Efficacy and safety of revisional treatments for weight regain or insufficient weight loss after Roux-en-Y gastric bypass: A systematic review and meta-analysis.

Weight regain or inadequate weight loss following Roux-en-Y gastric bypass poses a significant clinical challenge. Our objective was to evaluate various revisional techniques for addressing weight regain and insufficient weight loss after Roux-en-Y gastric bypass through a systematic review and meta-analysis. We performed a literature search (in PubMed and Embase) on revisional interventions in collaboration with a medical information specialist. Measured outcomes included body mass index at intervention, total weight loss during follow-up, and complications. Random effects models were used to determine pooled effect size and corresponding 95% confidence intervals. Thirty-nine studies were included: four studies reported on argon plasma coagulation, four studies on transoral outlet reduction, nine studies on transoral outlet reduction + argon plasma coagulation, four studies on pouch/gastrojejunal anastomosis revision, five on laparoscopic gastric banding, two studies on laparoscopic gastric banding + pouch resizing, 10 on distalization-RYGB, and one on duodenal switch. All techniques resulted in short-term clinically relevant weight loss. Endoscopic procedures had a short follow-up and resulted in modest and temporary weight loss. Surgical revision techniques were successful for weight loss in longer term follow-up, at the expense of high complication rates.

Treatment Options for Weight Regain or Insufficient Weight Loss After Sleeve Gastrectomy: a Systematic Review and Meta-analysis.

Weight failure after sleeve gastrectomy (SG) is frequently observed. Consensus on the most effective treatment is lacking. The aim of this meta-analysis was to assess revisional strategies for weight regain (WR) or insufficient weight loss (IWL) following SG. The included studies reported on endoscopic gastroplasty (ESG), re-sleeve gastrectomy (re-SG), Roux-en-Y gastric bypass (RYGB), one-anastomosis gastric bypass (OAGB), single-anastomosis duodeno-ileal bypass (SADI), and duodenal switch (DS). All techniques resulted in clinically relevant weight loss. Although our data suggest that revisional OAGB was the most effective procedure, the lack of direct comparisons precludes strong conclusions. All procedures were feasible but differed regarding complication rates. Choice of procedure is depending on patient's characteristics and surgeons' expertise.

Gastro-esophageal Reflux After Laparoscopic Gastrostomy Placement in Children.

OBJECTIVES: Gastrostomy placement is frequently performed in pediatric patients who require long-term enteral tube feeding. Evidence on the influence of gastrostomy placement on gastro-oesophageal reflux disease has been inconsistent. The aim of this study was to investigate the influence of gastrostomy on gastro-oesophageal reflux. METHODS: A prospective, longitudinal cohort study was performed including 50 patients who underwent laparoscopic gastrostomy between May 2012 and April 2014. Before and 3 months after surgery 24-hour multichannel intraluminal impedance pH monitoring was performed and caregivers filled out reflux symptom questionnaires. RESULTS: Gastro-oesophageal reflux symptoms were present in a comparable number of patients before (44%) and after gastrostomy placement (40%; P = 0.73). Twenty-five of the patients (50%) underwent both the preoperative and postoperative tests and were included in impedance-pH analysis. Acid exposure time (percentage of time with pH below 4) did not change significantly after gastrostomy placement: from 6.2% (3.0-18.1) to 6.1% (2.6-14.9). The number of reflux episodes did not significantly change, for either liquid [mean difference 4.3 (-4.5 to 13.2)] or mixed liquid-gas reflux [mean difference 2.0 (-9.3 to 13.3)]. Before gastrostomy placement, 18 out of 25 patients had pathological reflux (72%) on pH-impedance measurement. In 4 patients, pathological reflux dissolved, whereas 4 patients newly developed pathological reflux. A low preoperative weight-for-height percentile was associated with increased acid exposure after gastrostomy placement. CONCLUSIONS: Overall, gastrostomy placement was not associated with an increase in acid exposure on 24-hour multichannel intraluminal impedance pH monitoring. Similarly, the prevalence of gastro-oesophageal reflux-related symptoms did not change after gastrostomy.

Health-related quality of life in children after laparoscopic gastrostomy placement.

INTRODUCTION: A gastrostomy placement (GP) is an established treatment to provide enteral feeding in pediatric patients with feeding difficulties aiming to improve nutritional status and health-related quality of life (HRQoL). The aim of this study was to evaluate HRQoL in children with severe feeding difficulties who have undergone GP. MATERIALS AND METHODS: A cross-sectional study was performed including 128 patients who had undergone laparoscopic GP (2004-2011). HRQoL was evaluated using the validated Pediatric Quality of Life 4.0 Inventory. Multiple regression analysis was performed to identify predictors of HRQoL. RESULTS: After a mean follow-up of 4.0 years (interquartile range 2.9-6.2) after GP, mean HRQoL was 53.0 out of 100 (standard deviation 21.1). HRQoL was significantly lower in children with neurologic impairment, with a mean difference of -21.4 points between neurologically impaired and neurologically normal children (p < 0.001). HRQoL was also lower in children with cardiac disease (-19.0 points; p = 0.01) and in children with a history of previous gastrointestinal surgery (-15.2 points; p = 0.03). Feeding through a gastrojejunostomy tube (-33.0 points; p = 0.01) and higher age at the time of operation (-1.2 points per year; p = 0.03) were also associated with lower HRQoL. GP-related complications requiring reintervention were associated with lower HRQoL, although this association was not statistically significant (p = 0.06). CONCLUSIONS: Children with severe feeding difficulty, who have undergone GP, have significantly lower HRQoL compared to a healthy pediatric population. Neurologic impairment, cardiac disease, a history of gastrointestinal surgery, older age, and the need for jejunal feeding through the gastrostomy were predictive of even lower HRQoL.

The Effect of Gastrostomy Placement on Health-Related Quality of Life in Children.

BACKGROUND AND PURPOSE: A gastrostomy placement (GP) aims to improve nutritional status and health-related quality of life (HRQoL) in children who require long-term enteral tube feeding. We evaluated the effect of GP on HRQoL. METHODS: A prospective, longitudinal cohort study was performed including patients referred for laparoscopic GP. Children and/or caregivers were asked to fill out the validated PedsQL™ questionnaire before and 3 months after surgery. The aim was to compare preoperative with postoperative HRQoL and to identify predictors of HRQoL. RESULTS: Fifty patients were included with a median age of 3.4 years (interquartile range 1.4-5.6). After GP, total HRQoL did not significantly increase (p = 0.30). However, psychosocial health significantly increased: 55.8 (standard deviation ±20.8) to 61.2 (±19.6; p = 0.03) on a 100-point scale. This was mainly owing to an increase in social HRQoL: 58.2 (±32.3) to 68.3 (±27.9; p = 0.04). HRQoL both before and after GP was significantly lower in children with neurologic impairment (p < 0.0005). However, neurologic impairment did not influence the effect of surgery on HRQoL (p = 0.66). Low preoperative body mass index was a predictor for improvement in HRQoL after GP. CONCLUSIONS: After GP in children, psychosocial HRQoL improved significantly. This was mainly owing to an improvement in social HRQoL. LEVEL OF EVIDENCE: IV.

The Effect of Gastrostomy Placement on Gastric Function in Children: a Prospective Cohort Study.

BACKGROUND: A gastrostomy placement is frequently performed in pediatric patients who require long-term enteral tube feeding. Unfortunately, postoperative complications such as leakage, feeding intolerance, and gastroesophageal reflux frequently occur. These complications may be due to postoperative gastric dysmotility. Our aim was to evaluate the effect of gastrostomy placement on gastric emptying in children. METHODS: A prospective study was performed including 50 children undergoing laparoscopic gastrostomy. Before and 3 months after gastrostomy, assessment was performed using the 13C-octanoic acid breath test, 24-h pH monitoring, and reflux symptom questionnaires. RESULTS: Gastric half-emptying time significantly increased from the 57th to the 79th percentile (p < 0.001) after gastrostomy (p < 0.001). Fifty percent of patients with normal preoperative gastric emptying develop delayed gastric emptying (DGE, P > 95) after gastrostomy (p = 0.01). Most patients (≥75%) with leakage and/or feeding intolerance after gastrostomy had DGE after operation. A decrease in gastric emptying was associated with an increase in esophageal acid exposure time (r = 0.375, p < 0.001). CONCLUSION: Gastrostomy placement in children causes a significant delay in gastric emptying. Postoperative DGE was associated with gastroesophageal reflux and was found in most patients with postoperative leakage and feeding intolerance. These negative physiologic effects should be taken into account when considering gastrostomy placement in children.

Laparoscopic versus percutaneous endoscopic gastrostomy placement in children: Results of a systematic review and meta-analysis.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) and laparoscopic-assisted gastrostomy (LAG) are widely used in the paediatric population. The aim of this study was to determine which one of the two procedures is the most effective and safe method. METHODS: This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses statement. Primary outcomes were success rate, efficacy of feeding, quality of life, gastroesophageal reflux and post-operative complications. RESULTS: Five retrospective studies, comparing 550 PEG to 483 LAG placements in children, were identified after screening 2347 articles. The completion rate was similar for both procedures. PEG was associated with significantly more adjacent bowel injuries (P = 0.047), early tube dislodgements (P = 0.02) and complications that require reintervention under general anaesthesia (P < 0.001). Minor complications were equally frequent after both procedures. CONCLUSIONS: Because of the lack of well-designed studies, we have to be cautious in making definitive conclusions comparing PEG to LAG. To decide which type of gastrostomy placement is best practice in paediatric patients, randomised controlled trials comparing PEG to LAG are highly warranted.

Efficacy and adverse events of laparoscopic gastrostomy placement in children: results of a large cohort study.

INTRODUCTION: A gastrostomy placement is frequently performed in pediatric patients who require long-term enteral tube feeding. However, data on efficacy, perioperative complications and postoperative gastroesophageal reflux (GER) after laparoscopic gastrostomy (LAG) placement is limited. The aim of this study is to evaluate long-term efficacy and adverse events after LAG in a large cohort and determine whether routine preoperative 24-h pH monitoring should be used to predict postoperative GER. METHOD: A retrospective observational cohort study was performed including 300 patients (75 % neurologically impaired) that underwent LAG. RESULTS: After a median follow-up of 2.63 years, feeding was successful in 95.9 % of patients. Weight-for-length z-scores significantly increased (p < 0.0005). Major complications were seen in only 6 patients (2.0 %), but minor complications occurred frequently (73.6 %). Overall incidence of GER remained unchanged after LAG. Sensitivity and specificity of preoperative pH monitoring were 17.5 and 76.9 %, respectively. CONCLUSION: LAG placement in pediatric patients leads to successful feeding in 96 % of patients and serious adverse events are rare. However, the minor complication rate is high. Overall incidence of GER does not increase after LAG. Preoperative 24-h pH monitoring is not a reliable tool to predict postoperative GER. This invasive investigation technique should therefore not be routinely performed.