Roux-en-Y Gastric Bypass after Laparoscopic Sleeve Gastrectomy Failure: Could the Number of Previous Operations Influence the Outcome?

After a failed laparoscopic adjustable gastric band (LAGB), laparoscopic sleeve gastrectomy (LSG) has been proposed as revisional surgery. Those patients that receive a second restrictive procedure fall into a small subgroup of patients with more than one restrictive procedure (MRP). If also the second restrictive procedure fails, the correct surgical strategy is a challenge for the surgeon. Roux-en-Y gastric bypass (RYGB) may be an option but there is no evidence in the literature on whether the procedure is effective in treating failures after MRP. This study aims to evaluate the influence of the previous number of restrictive interventions (MRP vs single LSG) in the results of RYGB as revisional surgery. We have retrospectively analyzed patients who underwent conversion from laparoscopic sleeve gastrectomy (LSG), or from multiple restrictive procedures (MRP), to RYGB for weight regain (WR) or insufficient weight loss (IWL) between 2009 and 2019. The number of patients analyzed was 69 with conversion to RYGB after LSG and 44 after MRP. The reduction of excess weight (%TWL) at 3, 6, 12, 24 RYGB postoperative months was respectively of 11.03%, 16.39%, 21.43%, and 24.22% in the MRP group, and of 10.97%, 16.4%, 21.22%, and 22.71% in the LSG group. No significant difference was found in %TWL terms after RYGB for the MRP group and the LSG group with an overall %TWL, which was 11.00 ± 6.03, 16.40 ± 8.08, 21.30 ± 9.43, and 23.30 ± 9.91 respectively at 3, 6, 12, and 24 months. The linear regression model highlighted a positive relationship between the %EWL post-bypass at 24 months and the time elapsed only between the LSG and RYGB in the MRP group patients (p < 0.001). RYGB has proved to be a reliable technique with good results in terms of weight loss after failed bariatric surgery both in patients who previously underwent MRP and in those who underwent exclusively LSG. RYGB showed better results in patients who experienced WR than in those who had IWL from previous techniques.

Conversion of one-anastomosis gastric bypass (OAGB) to Roux-en-Y gastric bypass (RYGB) for gastroesophageal reflux disease (GERD): who is more at risk? A multicenter study.

BACKGROUND: Although gastroesophageal reflux disease (GERD) affects 0.6% to 10% of patients operated on for one-anastomosis gastric bypass (OAGB), only about 1% require surgery to convert to Roux-en-Y gastric bypass (RYGB) [3-5]. The aim of the present study was to analyze the characteristics of OAGB patients converted to RYGB for GERD not responding to medical treatment. METHODS: This retrospective multicenter study included patients who underwent conversion from OAGB to RYGB for severe GERD. The conversion was performed with resection of the previous gastro-jejunal anastomosis and the use of the afferent loop as a new biliary loop. RESULTS: A total of 126 patients were included in the study. Of these patients, 66 (52.6%) had a past medical history of bariatric restrictive surgery (gastric banding, sleeve gastrectomy). A hiatal hernia (HH) was present in 56 patients (44.7%). The association between previous restrictive surgery and HH was recorded in 33 (26.2%) patients. Three-dimensional gastric computed tomography showed an average gastric pouch volume of 242.4 ± 55.1 cm3. Conversion to RYGB was performed on average 60 ± 35.6 months after OAGB. Seven patients (5.5%) experienced an early postoperative complication (4 patients grade IIIb and 3 grade IIb), and 3 (2.4%) a late complication. Patients showed further weight loss after RYGB conversion and an average of 24.8 ± 21.7 months after surgery, with a mean % of total weight loss (%TWL) of 6.9 ± 13.6 kg. From a clinical point of view, the problem of GERD was definitively solved in more than 90% of patients. CONCLUSIONS: Situations that weaken the esogastric junction appear to be highly frequent in patients operated on for OAGB and converted to RYGB for severe reflux. Similarly, the correct creation of the gastric pouch could play an important role in reducing the risk of conversion to RYGB for GERD.

Endoscopic Revisional Gastroplasty After Bariatric Surgery with a Single-Channel Endoscope.

BACKGROUND: Less invasive endoscopic bariatric procedures are under development for the management of recurrence of obesity. The purpose of the current manuscript was to evaluate the safety of the endoscopic revisional gastroplasty (ERG) for patients with recurrence of weight gain following different bariatric procedures. MATERIALS AND METHODS: This is a retrospective single-center study over 22 patients using the ERG between January 2020 to July 2022 at Bouchard Private Hospital (Marseille, France). The demographic data, past surgical history, obesity complications, time interval between the surgical and endoscopic procedures, and intra and postoperative parameters and outcomes were analyzed. RESULTS: A total of 22 patients underwent ERG: 19 female (86.4%) with a mean age of 34.2 years and a mean BMI of 32.9 kg/m2 (± 3.4). Average time between the revisional bariatric surgery and ERG was 14.4 months (range 5-36). There were 14 cases of LSG (77.8%), 9 cases of RYGBP (19.4%), and 3 cases with previous gastric band. All procedures were completed by endoscopy with no complication and a mean length of hospital stay of 1.1 days (± 0.9). The weight loss results at 1-year follow-up were available for 17 of the 22 patients: two patients were lost to follow-up (4%) and 3 patients had less than a 1-year follow-up from the ERG. The mean BMI, 1 year after ERG, was 28.7 kg/m2 (± 7.4); the mean BMI loss and %EWL were, respectively, 4.2 kg/m2 (± 4.7) and 53.1% (± 17). CONCLUSION: Endoscopic revisional gastroplasty represents a safe minimal invasive approach that can be considered an effective and well-tolerated procedure for patients with previous bariatric surgery.

Classification of Slippage Following Laparoscopic BariClip Gastroplasty.

INTRODUCTION: Laparoscopic BariClip gastroplasty (LBCG) is a new reversible gastric sleeve-like procedure without gastrectomy proposed to minimize the risk of severe complications. Still one of the possible complications described with LBCG is slippage. The purpose of the current manuscript is to analyze different cases of slippage and propose a classification of this complication. METHODS: A number of 381 patients who underwent LBCG in 8 different centers were analyzed concerning the risk of slippage. All cases with documented slippage were carefully reviewed in terms of patients' symptomatology (presence of satiety, vomiting), history of weight loss, radiological data, and management of their slippage. A new classification was proposed depending on the anatomy, the symptomatology, and the time of occurrence. RESULTS: We have identified a total of 17 cases (4.46%) of slippage following LBCG. In 11 patients, the slippage was symptomatic with repetitive vomiting and nausea, and in the remaining 6 patients, the slippage was identified by radiological studies for insufficient weight loss, weight regain, or routine radiological follow-up. Depending on the interval time, the slippage was classified as either immediate (in first 7 days) in 6 cases, early (in less than 90 days) in 4 cases, and late (after 3 months) in 7 cases. Evaluation of the radiological studies in these cases identified the following: anterosuperior displacement (type A) in 9 cases, posteroinferior displacement (type B) in 6 cases (one case after 3 months), and lateral displacement (type C) in the remaining 2 cases. The management of the slippage consisted of BariClip removal in 7 cases, repositioning in 5 cases, and conservative treatment in the remaining 5 cases. All patients with conservative treatment were recorded at the beginning of the experience. CONCLUSIONS: Slippage is a possible complication after LBCG. This classification of the different types of slippage can benefit the surgeon in the management and treatment of this complication of LBCG.

Long-Term Results After Bariatric Surgery in Super-Super-Obese Patients.

Introduction: Despite addressing to high risk population, we can propose laparoscopic bariatric surgery to super-super-obese (SSO) patients (body mass index [BMI] ≥60 kg/m2). The aim of this study was to report our experience in terms of weight loss and improvement of medical comorbidities after a follow-up of 5 years in the SSO population who underwent different bariatric procedures. Methods: This retrospective study includes all SSO patients who underwent bariatric surgery (sleeve gastrectomy [SG] and/or gastric bypass) between 2006 and 2017. The population was divided in three groups (SG alone; Roux-en-Y gastric bypass [RYGB] alone and SG+RYGB). The rate of complication and the weight-loss results were analyzed. Results: Among 43 patients who underwent surgery, the mean age was 42[31-54]. There were more women (72%) with the mean preoperative BMI of 64.9 kg/m2 [59.6-70.1]. There were 9 SGs, 26 RYGB, and 8 SG revised to gastric bypass (SG+RYGB) after a median delay of 23.5 months [16.5-32]. The perioperative complication rate was 25%, and there was 1 postoperative death. The median follow-up was 69 months [1-128]. The mean percentage of excess weight loss (%EWL) was 39.2% [18.2-60.3] after 5 years. For the SG group, the %EWL was inferior -27.1 [-3.6 to 57.8], but with no significant difference. An improvement of comorbidities' rate was recorded in all groups of patients. Conclusion: Bariatric surgery in SSO patients leads to an improvement of comorbidities even if the weight-loss results, especially in the SG group, are less favorable. The two steps approach should be re-evaluated by shortening the interval between. Other surgical strategies than RYGB are needed to be evaluated to improve long-term weight loss.

Evolving Technique of Laparoscopic Vertical Gastric Clip Placement.

INTRODUCTION: Laparoscopic BariClip gastroplasty (LBCG) will address a similar tubular restriction than the one achieved with the laparoscopic sleeve gastrectomy (LSG) at the level of the gastric fundus, while maintaining the advantage of simplicity and anatomic preservation. The purpose of the current study was to analyze the risk of slippage and to present the evolving technique by adding gastro-gastric plication of the gastric wall covering the BariClip at those areas where the gastric wall "slips" between the limbs of the clip. METHODS: All patients undergoing LBCG with the evolving technique of gastric plication around the device associated with antral gastroplasty from January 2021 to May 2022 were included in the study group (group A). A control group (group B) was designed with patients who underwent previous LBCG technique between May 2017 and June 2019. This is a case-controlled group with patients matched by gender and BMI. We have analyzed the postoperative complications and more notably the slippage. RESULTS: One hundred seventy-six patients (44 male and 132 female) with a mean age of 33 years (± 11) underwent evolving technique of LBCG. A control group of 67 patients who underwent previous technique of LBCG was included. All procedures were completed by laparoscopy with no intraoperative complication. For the study group, we have recorded a number of 5 slippages (2.8%). The diagnosis occurred during the first 6 months after the operation. The management consisted of repositioning-3 cases-and BariClip removal-2 cases. For the control group, we have recorded a number of 3 slippages (4.3%). All three patients underwent BariClip removal, with no repositioning. CONCLUSIONS: We reported a new technique of placement of the BariClip with additional gastric plication anterior, posterior, and volume reduction in the antrum to potentially reduce the rate of slippage and improve weight loss outcomes.

Is the Surgical Drainage Mandatory for Leak after Sleeve Gastrectomy?

INTRODUCTION: Despite the unanimous acknowledgement of the laparoscopic sleeve gastrectomy (LSG) worldwide, the leak remains its deficiency. For the last decade, the surgical treatment was practically considered mandatory for almost any collection following LSG. The aim of this study is to evaluate the need for surgical drainage for leak following LSG. METHODS: All consecutive patients having gone through LSG from January 2017 to December 2020 were enrolled in our study. Once the demographic data and the leak history were registered, we analyzed the outcome of the surgical or endoscopic drainage, the characteristics of the endoscopic treatment, and the evolution to complete healing. RESULTS: A total of 1249 patients underwent LSG and the leak occurred in 11 cases (0.9%). There were 10 women with a mean age of 47.8 years (27-63). The surgical drainage was performed for three patients and the rest of the eight patients underwent primary endoscopic treatment. The endoscopic treatment was represented with pigtails for seven cases and septotomy with balloon dilation for four cases. In two out of these four cases, the septotomy was anticipated by the use of a nasocavitary drain for 2 weeks. The average number of endoscopic procedures was 3.2 (range 2-6). The leaks achieved complete healing after an average duration of 4.8 months (range 1-9 months). No mortality was recorded for a leak. CONCLUSIONS: The treatment of the gastric leak must be tailored to each patient. Although there is still no consensus for the endoscopic drainage of leaks after LSG, the surgical approach can be avoided in up to 72%. The benefits of pigtails and nasocavitary drains followed by endoscopic septotomy are undeniable, and they should be included in the armamentarium of any bariatric center.

Endoscopic Gastric Band Removal.

BACKGROUND: Laparoscopic adjustable gastric band (LAGB) procedures have declined worldwide in recent years. A known complication is the intraluminal erosion of the prosthetic material. The endoscopic management of gastric band erosion represents the recommended approach nowadays, and it avoids any additional trauma to the gastric wall already damaged by the migration. The purpose of our study was to assess the feasibility of endoscopic management for intraluminal gastric band erosion following LAGB. METHODS: From January 2009-December 2020, a total of 29 patients were retrospectively reviewed after undergoing endoscopic gastric band removal. The study included all consecutive patients who underwent endoscopic gastric band removal in this period. No patients were excluded from the study. Data on patient demographic characteristics, case history, operative details (procedural time, adverse events), and complications were reviewed retrospectively. RESULTS: Twenty-nine patients underwent endoscopic gastric band removal: 22 women (75.8%) with a mean age of 45 years (range: 28-63) and mean Body Mass Index (BMI) of 31 ± 4.7 kg/m2 (range: 24-41). The average time to the identification of erosion after LAGB was 42 months (range: 28-137). The initial upper endoscopy found a migrated band of more than half of the diameter in 21 cases, less than a half but more than a third in seven cases and in one case, less than a third (use of a stent). Twenty-seven patients were successfully treated with endoscopic removal, and in two cases, the endoscopic approach failed, and laparoscopy was further performed. CONCLUSIONS: The endoscopic management of intraluminal erosion after LAGB can be safe and effective and should be considered the procedure of choice when treating this complication. The percentage of the band migration is important for the timing of the endoscopic removal.

The Reflux and BariClip: Initial Results and Mechanism of Action.

INTRODUCTION: Laparoscopic BariClip Gastroplasty (LBCG) represents a new bariatric procedure that mimics the principle of the Laparoscopic Sleeve Gastrectomy (LSG), but using a completely reversible mechanism, which is essential for gastroesophageal reflux disease (GERD). The purpose of our study was to evaluate the evolution of GERD following the initial experience with LBCG. METHODS: The first 43 obese patients who underwent LBCG performed by the same surgeon in two different medical centers in May 2018-December 2019 were included in the current study. Twelve patients had issues of reflux, regularly receiving PPIs (proton pump inhibitors) treatment in eight cases, and occasionally in four cases. Thirty-two patients completed the follow-up at one year and the GERD was evaluated using the PPI medications and the GerdQ. RESULTS: The median preoperative GerdQ score was (14.58 ± 1.9). Three patients out of the twelve who had complained about preoperative GERD did not consent to the one year follow-up form. For the rest of nine patients, the median post-operative GerdQ score was (10.11 ± 3.2). The PPIs were used at one year follow-up in six patients: four with occasional use, one patient with regular use showing no improvement, and one who experienced de novo GERD symptomatology (3.1%). No statistically significant difference between the groups was recorded in terms of GERD. We recorded no intraoperative complications. No case of erosion occurred in the post-operative period, but we encountered two cases of slippage. One additional BariClip was removed at 14 months. CONCLUSION: LBCG represents a new bariatric procedure that mimics the principle of the laparoscopic sleeve gastrectomy, but with a completely reversible mechanism. Even with limited cases, our experience reports several mechanisms of action that will be evaluated and discussed in further prospective clinical trials. After this preliminary clinical study, LBCG's effects on GERD and its safety are highly encouraging.

Resizing of the Gastric Pouch for Weight Regain after Laparoscopic Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass: Is It a Valid Option?

Introduction: The laparoscopic resizing of the gastric pouch (LPR) has recently been proposed as a revisional technique in the case of weight regain (WR) after gastric bypass procedures. The aim of this study was to report our experience with LPR for WR. Materials and Methods: All patients with WR ≥ 25% after gastric bypass and with a dilated gastric pouch and/or gastrojejunal anastomosis who underwent LPR between January 2017 and January 2022 were retrospectively reviewed. From a radiological point of view, a gastric pouch was considered dilated when its volume was calculated at >80 cm3 for LRYGB and >200 cm3 for OAGB upon a 3D-CT scan. The endoscopic criterion considered both the diameter of the gastrojejunal anastomosis and the gastric pouch volume. All anastomoses > 20 mm for LRYGB and >40 mm for OAGB were considered dilated, while a gastric pouch was considered endoscopically dilated when the retrovision maneuver with the gastroscope was easily performed. These selection criteria were arbitrarily established on the basis of both our personal experience and literature data. Results: Twenty-three patients had LPR after a Roux-en-Y gastric bypass or one-anastomosis gastric bypass. The mean BMI at LPR was 36.3 ± 4.7 kg/m2. All patients underwent LPR, while the resizing of the GJA was also performed in 3/23 (13%) cases, and hiatoplasty was associated with the resizing of the pouch in 6/23 cases (26.1%). The mean BMI at the last follow-up was 29.3 ± 5.8 kg/m2. The difference between the BMI before resizing and the BMI at the last follow-up visit was statistically significant (p = 0.00005). The mean %TWL at 24.2 ± 16.1 months was 19.6 ± 9%. Comorbidities had an overall resolution and/or improvement rate of 47%. The mean operative time was 71.7 ± 21.9 min. The conversion rate was nil. Postoperative complications occurred in two cases (8.7%). Conclusions: In our series, LPR for WR showed good results in weight loss and in improvement/resolution of comorbidities, with an acceptable complication rate and operative time. Only further studies with a greater cohort of patients and a longer postoperative follow-up will be able to highlight the long-term benefits of this technique.

One-Anastomosis Gastric Bypass and Hiatal Hernia: Nissen Fundoplication with the Excluded Stomach to Decrease the Risk of Postoperative Gastroesophageal Reflux.

INTRODUCTION: The realization of an antireflux valve according to the Nissen technique during the operation of one-anastomosis gastric bypass (OAGB) may theoretically decrease the incidence of postoperative reflux in patients with hiatal hernia (HH). MATERIAL AND METHODS: In this retrospective study, we included all patients operated on between January 2015 and January 2019 for an OAGB associated with the creation of an antireflux Nissen valve (360-degree wrap). The patients included had type II or type III HH that had been diagnosed preoperatively or discovered intraoperatively. RESULTS: Twenty-two patients were operated on during the period considered. The mean preoperative BMI was 40 ± 14 kg/m2. Five patients (22.7%) had a history of bariatric surgery. Typical symptoms of gastroesophageal reflux disease (GERD) were preoperatively present in four patients (18%), and HH was revealed preoperatively only in four patients; for all the other patients, the diagnosis of HH was made intraoperatively. The rate of early and/or late postoperative complications was 0%. The mean duration of follow-up was 23 ± 15 months. No dysphagia was reported during follow-up. Three patients presented with symptomatic GERD postoperatively, including one de novo. Mean BMI at the end of follow-up was 24 ± 3 kg/m2, and the % of total weight loss was 108 ± 30%. CONCLUSIONS: OAGB with a Nissen antireflux valve seems to be a safe and effective surgical technique and it could be an extra arrow in the surgeon's quiver in the presence of HH in a patient scheduled for OAGB.

The Utility of Video Recording in Assessing Bariatric Surgery Complications.

INTRODUCTION: Recording every procedure could diminish the postoperative complication rates in bariatric surgery. The aim of our study was to evaluate the correlation between recording every bariatric surgery and their postoperative analysis in relation to the early or late postoperative complications. METHODS: Seven hundred fifteen patients who underwent a bariatric procedure between January 2018 and December 2019 were included in a retrospective analysis. There were: 589 laparoscopic sleeve gastrectomies (LSGs); 110 Roux-en-Y bypasses (RYGBs) and 16 gastric bands (LAGBs). The video recording was systematically used, and all patients were enrolled in the IFSO registry. RESULTS: There were 15 patients (2.1%) with surgical postoperative complications: 5 leaks, 8 hemorrhages and 2 stenosis. Most complications were consequent to LSG, except for two, which occurred after RYGB. In four cases a site of active bleeding was identified. After reviewing the video, in three cases the site was correlated with an event which occurred during the initial procedure. Three out of five cases of leak following sleeve were treated purely endoscopically, and no potential correlated mechanism was identified. Two other possible benefits were observed: a better evaluation of the gastric pouch for the treatment of the ulcer post bypass and the review of one per operative incident. Two negative diagnostic laparoscopies were performed. The benefit of the systematic video recording was singled out in eight cases. All the other cases were completed by laparoscopy with no conversion. CONCLUSION: To record every bariatric procedure could help in understanding the mechanism of certain complications, especially when the analysis is performed within the team. Still, recording the procedure did not prevent the negative diagnostic laparoscopy, but it could play a significant role for the medico-legal aspect in the future.

Safety of Endoscopic Sleeve Gastroplasty with a Single-Channel Endoscope.

PURPOSE: Less invasive endoscopic bariatric procedures are under development for the management of class I of obesity. The purpose of our study is to evaluate the safety of endoscopic sleeve gastroplasty (ESG) using the new suturing device OverStitch Sx™. MATERIALS AND METHODS: This is a retrospective single-center study over 191 patients using the ESG under general anesthesia with overnight inpatient observation between January 2019 and December 2020. The analyzed variables were adverse effects and change in body weight at 6 and 12 months of follow-up. RESULTS: A total of 191 patients underwent ESG for primary obesity. There were 173 female (90.6%) with a mean age of 36.9 years. The mean BMI was 33.7 kg/m2 (range: 28.9-54). There were no major intra-procedure adverse events. There were two postprocedural complications (1.04%), a transparietal suturing of falciform ligament which needed laparoscopic exploration for severe abdominal pain and a perigastric collection with antibiotic treatment, both with favorable outcome. Considering the weight loss results, the %TWL recorded was 22.4% for 84 patients (43.9%, 6 months' follow-up) and 18.7% for 69 patients (36.1%, 12 months' follow-up) with the mean EWL of 41.6% and respectively 34.7%. A total of 59 patients (30.9%) were lost follow-up and 12 patients underwent revisional bariatric procedure. According to ASGE definition, 53.8% (n = 71) reached > 25% of EWL. CONCLUSION: Endoscopic gastroplasty represents a safe minimal invasive approach with the new device OverStitch Sx™ that can be considered an effective and well-tolerated procedure especially for primary obesity treatment.

One-stage conversion of laparoscopic adjustable gastric banding to laparoscopic 1-anastomosis gastric bypass: a single-center experience on 1,000 patients at 5 years of follow-up.

BACKGROUND: Data regarding the use of 1-anastomosis gastric bypass (OAGB) as a conversion technique after laparoscopic adjustable gastric banding (LAGB) failure is scarce in the literature. OBJECTIVES: The aim of this study was to assess our experience with OAGB as a rescue procedure after failed LAGB. SETTING: This study involved patients treated at a private hospital in France. METHODS: This single-center retrospective study included all consecutive patients receiving OAGB from January 2005 to January 2016. Of the 3,224 patients, 63.5% received primary OAGB (pOAGB) and 36.5% received OAGB as a conversion procedure after LAGB (cOAGB). RESULTS: During the period considered, 2,046 patients with obesity received pOAGB, whereas 1,000 patients underwent conversion of LAGB to OAGB in 1 step. The rate of patients lost to follow-up at 5 years was 31% in the pOAGB group and 32.5% in the cOAGB group (P = .4). Five years after the surgery, the mean body mass index was 30.8 ± 10.2 kg/m2, the mean percentage total weight loss was 34.6% ± 9.6%, and the mean percentage excess weight loss was 76.1% ± 24.6% in the pOAGB group, and the mean was 29.7 ± 10.4 kg/m2 (P = .58), the mean percentage total weight loss was 33.8% ± 10.2% (P = .82) and the mean percentage excess weight loss was 73.5% ± 22.2% (P = .78) in the cOAGB group. There was no difference in terms of early complications between the 2 groups (3.2% pOAGB versus 3.6% cOAGB, P = .59), while there was a statistically significant difference in terms of late complications (11% pOAGB versus 18% cOAGB, P < .00001). In particular, there was a significantly higher incidence of symptomatic postoperative biliary reflux in the cOAGB group (12% in cOAGB versus 5% in pOAGB, P < .00001). CONCLUSION: In this study, OAGB was effective and safe as a rescue technique after LAGB failure. Conversion in one step did not appear to increase the risk of early complications, whereas a history of gastric banding seems to increase the risk of bile reflux in the long term.

Revisional Surgery After One Anastomosis/Minigastric Bypass: an Italian Multi-institutional Survey.

BACKGROUND: Efficacy and safety of OAGB/MGB (one anastomosis/mini gastric bypass) have been well documented both as primary and as revisional procedures. However, even after OAGB/MGB, revisional surgery is unavoidable in patients with surgical complications or insufficient weight loss. METHODS: A questionnaire asking for the total number and demographics of primary and revisional OAGB/MGBs performed between January 2006 and July 2020 was e-mailed to all S.I.C. OB centres of excellence (annual caseload > 100; 5-year follow-up > 50%). Each bariatric centre was asked to provide gender, age, preoperative body mass index (BMI) and obesity-related comorbidities, previous history of abdominal or bariatric surgery, indication for surgical revision of OAGB/MGB, type of revisional procedure, pre- and post-revisional BMI, peri- and post-operative complications, last follow-up (FU). RESULTS: Twenty-three bariatric centres (54.8%) responded to our survey reporting a total number of 8676 primary OAGB/MGBS and a follow-up of 62.42 ± 52.22 months. A total of 181 (2.08%) patients underwent revisional surgery: 82 (0.94%) were suffering from intractable DGER (duodeno-gastric-esophageal reflux), 42 (0.48%) were reoperated for weight regain, 16 (0.18%) had excessive weight loss and malnutrition, 12 (0.13%) had a marginal ulcer perforation, 10 (0.11%) had a gastro-gastric fistula, 20 (0.23%) had other causes of revision. Roux-en-Y gastric bypass (RYGB) was the most performed revisional procedure (109; 54%), followed by bilio-pancreatic limb elongation (19; 9.4%) and normal anatomy restoration (19; 9.4%). CONCLUSIONS: Our findings demonstrate that there is acceptable revisional rate after OAGB/MGB and conversion to RYGB represents the most frequent choice.

Revisional Surgery from Vertical Banded Gastroplasty to Roux-en-Y Gastric Bypass with Gastric Resection.

Introduction: Vertical banded gastroplasty (VBG) was a common bariatric procedure by laparotomy and or at the beginning of the laparoscopy, but nowadays it is almost an abandoned procedure. However, the young generation of bariatric surgeons should be aware about this procedure especially for revisional cases. Roux-en-Y gastric bypass (RYGB) is considered the procedure of choice for the revision of VBG. Materials and Methods: The evolution of revisional surgery to RYGB has known several technical steps. At the beginning, the procedure was performed with no gastric resection. Then a limited resection of the ancient staple line along with the fibrous tissue under the previous band or mesh was performed. The purpose of this article is to describe a simplified operative technique to simultaneously resect the ancient staple line and the calibration band. Results: After the initial viscrerolysis, an attempt to distinguish the course of the ancient section line of the stomach during the VBG is done. The dissection can become extremely challenging, with too much fibrosis and nonanatomical planes of dissection. At this point, we counsel to abandon the anterior direct dissection of the upper part of the stomach and to switch to a posterior dissection with the approach of greater curvature. Driven by the potential advantages (no risk of mucocele or gastrogastric fistula), for the past several years, we have changed the technique from resecting only the ancient staple line to perform a partial gastrectomy. The gastrectomy is larger and includes the complete resection of the gastric fundus, ancient staple line, the region with the mesh inside, and part of the gastric body. Once the stomach is extracted, the subsequent steps are similar to those of a primary RYGB. Conclusion: The procedure of choice for the revision of VBG is represented by RYGBP. Associating an atypical gastrectomy of the previous staple line with the region of mesh migration is a safe approach, eliminating the risk of mucocele.

Total Gastrectomy with Roux-en-Y Limb Reconstruction for Complex and Chronic Fistulas After Laparoscopic Sleeve Gastrectomy: Single-Center Experience.

PURPOSE: When a leak after laparoscopic sleeve gastrectomy (LSG) becomes a chronic fistula, the best surgical treatment remains controversial. The aim of study was to review our experience concerning the treatment of chronic and complex fistulas after LSG. MATERIALS AND METHODS: A retrospective analysis of patients with a gastric fistula following LSG who were treated at our center between January 2013 and December 2018 was performed. All patients included underwent a total gastrectomy with a Roux-en-Y reconstruction (TG) for LSG chronic fistula. RESULTS: During the period considered, 13 patients had a chronic fistula and were treated with open TG. The primary leak evolved to a gastro-cutaneos fistula in three patients (23%), to a gastro-splenic fistula in two patients (15.4%), to a gastro-pleural fistula in four patients (30.8%), and to a gastro-bronchial fistula in four patients (30.8%). During TG, a splenectomy and a spleno-pancreatectomy were needed in the two cases of gastro-splenic fistula. Five patients (38.5%) developed an early complication. Two patients developed an esophago-jejunal anastomotic leak treated with a conservative approach (15.4%). No patients needed hospitalization in the intensive care unit. Overall mean length of stay was 19 days (8-30 days). Mean BMI before LSG was 36 (± 5 kg/m2), mean BMI before TG was 30.3 (± 5.2 kg/m2), and mean BMI 2 years after TG was 23.5 (± 2.9 kg/m2). CONCLUSION: When a more conservative and less mutilating surgical option is not possible, open TG with esophago-jejunostomy remains a valuable salvage procedure in the case of complex and extensive fistulas after LSG.

Leak After Sleeve Gastrectomy: Updated Algorithm of Treatment.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is currently the most common procedure performed worldwide, and still the leak is considered the main limitation. After an initial enthusiasm for stents, the endoscopic treatment evolved including in the current management the septotomy with balloon dilatation and pigtails insertions. The aim of this study was to evaluate the updated algorithm of endoscopic treatment of leak following LSG including septotomy and balloon dilatation. METHODS: All consecutive patients treated by endoscopy between January 2018 and March 2020 for leak following LSG were included in the current study. After recording the demographic and the leak history, we have analyzed the number of endoscopic sessions, the duration of treatment, and the healing rate of endoscopic treatment for 3 groups: A, small orifice (< 10 mm); B, large orifice (> 10 mm) and acute leak; and group C with large orifice and late leak. RESULTS: A total of 53 patients received endoscopic treatment for leak following LSG. The leaks achieved complete healing after average duration of 3.2 months (range 1-7 months), 2.3 months for group A, 4.2 months for group B, and 3.7 months for group C. The average number of endoscopic procedures was 2.8 (range 2-6) and was required for general population: for group A, 2.3 sessions; in group B, 3.4 sessions; and in group C, 2.7 sessions. Two out of 53 patients (3.8%) required additional treatment outside of the current algorithm, one in group A and another in group B. One patient was transferred for pulmonary abscess, and for another patient, the leak was considered chronic after a total of 14 months, and a laparoscopic fistula-jejunostomy was performed with favorable outcomes. CONCLUSIONS: Although there is still no consensus for endoscopic management of leaks after LSG, the benefits of pigtails and the septotomy are undeniable, and it should be included in the armamentarium of any bariatric endoscopic service.