The Management of Biliary Disease in Patients with Severe Obesity Undergoing Metabolic and Bariatric Surgery-An International Expert Survey.

OBJECTIVE: This study aimed to survey international experts in metabolic and bariatric surgery (MBS) to improve and consolidate the management of biliary disease in patients with severe obesity undergoing MBS. BACKGROUND: Obesity and rapid weight loss after MBS are risk factors for the development of gallstones. Complications, such as cholecystitis, acute cholangitis, and biliary pancreatitis, are potentially life-threatening, and no guidelines for the proper management of gallstone disease exist. METHODS: An international scientific team designed an online confidential questionnaire with 26 multiple-choice questions. The survey was answered by 86 invited experts (from 38 different countries), who participated from August 1, 2023, to September 9, 2023. RESULTS: Two-thirds of experts (67.4%) perform concomitant cholecystectomy in symptomatic gallstones during MBS. Half of experts (50%) would wait 6-12 weeks between both surgeries with an interval approach. Approximately 57% of the experts prescribe ursodeoxycholic acid (UDCA) prophylactically after MBS, and most recommend a 6-month course. More than the half of the experts (59.3%/53.5%) preferred laparoscopic assisted transgastric ERCP as the approach for treating CBD stones in patients who previously had RYGB/OAGB. CONCLUSION: Concomitant cholecystectomy is preferred by the experts, although evidence in the literature reports an increased complication rate. Prophylactic UDCA should be recommended to every MBS patient, even though the current survey demonstrated that not all experts are recommending it. The preferred approach for treating common bile duct stones is a laparoscopic assisted transgastric ERCP after gastric bypass. The conflicting responses will need more scientific work and clarity in the future.

Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus.

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

Nissen Sleeve as a Redo Surgery Post Gastric Banding for Non-responders to Weight Loss and Therapy-Resistant Reflux.

Roux-en-Y gastric bypass (LRYGB) would be the procedure of choice for non-responders of weight loss and patients with reflux symptoms (GERD). However, not every patient is a candidate for RYGB, and sometimes, the patient can insist only on alternatives other than malabsorption procedures, as was the case with our patient. We report a case with symptomatic GERD who underwent a successful Nissen sleeve gastrectomy after band removal. To our knowledge, this is the first case using Nissen sleeve as a redo surgery after a previous bariatric procedure.

Roux-en-Y Gastric Bypass as Conversion Procedure of Failed Gastric Banding: Short-Term Outcomes of 1295 Patients in One Single Center.

PURPOSE: Laparoscopic adjustable gastric band (LAGB) has high technical and weight loss failure rates. We evaluate here the 1-year morbidity, mortality, and weight loss of laparoscopic Roux-en-Y-gastric bypass (LRYGB) as a feasible conversion strategy. METHODS: Patients with a failed primary LAGB who underwent LRYGB from July 2004 to December 2019 were selected from an electronic database at our center. Patients had a conversion to LRYGB at the same time (one-stage approach) or with a minimum of 3 months in between (two-stage approach). Primary outcomes included 30-day morbidity and mortality. Secondary outcomes were body mass index (BMI), percent excess weight loss (%EWL), and percent excess BMI lost (%EBMIL) at 1 year postoperatively. RESULTS: A total of 1295 patients underwent a conversion from LAGB to LRYGB at our center: 1167 patients (90.1%) in one stage and 128 patients (9.9%) in two stages. There was no mortality. An early (30-day) postoperative complication occurred in 93 patients (7.2%), with no significant difference found between groups. Hemorrhage was the most common complication in 39 patients (3.0%), and the reoperation was required in 19 patients (1.4%). At 1 year postoperatively, the mean BMI was 28.0 kg/m2, the mean %EWL 72.8%, and the mean %EBMIL 87.0%. No statistically significant difference was found between the groups. CONCLUSION: Conversion to LRYGB can be considered as a safe and effective option with low complication rate and good weight loss outcomes at 1 year. One-stage conversion provides the same early outcome as two-step surgery with a competent surgeon.

Defining Global Benchmarks in Elective Secondary Bariatric Surgery Comprising Conversional, Revisional, and Reversal Procedures.

OBJECTIVE: To define "best possible" outcomes for secondary bariatric surgery (BS). BACKGROUND: Management of poor response and of long-term complications after BS is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. METHODS: Out of 44,884 BS performed in 18 high-volume centers from 4 continents between 06/2013-05/2019, 5,349 (12%) secondary BS cases were identified. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of centers. Benchmark cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, thromboembolic events, BMI> 50 kg/m2 or age> 65 years. RESULTS: The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8 ±â€Š10 years, 8.4 ±â€Š5.3 years after primary BS, with a BMI 35.2 ±â€Š7 kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.6% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.37) and after conversional/reversal or revisional procedures with gastrointestinal suture/stapling (OR 1.84). Benchmark cutoffs for conversional BS were ≤4.5% re-intervention, ≤8.3% re-operation 90-days postoperatively. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation. CONCLUSION: Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.

Laparoscopic Adjustable Gastric Banding with the Adhesix® Bioring® for Weight Regain or Insufficient Weight Loss After a Roux-en-Y Gastric Bypass: Midterm Data from the Pronto Registry.

PURPOSE: Although Roux-en-Y gastric bypass (RYGB) is one of the most common bariatric procedures, insufficient weight loss is described to be as high as 20-35%. To treat weight regain/inadequate weight loss, laparoscopic adjustable gastric banding (LAGB) could be a feasible revisional strategy. MATERIALS AND METHODS: We report on a prospective study which included 35 patients who presented inadequate weight loss or significant weight regain after primary RYGB (percentage excess weight loss [%EWL] at revision < 50%). All patients underwent revisional LAGB with the placement of an Adhesix® Bioring® adjustable gastric band (Cousin Biotech, Wervicq-Sud, France). Patients' weight loss, complications, frequency of revisions and quality of life were evaluated. RESULTS: Follow-up data at 24 months are available for 80% of the included patients. The mean BMI before RYGB was 43.6 ± 5.4 kg/m2 and before revisional LAGB was 38.8 ± 4.3kg/m2. The %EWL before revisional surgery was 23.3 ± 24.8%. The average time between both procedures was 6.7 (mean) ± 3.6 (SD) years. Twenty-four months after revisional LAGB, the average BMI calculated from the weight at RYGB dropped to 32.0 ± 4.5 kg/m2, with an additional %EWL of 49.9 ± 30.3% resulting in a total %EWL of 60.7 ± 28%. The reoperation rate for complications related to LAGB was 21.2%. No band erosions occurred, but two bands needed to be removed during the study. CONCLUSION: Revisional LAGB may be considered a valid salvage procedure in patients with weight regain or inadequate weight loss after RYGB, though band- and port-related complications remain a notable concern.

Post-bariatric Abdominoplasty: Identification of Risk Factors for Complications.

PURPOSE: The aim was to evaluate the complication rate after abdominoplasty procedures performed in a high volume post-bariatric center and to identify predictors of complications. MATERIAL AND METHODS: A retrospective analysis was performed and included all abdominoplasty procedures performed between January 2011 and December 2019. Complications classified according to the Clavien-Dindo classification were documented and potential risk factors were statistically evaluated. RESULTS: A total of 898 patients were included. Overall complication rate was 29.8%. Type I complications (minor wound problems) occurred in 15.8% (n = 140). Type II complications requiring medical intervention occurred in 10% (n = 90). Five patients had deep venous thrombosis or pulmonary embolism; others received antibiotic treatment for wound infections. In total 42 type III complications occurred in 36 patients, with re-intervention for wound problems (n = 16), seroma (n = 16), umbilical necrosis (n = 4), and bleeding (n = 6). The weight of tissue resected (p < 0.001), the interval between bariatric and body contouring surgery (p < 0.05), preoperative BMI (p < 0.05), male gender (p < 0.05), diabetes mellitus type 2 (p = 0.05), and smoking (p < 0.05) were important predictors for developing complications. CONCLUSION: In this large retrospective post-bariatric abdominoplasty series, the overall complication rate is low compared to other published series as a consequence of our completely standardized approach and technique. Our analysis shows a significant linear correlation between the amount of skin tissue resected and postoperative complications. Moreover, the longer the interval between bariatric surgery and abdominoplasty, the higher the complication rate. High preoperative BMI, diabetes mellitus type 2, smoking, and male gender were identified as independent significant risk factors for complications.

Modified Nissen Fundoplication for Late Dumping Syndrome After Roux-en-Y Gastric Bypass.

INTRODUCTION: Postoperative dumping syndrome (DS) is a common complication after Roux-en-y gastric bypass (RYGB) for morbid obesity. DS is mostly treated conservatively through dietary or pharmacologic measures. In case of non-responding to or contraindication for conservative treatment, surgical intervention may be considered. Various procedures have been described, as there is currently no gold standard technique. We present a new approach by performing a modified Nissen fundoplication. CASE: A 34-year-old female consulted at our outpatient clinic. In her history, she had a laparoscopic RYGB 6 years earlier because of morbid obesity (BMI 37.6 kg/m2). Two years postoperatively, she developed a late DS, for which she was successfully treated with long-acting octreotide. Because of pregnancy wish, octreotide needed to be halted. A laparoscopic modified Nissen fundoplication was performed, creating a cuff around the oesophageal-gastric junction with the fundus of the remnant stomach. This slows down the passage of food through the gastric pouch. Postoperatively, the octreotide treatment was halted without any problems. At 6 months, the patient is still free of dumping complaints. DISCUSSION: Postoperative DS is a common complication after bariatric surgery. Dietary measures form the first treatment of DS, followed by pharmacologic treatment. Since octreotide is contraindicated in pregnancy, a surgical intervention was opted for. Our case is the first documented modified Nissen fundoplication to treat late postoperative DS after RYGB for morbid obesity. CONCLUSION: A laparoscopic modified Nissen fundoplication could be a promising surgical alternative in the treatment of late dumping syndrome after RYGB for morbid obesity.

Gestational weight gain and postpartum weight retention after bariatric surgery: data from a prospective cohort study.

BACKGROUND: It is unknown whether international guidelines on gestational weight gain can be used in pregnancies after bariatric surgery. OBJECTIVES: To investigate gestational weight gain, intrauterine growth, and postpartum weight retention in postbariatric women. SETTING: 8 Belgian hospitals. METHODS: Prospective data from 127 postbariatric pregnancies from September 2014 through October 2018. Patients were grouped according to achievement of 2009 Institute of Medicine (IOM) guidelines. RESULTS: In 127 patients with a mean age of 30.2 years (standard deviation [SD], 4.7), the mean gestational weight gain was 12.5 kg (SD, 6.7). Of these patients, 24% (30 of 127) showed insufficient weight gain, 20% (26 of 127) showed adequate weight gain, and 56% (71 of 127) showed excessive weight gain. Of 127 patients, 27 (21%) had small-for-gestational-age infants. This peaked in the group with insufficient weight gain (47%; 95% confidence interval [CI], 29%-65%; P < .001). The prevalence of large-for-gestational-age infants was comparable between groups, although highest in the group with excessive weight gain (0% in those with insufficient weight gain, 4% in those with adequate weight gain, and 8% in those with excessive weight gain). Preterm births were recorded more in patients with insufficient weight gain (23%; 95% CI, 8%-38%; P = .048). The mean amounts of postpartum weight retained were 4.0 kg (SD, 7.4) at 6 weeks and 3.0 kg (SD, 9.1) at 6 months. Weight retention at 6 weeks (7.1 kg; 95% CI, 5.5-8.7; P < .001) and 6 months (8.3 kg; 95% CI, 4.5-12.2; P < .001) was highest in women gaining excessive weight. CONCLUSION: Achievement of IOM guidelines is low in postbariatric pregnancies. Insufficient weight gain increases the risk for small-for-gestational-age babies. Excessive weight gain increases weight retention after delivery and could precipitate weight regain. After bariatric surgery, women should be encouraged to achieve IOM recommendations.

Shortening and Plication of Entero-enterostomy for Intussusception in Roux-en-Y Gastric Bypass: Video Report.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered by a large percentage of bariatric surgeons' the operation of choice for obesity surgery as reported by Melvin (J Gastrointest Surg. 4:398-400, 2004). It is considered a generally safe procedure with a low percentage of complications. One of these complications is small bowel obstruction which has different etiologies. A rare cause of intestinal obstruction is intussusception at the entero-enterostomy as reported by Arapis et al. (Surg Obes Relat Dis. 1:23-33, 2019) and Sneineh et al. (OBES SURG 30:846-850, 2020). The accurate incidence of intussusception after LRYGB is unknown but Simper et al. (Surg Obes Relat Dis. 4:77-83, 2008) found a 0.15% incidence in their study. Diagnosis of intussusception requires a high index of suspicion because neither physical examination nor imaging is sensitive. CT scan might identify the problem, but a negative CT scan image does not rule out intussusception. Treatment of intussusception varies according to the clinical picture of the patient at the presentation. These variations may include conservative treatment up to resection of the entero-enterostomy and do a re-anastomosis as discussed by Daellenbach et al. (OBES SURG 21:253-263, 2011). The video aims to present an alternative option for surgical management of intussusception of the entero-enterostomy following LRYGB which to our knowledge was not published before.

Sometimes the Best Solution Is Transit Bipartition: Video Case Report.

The simplest definition of Santoro's operation is a sleeve gastrectomy with transit bipartition. Santoro et al. reported long-term data regarding sleeve gastrectomy with transit bipartition, which is a similar operation to duodenal switch but without complete exclusion of the duodenum to minimize nutritional complications and to allow endoscopic management of obstructive jaundice. Afterward, several studies proved the efficacy and safety of transit bipartition; the real benefit of this operation is the reduction of side effects and protein malnutrition compared with the bilio-pancreatic diversion with duodenal switch or Roux-en-Y gastric bypass. One of the well-known complications of sleeve gastrectomy is reflux which usually responds well to medical treatment, but in few cases, the reflux is refractory to conservative management and warrants surgical intervention as a conversion of the sleeve gastrectomy to other bariatric procedures. There are many theories concerning the increased incidence of gastro-esophageal reflux disease after sleeve gastrectomy which included reduction of lower esophageal sphincter pressure due to the division of ligaments and blunting of the angle of His, reduction in gastric compliance, increased sleeve pressure with an intact pylorus due to the use of Bougie < 40 Fr, decreased sleeve volume and distensibility, and dilated upper part of the final shape with a relative narrowing of the mid-stomach without complete obstruction. Our video report aims to present a unique surgical case and to show the surgical technique in this patient despite the complex surgical history.

Gastric pouch sero-myotomy for persistent dysphagia after roux-en-Y gastric bypass: Video report.

Laparoscopic Sleeve Gastrectomy (LSG) is one of the most common bariatric operations done worldwide [1]. About 6.6% of the LSG is being converted to laparoscopic roux-en-Y gastric bypass (LRYGB), most commonly due to inadequate weight loss (65%) and severe reflux (26%) [2]. The most common late complications after LRYGB are dumping, small bowel obstruction, internal hernia, weight regain, marginal ulcer, strictures of the gastro-jejunostomy [3] and rarely proximal stricture at the gastric pouch as our presented case. Treatment options for such a case may start with endoscopic dilatation and if not succeeded it may warrant surgical intervention as shortening of the pouch and redo of the gastrojejunostomy proximal to the stricture or even total gastrectomy and esophago-jejunal anastomosis. Sero-myotomy of the gastric pouch can be done as the same technique which can be used in sero-myotomy of sleeved stomach with stricture [4] and spare resection of the pouch. This report aims to present a new option of surgical management for proximal stricture of the gastric pouch after LRYGB which to our knowledge was never published in the literature.

Towards Optimized Care After Bariatric Surgery by Physical Activity and Exercise Intervention: a Review.

Although there is growing evidence on the importance of physical activity and exercise intervention after bariatric surgery, it remains to be clarified as to why and how post-operative exercise intervention should be implemented. In this narrative and practically oriented review, it is explained why exercise interventions and physical activity are important after bariatric surgery, how to prescribe exercise and monitor physical activity and how and when physical fitness, muscle strength, fat (-free) mass and bone mineral density could be assessed during follow-up. It is suggested that the inclusion of physical activity and exercise training in the clinical follow-up trajectory could be of great benefit to bariatric surgery patients, since it leads to greater improvements in body composition, bone mineral density, muscle strength and physical fitness.

Hypermetabolic lesion in the prevascular mediastinum - always a thymoma/lymphoma?

Cholesterol granuloma is a foreign-body giant cell reaction that can occur in response to the presence of cholesterol crystals. They are usually found in the middle ear, paranasal sinuses or mastoid process due to chronic inflammation. Presentation in the prevascular mediastinum is a rare finding. We describe a case of a cholesterol granuloma located in the prevascular mediastinum in a symptomatic 57-year-old male patient.

The first consensus statement on revisional bariatric surgery using a modified Delphi approach.

BACKGROUND: Revisional bariatric surgery (RBS) constitutes a possible solution for patients who experience an inadequate response following bariatric surgery or significant weight regain following an initial satisfactory response. This paper reports results from the first modified Delphi consensus-building exercise on RBS. METHODS: We created a committee of 22 recognised opinion-makers with a special interest in RBS. The committee invited 70 RBS experts from 27 countries to vote on 39 statements concerning RBS. An agreement amongst ≥ 70.0% experts was regarded as a consensus. RESULTS: Seventy experts from twenty-seven countries took part. There was a consensus that the decision for RBS should be individualised (100.0%) and multi-disciplinary (92.8%). Experts recommended a preoperative nutritional (95.7%) and psychological evaluation (85.7%), endoscopy (97.1%), and a contrast series (94.3%). Experts agreed that Roux-Y gastric bypass (RYGB) (94.3%), One anastomosis gastric bypass (OAGB) (82.8%), and single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) (71.4%) were acceptable RBS options after gastric banding (84.3%). OAGB (84.3%), bilio-pancreatic diversion/duodenal switch (BPD/DS) (81.4%), and SADI-S (88.5%) were agreed as consensus RBS options after sleeve gastrectomy. lengthening of bilio-pancreatic limb was the only consensus RBS option after RYGB (94.3%) and OAGB (72.8%). CONCLUSION: Experts achieved consensus on a number of aspects of RBS. Though expert opinion can only be regarded as low-quality evidence, the findings of this exercise should help improve the outcomes of RBS while we develop robust evidence to inform future practice.

Surgical treatment of therapy-resistant reflux after Roux-en-Y gastric bypass. A case series of the modified Nissen fundoplication.

Introduction: Patients with intractable reflux after RYGB have limited treatment options. Here a modified Nissen fundoplication (MNF) as described by N. Kawahara might be the answer.Methods: In this retrospective case study we identified six patients with therapy-resistant GERD after RYGB. All six were treated with a MNF, using the remnant stomach to construct the fundoplication. Short term follow-up 1 month and 6-12 months postoperatively was conducted to inquire about GERD symptoms.Results: Six patients underwent a MNF. Three out of six patients had had a gastric band in their medical history. Upper GI barium swallow test revealed herniation of the gastric pouch in 4/6 patients. After surgery all patients were symptom free and 4/6 completely stopped PPI treatment.Discussion: Mechanisms of new onset or deteriorating GERD after RYGB are herniation of gastric pouch and destruction of the lower esophageal sphincter after banding. Both problems are tackled when constructing a MNF.Conclusion: Complete symptom relief was seen 1 month after MNF. The procedure seems safe, feasible and effective. The study is limited by small sample size and short follow-up yet shows clear improvement of symptoms. Larger trials are needed to establish validity of the MNF.

Defining Global Benchmarks in Bariatric Surgery: A Retrospective Multicenter Analysis of Minimally Invasive Roux-en-Y Gastric Bypass and Sleeve Gastrectomy.

OBJECTIVE: To define "best possible" outcomes for bariatric surgery (BS)(Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]). BACKGROUND: Reference values for optimal surgical outcomes in well-defined low-risk bariatric patients have not been established so far. Consequently, outcome comparison across centers and over time is impeded by heterogeneity in case-mix. METHODS: Out of 39,424 elective BS performed in 19 high-volume academic centers from 3 continents between June 2012 and May 2017, we identified 4120 RYGB and 1457 SG low-risk cases defined by absence of previous abdominal surgery, concomitant procedures, diabetes mellitus, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, anticoagulation, BMI>50 kg/m and age>65 years. We chose clinically relevant endpoints covering the intra- and postoperative course. Complications were graded by severity using the comprehensive complication index. Benchmark values were defined as the 75th percentile of the participating centers' median values for respective quality indicators. RESULTS: Patients were mainly females (78%), aged 38±11 years, with a baseline BMI 40.8 ±â€Š5.8 kg/m. Over 90 days, 7.2% of RYGB and 6.2% of SG patients presented at least 1 complication and no patients died (mortality in nonbenchmark cases: 0.06%). The most frequent reasons for readmission after 90-days following both procedures were symptomatic cholelithiasis and abdominal pain of unknown origin. Benchmark values for both RYGB and SG at 90-days postoperatively were 5.5% Clavien-Dindo grade ≥IIIa complication rate, 5.5% readmission rate, and comprehensive complication index ≤33.73 in the subgroup of patients presenting at least 1 grade ≥II complication. CONCLUSION: Benchmark cutoffs targeting perioperative outcomes in BS offer a new tool in surgical quality-metrics and may be implemented in quality-improvement cycle.ClinicalTrials.gov Identifier NCT03440138.

Twelve-Year Experience with Roux-en-Y Gastric Bypass as a Conversional Procedure for Vertical Banded Gastroplasty: Are We on the Right Track?

BACKGROUND: Vertical banded gastroplasty (VBG) has high rates of long-term complications. Conversion to Roux-en-Y gastric bypass (RYGB) is considered optimal; however, there are limited data on the late results of these conversions. We aimed to analyze our single-center long-term outcomes of patients requiring conversional RYGB for a failed VBG. METHODS: The records of patients who underwent RYGB as a conversional procedure after VBG from November 2004 to December 2016 were reviewed. Follow-up data were obtained by direct telephone calls with patients, electronic files, and general practitioner reports. Characteristics, indications of conversion, long-term (> 30 days) morbidities, weight records, obesity-related comorbidities, and overall patient satisfaction were analyzed. RESULTS: Overall, 305 VBG patients (82% female) underwent conversional RYGB during the study period. The mean pre-RYGB body mass index (BMI) was 35.6 (23-66) kg/m2. Conversions were indicated in 61% of patients because of simultaneous VBG complications and weight regain. After a median follow-up of 74.3 (5-151) months, 225 (73.8%) patients agreed to participate. The mean BMI and percentage of total weight loss (%TWL) were 28.6 (18-45) kg/m2 and 17.4%, respectively. Nearly all conversion indications were addressed effectively. Surgical reintervention was mandatory in 28 of 225 patients (12.4%) due to complications. Approximately 85% of patients reported complete remission of obesity-related comorbidities, and four-fifths were fully satisfied. CONCLUSION: RYGB resolves VBG complications, improves quality of life, and results in prolonged stable weight loss. It has a key role in the management of obesity-related comorbidities and in expert hands is the preferred conversional procedure for patients with failed VBG.

Anaesthetic Factors Affecting Outcome After Bariatric Surgery, a Retrospective Levelled Regression Analysis.

BACKGROUND: Deep neuromuscular block (NMB) and opioid-free anaesthesia (OFA) improve surgical workspace and reduce post-operative opioid consumption, but its impact on perioperative outcomes is unknown. This observational study compared complications and healthcare resource utilization after bariatric surgery, with or without continuous deep NMB or OFA. METHODS: We included all 9246 patients who underwent laparoscopic bariatric surgery at our institution from January 2009 to February 2017. Continuous clinical deep NMB was defined as receiving a continuous infusion of rocuronium with a dose of > 1 mg/kg IBW for each hour or sugammadex > 2 mg/kg total body weight at the time of reversal. We analysed the effect of continuous clinical deep NMB and OFA and covariates on 1 month post-operative complications using the Clavien-Dindo (CD) classification (grades II-V) and healthcare utilization (hospital length of stay [LOS], rates of reoperations within 1 week, high-dependency care unit admissions, and readmissions within 1 month). Covariates included experience of the attending anaesthesiologist, patient age, sex, body mass index, American Society of Anesthesiologists physical status score, obstructive sleep apnoea syndrome, diabetes, hypertension, surgery type, surgical team experience, and neostigmine use. RESULTS: OFA, continuous deep NMB, surgical and anaesthesia team experience, younger age, and surgery type were associated with fewer complications. OFA was associated with lower healthcare resource utilization. Reduced LOS was also associated with younger age, surgical team experience, and surgery type, but not continuous deep NMB. CONCLUSION: Continuous deep NMB and OFA were associated with fewer complications after bariatric surgery.

Conversion of both Versions of Vertical Banded Gastroplasty to Laparoscopic Roux-en-Y Gastric Bypass: Analysis of Short-term Outcomes.

BACKGROUND: Conversional bariatric surgery has relatively high rates of complications. We aimed to analyze our single-center experience with patients requiring conversional laparoscopic Roux-en-Y gastric bypass (LRYGB) following a failed primary open or laparoscopic vertical banded gastroplasty (OVBG or LVBG, respectively). METHODS: The records of patients who underwent LRYGB as a conversional procedure after VBG between November 2004 and December 2017 were reviewed. Characteristics, body mass index (BMI), operation time, intraoperative problems, length of hospitalization, and early (< 30 days) morbidity and mortality were analyzed. Data were expressed as mean ± standard deviation or frequency. RESULTS: A total of 329 patients (81.76% females) who underwent conversional RYGB were included. For the LVBG group (224 patients) and OVBG group (105 patients), respectively, BMI was 34.15 ± 6.38 and 37.79 ± 6.31 kg/m2 (p < 0.05), the operation time was 96.00 ± 31.40 and 123.15 ± 40.26 min (p < 0.05), hospitalization duration was 2.96 ± 1.13 and 3.20 ± 1.20 days (p = 0.08), the early complication rate was 7.14 and 11.43% (p = 0.19), and the reoperation rate was 2.23 and 2.86% (p = 0.73). There were no major intraoperative problems. Three patients with OVBG were converted to open RYGB (2.86%). There was no mortality. CONCLUSION: The conversion of OVBG and LVBG to laparoscopic RYGB is technically feasible and provides comparably low early morbidity rates and length of hospitalization. However, compared to LVBG, conversional laparoscopic RYGB following OVBG is technically more challenging and time-consuming, with a slightly higher risk of conversion to open surgery. We support the use of such conversional bariatric surgery in specialized, high-volume bariatric centers.