoscopic therapies with inconsistent outcomes, and dietary/behavioral counseling. Revision and conversion surgeries have higher complication rates than primary operations. Although there is no standard pharmacological regimen for that indication, the new agents seem efficient and safe to promote the loss of the regained weight and even be adjunctive to selected patients before they reach the plateau. This review aims to summarize the knowledge of the best approach for patients with weight regain/insufficient weight loss and suggests an algorithm to customize the approach and therapeutic options after bariatric surgery.

The rising tide of revisional surgery: tracking changes in index cases among bariatric-accredited fellowships.

BACKGROUND: The field of bariatric surgery has seen peaks and troughs in the types of metabolic procedures performed. Our primary aim was to evaluate bariatric case volumes among fellows enrolled in bariatric Fellowship Council (FC)-accredited programs. Our secondary aim was to assess trends in revisional case volumes. METHODS: We reviewed de-identified FC case logs for all bariatric surgery-accredited programs from 2010 through 2019. The number of primary sleeve gastrectomy, gastric band, gastric bypass, biliopancreatic diversion, and major revisional bariatric surgical procedures (defined as a revision with creation of a new anastomosis) were graphed for each academic year. Fellows were stratified into quartiles based on the number of revisional operations per year and graphed over ten years. Volumes of primary gastric bypass, major revisions, and total anastomotic cases were compared over time using ANOVA with p < 0.05 considered significant. RESULTS: Case volumes for 822 fellows were evaluated. Sleeve gastrectomy had a significant surge in 2010 and plateaued in 2016. The fellows' number of primary gastric bypasses had a non-significant decrease from 84 to 75 cases/fellow from 2010 to 2019. This decrease was offset by a significant increase in major revisional surgery from 8 to 19 cases/fellow. As a result, the number of anastomotic cases did not change significantly over the study time period. Interestingly, as revisional volume has grown, the gap between quartiles of fellowship programs has widened with the 95th percentile growing at a much faster rate than lower quartiles. CONCLUSION: The volume of bariatric procedures performed in the last decade among FC fellows follows similar trends to national data. Major revisional cases have doubled with the most robust growth isolated to a small number of programs. As revisional surgery continues to increase, applicants interested in a comprehensive bariatric practice should seek out training programs that offer strong revisional experience.

Weight loss and clinical outcomes following primary versus secondary Roux-en-Y gastric bypass: a multi-institutional experience.

BACKGROUND: Revisional bariatric surgeries are increasing for weight recurrence and return of co-morbidities. Herein, we compare weight loss and clinical outcomes following primary Roux-en-Y Gastric Bypass (P-RYGB), adjustable gastric banding to RYGB (B-RYGB), and sleeve gastrectomy to RYGB (S-RYGB) to determine if primary versus secondary RYGB offer comparable benefits. METHODS: Participating institutions' EMRs and MBSAQIP databases were used to identify adult patients who underwent P-/B-/S-RYGB from 2013 to 2019 with a minimum one-year follow-up. Weight loss and clinical outcomes were assessed at 30 days, 1 year, and 5 years. Our multivariable model controlled for year, institution, patient and procedure characteristics, and excess body weight (EBW). RESULTS: 768 patients underwent RYGB: P-RYGB n = 581 [75.7%]; B-RYGB n = 106 [13.7%]; S-RYGB n = 81 [10.5%]. The number of secondary RYGB procedures increased in recent years. The most common indications for B-RYGB and S-RYGB were weight recurrence/nonresponse (59.8%) and GERD (65.4%), respectively. Mean time from index operation to B-RYGB or S-RYGB was 8.9 and 3.9 years, respectively. After adjusting for EBW, 1 year %TWL (total weight loss) and %EWL (excess weight loss) were greater after P-RYGB (30.4%, 56.7%) versus B-RYGB (26.2%, 49.4%) or S-RYGB (15.6%, 37%). Overall comorbidity resolution was comparable. Secondary RYGB patients had a longer adjusted mean length of stay (OR 1.17, p = 0.071) and a higher risk of pre-discharge complications or 30-day reoperation. CONCLUSION: Primary RYGB offers superior short-term weight loss outcomes compared to secondary RYGB, with decreased risk of 30-day reoperation.

The impact of prior endoscopic or surgical therapy on open Zenker's diverticulum surgery: analysis on a large single center cohort : Comparison of primary and revisional open surgery for Zenker's diverticulum.

BACKGROUND: Endoscopic treatment of Zenker's diverticulum is an attractive minimally invasive alternative compared to the classic open approach. However, increased recurrence rate were reported. In case of relapse, endoscopic therapy might be repeated, or alternatively open surgery is performed. This study aimed to identify potential differences in the outcomes between primary or secondary surgical treatment in Zenker's diverticulum. METHODS: From January 2003 to April 2019, 227 subsequent patients underwent surgical diverticulectomy and cervical myotomy at the surgical department of TUM. 41 of 227 patients had received previous therapy, either open or endoscopic. Perioperative parameters in priorly untreated patients were retrospectively compared to those after previous therapy (mostly endoscopic) with special regard to perioperative data and postoperative complications. Univariate and multivariate regression analyses were performed to identify predictors for postoperative complications. RESULTS: We could show that the number of complications (p = 0.047) in pretreated patients is significant higher as well as the severity after Clavien-Dindo (p = 0.025). Stapler line leakage, wound infections, and operative revision rate was higher also pretreated group. Pretreatment and surgery time showed a significant association with postoperative complications in univariate analysis. In multivariate analysis, pretreatment remained a significant independent predictor of complications. CONCLUSION: The present data indicate that endoscopic therapy might represent a risk factor for postoperative complications in case of relapse surgery. Therefore primary open surgery should be debated in patients with an increased high risk of relapse.

Comparing weight loss outcomes after conversion to Roux-en-Y gastric bypass versus duodenal switch from sleeve gastrectomy in a community hospital.

BACKGROUND: Recidivism after initial sleeve gastrectomy (SG) remains common. Revisional surgery to convert SG to Roux-en-Y gastric bypass (RYGB) or duodenal switch (DS) for additional weight loss is increasing. This study aims to compare the outcomes after conversion of SG to RYGB or DS. METHODS: A retrospective single-institution review was conducted from 2015 to 2021, identifying 75 patients who underwent conversion from prior SG to either RYGB (40) or DS (35). Mean excess body weight loss (EBWL) at 3, 6, 12, and 24 months was assessed and compared. Secondary measures of length of stay (LOS), procedure length, and 30-day readmission rate were also reviewed. RESULTS: Percentage EBWL for RYGB vs DS was 24.0% vs 18.8% at 3 months (N = 36 vs 26; P < 0.0491), 34.8% vs 29.0% at 6 months (N = 29 vs 17; P < 0.2192), 43.0% vs 40.1% at 12 months (N = 28 vs 12; P < 0.6828), and 36.2% vs 41.7% at 24 months (N = 27 vs 7; P < 0.5553). Average LOS was 2.6 days ± 1.4 for RYGB and 2.8 days ± 1.3 for DS (P < 0.6032). Average procedure length was 134.4 min for RYGB and 189.8 min for DS (P < 0.0001). 30-day readmission rate was 27.5% (N = 11) for RYGB and 14.3% (N = 5) for DS (P < 0.1645). Significant weight loss was observed in both subgroups up to 12 months, with no significant weight loss between 12 and 24 months (RYGB N = 21, P < 0.2961; DS N = 5, P < 0.7233). CONCLUSION: Both revisional RYGB and revisional DS procedures had significant and sustained weight loss in the first 12 months. There was no significant excess body weight loss difference between revisional RYGB and revisional DS patients at 6, 12, and 24 months, with only significant greater weight loss for RYGB patients at 3 months. Additionally, procedure length was significantly longer for DS compared to RYGB, with no significant differences in LOS and 30-day readmission rates.

Primary single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) versus sleeve gastrectomy to SADI conversions: a comparison study of prevalence and safety.

BACKGROUND: Conversion from sleeve gastrectomy (SG) to single anastomosis duodeno-ileal bypass (SADI) is becoming increasingly common, but data regarding safety is of these conversions is scarce. As such, the objective of this study was to compare the 30-day rate of serious complications and mortality of primary SADI (p-SADI-S) with SG to SADI (SG-SADI) conversions. METHODS: This retrospective cohort study analyzed the MBSAQIP database. Patients undergoing p-SADI-S and SG-SADI were included. Data collection was limited to 2020 and 2021. A multivariable logistic regression analysis was performed between groups to determine if SG-SADI was an independent predictor of 30-day serious complications or mortality. RESULTS: A total of 783 patients were included in this study, 488 (62.3%) underwent p-SADI-S and 295 (37.6%) underwent SG-SADI. The mean body mass index (BMI) at the time of surgery was lower in the SG-SADI cohort (45.1 vs 51.4 kg/m2, p < 0.001). Indications for revision in the SG-SADI cohort included weight recurrence (50.8%), inadequate weight loss (41.0%), other (3.0%), GERD (2.7%), and persistent comorbidities (2.5%). SG-SADI had longer operative times (156.7 vs 142.1 min, p < 0.001) and was not associated with a higher rate of serious complications (5.7 vs 6.9%, p = 0.508) compared to p-SADI-S. p-SADI-S was associated with a higher rate of pneumonia (1.2 vs 0.0%, p < 0.001), and SG-SADI was not correlated with higher rates of reoperation (3.0 vs 3.2%, p = 0.861), readmission (5.4 vs 5.5%, p = 0.948) and death (0.0 vs 0.2%, p = 0.437). On multivariable analysis, SG-SADI was not independently predictive of serious complications (OR 0.81, 95% CI 0.43 to 1.52, p = 0.514) when adjusting for age, sex, BMI, comorbidities, and operative time. CONCLUSIONS: The prevalence of SG-SADI is high, representing 37.6% of SADI-S procedures. Conversion from sleeve to SADI, is safe, and as opposed to other studies of revisional bariatric surgery, has similar 30-day complication rates to primary SADI-S.

Comparative analysis of 5-year efficacy and outcomes of single anastomosis procedures as revisional surgery for weight regain following sleeve gastrectomy.

BACKGROUND: It is imperative to assess the results of revisional procedures following Sleeve Gastrectomy (SG), given the substantially growing population of patients who experience weight regain within a few years after undergoing this procedure. OBJECTIVE: Examine the comparative effectiveness of the Single Anastomosis Duodeno-Ileal Bypass (SADI-S) and the One Anastomosis Gastric Bypass (OAGB-MGB) as revisional procedures, with respect to their impact on weight loss, resolution of comorbidities, incidence of complications, and rates of reoperation in patients who had weight regain after SG with up to or more than 5 years of follow-up. SETTING: Hamad General Hospital, Academic tertiary referral center, Qatar. METHODS: This study retrospectively analyzed a database of patients who underwent the Single Anastomosis Duodeno-Ileal Switch (SADI-S) or the One Anastomosis Gastric Bypass - Mini Gastric Bypass- (OAGB-MGB) as revisional procedures for weight recidivism after a primary Laparoscopic Sleeve Gastrectomy (LSG). The follow-up period was at least 5 years, during which the impact of both procedures on weight loss, comorbidities, nutritional deficiencies, complications, and outcomes were compared. RESULTS: The study comprised 91 patients, with 42 and 49 in the SADI-S and OAGB-MGB groups, respectively. Significant weight loss (measured by total weight loss percentage, TWL%) was observed at the 5-year follow-up for the SADI-S group compared to the OAGB-MGB group (30.0 ± 18.4 vs. 19.4 ± 16.3, p = 0.008). Remission of comorbidities, specifically diabetes mellitus and hypertension, was more prevalent in the SADI-S group. Notably, the OAGB-MGB group had a higher incidence of complications (28.6% vs. 21.42%) and reoperations (5 patients vs. 1 in the SADI-S group). No mortality events were reported in either group. CONCLUSION: While both the OAGB-MGB and SADI-S have demonstrated efficacy as revisional procedures for weight regain following SG, the SADI-S exhibits superior outcomes compared to the OAGB-MGB with regard to weight loss, resolution of comorbidities, complication rates, and reoperation rates.

Distal gastric bypass revision for weight recurrence or nonresponse to primary procedure: initial experience and outcomes in an academic practice.

BACKGROUND: Considerable weight recurrence (WR) after Roux-en-Y gastric bypass (RYGB) may occur in nearly 20% of patients. While several nonoperative, endoscopic, and surgical interventions exist for this population, the optimal approach is unknown. This study reports our initial experience with distal bypass revision (DGB) and provides a comparison with patients after primary RYGB. METHODS: Single-institution, retrospective review was conducted for patients who underwent DGB from 2018 to 2020. A Roux and common channel of 150 cm each were constructed (total alimentary limb 300 cm). A group of primary RYGB patients with similar demographics were selected as controls. Demographics, comorbidity resolution, surgical technique, complications, excess weight loss (EWL), total weight loss (TWL), BMI, and weight change data were compared. Patient postoperative weight loss (WL) was also compared after their primary and DGB operations. RESULTS: Sixteen DGB patients, all female, were compared with 29 controls. DGB was performed on average 12.3 years after primary RYGB. In the DGB group, mean BMI was 53.7 before primary RYGB, 31.9 at nadir, and 44.1 prior to DGB. Post-DGB, mean BMI was 40.5, 37.4, 34.8, and 34.4, at 3-, 6-, 12-, and 24-months, respectively. Five patients (31.3%) experienced complications and were readmitted within 30 days, with two of them (12.5%) requiring reintervention and one (6.3%) undergoing reoperation. Mean EWL and TWL up to 2 years after DGB were lower than that after the patient's original RYGB (52.3 ± 18.6 vs. 67.2 ± 33.2; p = 0.126 and 19.6 ± 13.3 vs. 29.6 ± 11.8; p = 0.027, respectively). CONCLUSIONS: DGB resulted in excellent WL up to 2 years after surgery but was associated with considerable postoperative complication rates. The magnitude of TWL was lower compared with the primary operation. Only a few patients experienced nutritional complications. Results of this study can help counsel patients pursuing DGB for WR or nonresponse to primary RYGB. The comparative effectiveness of this approach to other available options remains to be determined.

Clinical influence of conversion of laparoscopic sleeve gastrectomy to one anastomosis gastric bypass on gastroesophageal reflux disease.

PURPOSE: Assess the subjective impact of gastro-esophageal reflux disease (GERD) symptoms on patients undergoing revision from laparoscopic sleeve gastrectomy (LSG) to one-anastomosis gastric bypass (OAGB) using the Reflux Disease Questionnaire for GERD (RDQ) and the GERD-health related quality of life score (GERD-HRQL), prior to- and following conversion. METHODS: Patients undergoing revision from LSG to OAGB were prospectively followed between May 2015 and December 2020. Data retrieved included demographics, anthropometrics, previous bariatric history, time interval between LSG and OAGB, weight loss, and co-morbidities. Pre- and post-OAGB RDQ and GERD-HRQL questionnaires were obtained. In the case of sleeve dilatation, sleeve resizing was performed. RESULTS: During the study period, 37 patients underwent revision from LSG to OAGB. Mean ages at LSG and pre-OAGB were 38 ± 11.74 and 46 ± 12.75, respectively. Median follow-up time was 21.5 months (range 3-65). All patients underwent sleeve resizing. RDQ and GERD-HRQL scores were obtained at a median of 14 months (range 3-51) between pre- and post-OAGB. Median RDQ score pre-OAGB vs post-OAGB was significantly reduced (30 (range 12-72) vs 14 (range 12-60), p = 0.007). All 3 parts of the GERD- HRQL questionnaires were significantly reduced between pre-OAGB and post-OAGB: Symptoms (20; 62.5% vs 10; 31.3%, p = 0.012), overall score (15 (0-39) vs 7 (0-28), p = 0.04) and subjective improvement (10; 31% vs 20; 62.5%, p = 0.025). CONCLUSION: Conversion of LSG to OAGB showed subjective improvement of GERD symptoms both in RDQ and in GERD-HRQL.

One-anastomosis gastric bypass (OAGB) versus Roux-en-Y gastric bypass (RYGB) as revisional procedures after failed laparoscopic sleeve gastrectomy (LSG): systematic review and meta-analysis of comparative studies.

INTRODUCTION: The aim of this study was to compare weight loss and gastroesophageal reflux disease (GERD) remission after one-anastomosis gastric bypass (OAGB) versus Roux-en-Y gastric bypass (RYGB) as revisional procedures after laparoscopic sleeve gastrectomy (LSG). METHODS: In PubMed, Embase, and Cochrane Library, a search was performed using the terms "Roux-en-Y gastric bypass versus one anastomosis gastric bypass," "revisional surgery," and "sleeve gastrectomy." Only original articles in English language comparing OAGB and RYGB were included. No temporal interval was set. The primary outcome measure was weight loss (%TWL). The secondary endpoints were leak, bleeding, marginal ulcer, and GERD. PRISMA flowchart was used. Differences in continuous and dichotomous outcome variables were expressed as mean difference (MD) and risk difference (RD) with 95% CI, respectively. Heterogeneity was assessed by using I2 statistic. RESULTS: Six retrospective comparative articles were included in the present meta-analysis. Weight loss analysis showed a MD = 5.70 (95% CI 4.84-6.57) in favor of the OAGB procedure with a statistical significance (p = 0.00001) and no significant statistical heterogeneity (I2 = 0.00%). There was no significant RD for leak, bleeding, or marginal ulcer after the two revisional procedures. After conversion to OAGB, remission from GERD was 68.6% (81/118), and it was 80.6% (150/186) after conversion to RYGB with a RD = 0.10 (95% CI -0.04, 0.24), no statistical significance (p = 0.19), and high heterogeneity (I2 = 96%). De novo GERD was 6.3% (16/255) after conversional OAGB, and it was 0.5% (1/180) after conversion to RYGB with a RD = -0.23 (95% CI -0.57, 0.11), no statistical significance (p = 0.16), and high heterogeneity (I2 = 92%).

Salvage surgery for continent ileostomies (CI) after a first successful revision: more long-term blame on the reservoir than the nipple valve.

PURPOSE: The aim of the study was to investigate the underlying cause of long-term complications in patients requiring at least one revision surgery of a continent ileostomy (CI) and to analyze functional outcome. METHODS: Only patients with CI at least one revision were included in the retrospective data analysis. Four different classes of complications (Cl A-D) were defined: Cl A = Nipple valve (NV), Cl B = pouch, Cl C = outlet (stoma), and Cl D = afferent loop (AL). Associations between underlying disease and origin of complications were analyzed. Cumulative probabilities were calculated using Kaplan-Meier analysis. RESULTS: A total of 77 patients were identified with a follow-up of 30 years, requiring 133 surgeries for 148 complications (c.). Cl A 49 c. (33.1%), Cl B 50 c. (33.8%), Cl C 39 c. (26.4%), and Cl D 10 c. (6.8%). Cl A and C complications were not correlated to underlying disease, whereas Cl B and D complications were only found in ulcerative colitis (UC) and Crohn's disease (CD). The cumulative probability of a second revision showed a linear rise, reaching 62.5% after 20 years. Cl A and B complications both reached 42.1%. Eleven (14.3%) patients (10 Cl B) had pouch failure in a follow-up period of 11.5 ± 8.7 years (1-31 years), whereas 66 (85.7%) had successful revisional surgery. Overall CI survival was 78.8% at 44 years. CONCLUSION: CI survival is limited by inflammatory complications of the pouch based on the underlying disease and not by mechanical limitations of the NV. TRIAL REGISTRATION NUMBERS: None.

Reoperative bariatric surgery after primary laparoscopic gastric plication for morbid obesity: a systematic review and meta-analysis.

BACKGROUND: Laparoscopic gastric plication (LGP) often requires reoperative bariatric surgery (RBS) due to complications and insufficient weight loss. The aim of our study was to assess perioperative morbidity and weight loss during follow-up in patients undergoing RBS after primary LGP for morbid obesity. METHODS: A search of PubMed, Web of Science, Cochrane Library, and Google Scholar was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using ("conversion"OR "revision*""OR "reoperat*")AND("gastric"OR "curvatur*")AND "plication." Studies were deemed eligible if data on RBS after LGP were provided. For each study, data were extracted and analyzed. RESULTS: In the literature review, 291 articles were screened and 7 included. The studies covered a total of 367 patients, of whom 119 received a sleeve gastrectomy (SG), 85 a Roux-en-y gastric bypass (RYGB), 75 a one anastomosis-gastric bypass (OAGB), 45 a re-LGP, and 25 a jejuno-ileal bypass. After RBS, excess weight loss was 50.8 ± 6.5% at 6 months, 71.0 ± 7.7% at 12 months, and 89.0 ± 7.8% at 24 months. Operative time was 101.3 ± 14.6 min. Postoperatively, 18/255 patients (7.1%) had a complication, and leakage and reoperations were reported in 6/255 (2.4%) and 5/255 (2.0%) patients, respectively. Length of hospital stay was 3.1 ± 2.4 days. The quality of evidence was rated as "very low." CONCLUSIONS: Despite limitations, this systematic review and meta-analysis showed that RBS after LGP has an acceptable rate of complications and is effective in terms of excess weight loss during follow-up. No specific operation (e.g., SG, RYGB, OAGB) can be suggested over another due to the lack of evidence.

Revisional large gastric pouch with Roux-en-Y gastric bypass for patients with type 2 diabetes and a body mass index less than 35 kg/m2: a cause and effect analysis.

PURPOSE: To evaluate the long-term efficacy of large gastric pouch surgery and revisional surgery in patients with a body mass index (BMI) < 35 kg/m2 and type 2 diabetes mellitus (T2DM). METHODS: We conducted a retrospective review of patients who underwent laparoscopic Roux-en-Y gastrojejunostomy with a large gastric pouch in our hospital. The clinical pre- and post-surgery data, including BMI, waist circumference, fasting plasma glucose (FPG), glycated hemoglobin (HbA1c), lipid metabolism-related indicators, homoeostatic model assessment of insulin resistance (HOMA-IR), and major complications, were recorded and analyzed. RESULTS: Twenty-four patients were included in the analysis, 12 of whom underwent revisional surgery. At their 5-year-follow-up after the primary surgery, the BMI and waist circumference of the patients with T2DM were lower than their baseline values. The BMI, HbA1c, HOMA-IR, FPG and waist circumference also decreased after the revisional surgery. The rates of remission of diabetes after the primary vs. after the revisional surgery were 4.17% vs. 41.70%, respectively (P < 0.05). CONCLUSION: Roux-en-Y gastrojejunostomy with a large gastric pouch is not effective in the long term and, therefore, is unsuitable for Chinese patients with T2DM and a BMI < 35 kg/m2. Conversely, revisional surgery has a definite effect on these patients.

Revisional triangular fibrocartilage complex (TFCC) repair using arthroscopic one-tunnel transosseous suture: preliminary results.

PURPOSE: The purpose of this study was to report the clinical outcome of revision arthroscopic triangular fibrocartilage complex (TFCC) foveal repair using a one-tunnel transosseous suture technique after failed primary TFCC repair. METHODS: Consecutive patients treated with arthroscopic TFCC foveal repair using the uniform one-tunnel transosseous suture technique after failed TFCC repair from 2014 to 2018 were retrospectively reviewed. The clinical outcome was evaluated using the Modified Mayo Wrist Score (MMWS) and the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score. The Visual Analog Scale (VAS) for pain, stability of the distal radioulnar joint (DRUJ), grip strength, and active range of motion (ROM) of the wrist joint also were assessed. RESULTS: This study cohort consisted of eight patients, and their mean time to revision after initial surgery was 15.1 months. Previous surgeries were performed using an arthroscopy-assisted mini-open TFCC repair in six cases, an arthroscopic all-inside repair in one case, and an arthroscopic transosseous suture technique in the remaining case. After revisional TFCC foveal repair, all patients demonstrated improved pain and a stable DRUJ. Participants showed improvement in grip strength and mean active wrist ROM. There was improvement in MMWS (from 58.6 to 87.5) and Quick-DASH score (from 46.9 to 12.2) during the mean follow-up of 15.6 months (range: 8-36 months). CONCLUSION: Based on the results of this study, remaining ulnar TFCC remnants may be appropriate for sufficient stable repair using an arthroscopic one-tunnel transosseous suture technique after failed primary repair. However, only a small number of patients was examined. A larger number has to be investigated to confirm the promising preliminary results. LEVEL OF EVIDENCE: Level IV, therapeutic case series.