Long-term results of conversion of Roux-en-Y to biliopancreatic diversion with duodenal switch.

BACKGROUND: Despite the fact Roux-en-Y gastric bypass (RYGB) is one of the most efficient bariatric procedures, postoperative weight regain still can be seen. OBJECTIVES: To retrospectively assess the early outcomes and up to 10-year weight results of the conversion of RYGB to biliopancreatic diversion with duodenal switch (BPD-DS). SETTING: French private hospital, 2-surgeon practice in a bariatric surgery center with an experience of >20 RYGB procedures. METHODS: Analysis was conducted on patients who had a conversion of RYGB to BPD-DS performed since 2010 for a percentage of excess weight loss (%EWL) <50% with a small gastric pouch. RESULTS: A total of 65 females and 9 males aged 46.8 ± 8.8 years had an RYGB procedure done 110.6 ± 38.8 months earlier for a body mass index of 47.4 ± 7.8 kg/m2. Conversion was always performed in 1 stage and laparoscopically for 93% of the patients. The 30-day complication rate was 25.7%, with 14.8% of patients undergoing reoperation. Maximum results were seen 2 years after conversion, outranging RYGB: %EWL of 78.3% ± 24% with percent total weight loss (%TWL) of 35.9% ± 11.9% and %EWL of 72% ± 24.1% with %TWL of 32.6% ± 11%, respectively. The 5-year weight of all the patients (85.7% follow-up) remained lower than the pre-conversion weight. Over time, 1 reversal and 4 revisions were required, and frequent stools and gastroesophageal reflux were the most frequent complaints. CONCLUSION: Despite its complexity, conversion of RYGB to BPD-DS can be performed in 1 stage, although the use of an unconventional technique could not reduce the high complication rate. BPD-DS remains an efficient procedure after RYGB in selected patients, comparable to distalization of RYGB, which can be less risky.

Impact of Robotic Assistance on Complications in Bariatric Surgery at Expert Laparoscopic Surgery Centers: A Retrospective Comparative Study With Propensity Score.

OBJECTIVE: To investigate the way robotic assistance affected rate of complications in bariatric surgery at expert robotic and laparoscopic surgery facilities. BACKGROUND: While the benefits of robotic assistance were established at the beginning of surgical training, there is limited data on the robot's influence on experienced bariatric laparoscopic surgeons. METHODS: We conducted a retrospective study using the BRO clinical database (2008-2022) collecting data of patients operated on in expert centers. We compared the serious complication rate (defined as a Clavien score≥3) in patients undergoing metabolic bariatric surgery with or without robotic assistance. We used a directed acyclic graph to identify the variables adjustment set used in a multivariable linear regression, and a propensity score matching to calculate the average treatment effect (ATE) of robotic assistance. RESULTS: The study included 35,043 patients [24,428 sleeve gastrectomy (SG); 10,452 Roux-en-Y gastric bypass (RYGB); 163 single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S)], with 938 operated on with robotic assistance (801 SG; 134 RYGB; 3 SADI-S), among 142 centers. Overall, we found no benefit of robotic assistance regarding the risk of complications (average treatment effect=-0.05, P =0.794), with no difference in the RYGB+SADI group ( P =0.322) but a negative trend in the SG group (more complications, P =0.060). Length of hospital stay was decreased in the robot group (3.7±11.1 vs 4.0±9.0 days, P <0.001). CONCLUSIONS: Robotic assistance reduced the length of stay but did not statistically significantly reduce postoperative complications (Clavien score≥3) following either GBP or SG. A tendency toward an elevated risk of complications following SG requires more supporting studies.

Comparison of 2-Year Results of Roux-en-Y Gastric Bypass and Transit Bipartition with Sleeve Gastrectomy for Superobesity.

PURPOSE: Although Roux-en-Y gastric bypass is a powerful procedure, achieving and maintaining significant weight loss remains challenging in superobese populations. Transit bipartition with sleeve gastrectomy is derived from biliopancreatic diversion with duodenal switch and might improve weight loss control. MATERIALS AND METHODS: Two series of 71 primary laparoscopic Roux-en-Y gastric bypass (RYGB) and transit bipartition (TB) with a body mass index ≥ 50 kg/m2 were retrospectively compared after 2 years. Postoperative course, side effects, nutritional status, and weight outcomes were reviewed. Weight was expressed as BMI, percentage of excess BMI lost (%EBMIL), and percentage of total weight lost (%TWL). RESULTS: The 2 groups were comparable for age and BMI of 51.9 ± 1.8 for RYGB and 51.6 ± 5 for TB. TB was longer to perform (92 vs 74 min, p ≤ 0.001) with a 30-day complication rate of 4.2% and 5.6%, but there was 1 death after RYGB. Weight loss was greater after TB compared with RYGB with %EBMIL of 85.3 ± 15.8% vs 73.9 ± 17.2% (p = 0.0002). One TB patient suffered from protein malnutrition but none after RYGB. After TB, 7% of the patients experienced > 3 stools a day and 1 patient required revision, while 3 patients had diarrhea after RYGB. Late reoperations were required for 7 and 1 patients after RYGB and TB. Comorbidity improvement was similar. CONCLUSION: In a superobese population, TB appeared relatively safer compared with RYGB. It achieved a better weight loss at 2 years with a trend for more digestive side effects.

Weight Loss Trajectories After Bariatric Surgery for Obesity: Mathematical Model and Proof-of-Concept Study.

BACKGROUND: Obesity surgery has proven its effectiveness in weight loss. However, after a loss phase of about 12 to 18 months, between 20% and 40% of patients regain weight. Prediction of weight evolution is therefore useful for early detection of weight regain. OBJECTIVE: This proof-of-concept study aimed to analyze the postoperative weight trajectories and to identify "curve families" for early prediction of weight regain. METHODS: This was a monocentric retrospective study with calculation of the weight trajectory of patients having undergone gastric bypass surgery. Data on 795 patients after a 2-year follow-up allowed modeling of weight trajectories according to a hierarchical cluster analysis (HCA) tending to minimize the intragroup distance according to Ward. Clinical judgement was used to finalize the identification of clinically relevant representative trajectories. This modeling was validated on a group of 381 patients for whom the observed weight at 18 months was compared to the predicted weight. RESULTS: Two successive HCA produced 14 representative trajectories, distributed among 4 clinically relevant families: Of the 14 weight trajectories, 6 decreased systematically over time or decreased and then stagnated; 4 decreased, increased, and then decreased again; 2 decreased and then increased; and 2 stagnated at first and then began to decrease. A comparison of observed weight and that estimated by modeling made it possible to correctly classify 98% of persons with excess weight loss (EWL) >50% and more than 58% of persons with EWL between 25% and 50%. In the category of persons with EWL >50%, weight data over the first 6 months were adequate to correctly predict the observed result. CONCLUSIONS: This modeling allowed correct classification of persons with EWL >50% and could identify early after surgery the patients with potentially less that optimal weight loss. Further studies are needed to validate this model in other populations, with other types of surgery, and with other medical-surgical teams.

Is transit bipartition a better alternative to biliopancreatic diversion with duodenal switch for superobesity? Comparison of the early results of both procedures.

BACKGROUND: During the past years, 2 alternatives to the powerful but side-effect-prone biliopancreatic diversion with duodenal switch (BPD-DS) were developed: one-anastomosis duodenal switch (OADS) and sleeve gastrectomy with transit bipartition (TB). OBJECTIVES: To compare the 1-year results of TB and BPD-DS aiming at reducing the risk of protein malnutrition while keeping a similar weight loss for body mass index (BMI) ≥50 kg/m2. SETTING: Private hospital, single-surgeon practice in a bariatric surgery center. METHODS: After a change in practice in 2017, the last 71 primary BPD-DS and the first 71 TB in patients with a BMI ≥50 kg/m2 were retrospectively compared. Postoperative course, side effects, nutritional status, and need for revision and weight outcomes were reviewed. Weight was expressed as BMI, percentage of excess BMI lost, and percentage of total weight lost. RESULTS: TB was faster to perform (92 versus 149 min, P < .0001) with a comparable 30-day complication rate of 4.3% and 5.7%. TB patients had a shorter hospital stay (2.3 ± 1 versus 4.5 ± 3.4 d, P < .0001). At 1 year, weight loss was significantly lower after TB compared with BPD-DS with percentage of excess BMI loss of 83.7 ± 12.2% versus 78.6 ± 14.7% (P = .0023). Two patients were lost to follow-up after BPD-DS and 6 after TB. Seven BPD-DS patients were treated for protein malnutrition, whereas only 2 patients had severe side effects after TB. Only 7% of the TB patients experienced >3 stools a day compared with 33% after BPD-DS (P = .016). There was no significant difference in terms of co-morbidity improvement at 1 year: 81.8% and 61.9% of patients had remission of blood hypertension, 9% and 14.3% had improvement, type 2 diabetes was in remission in 90% and 88%, and obstructive sleep apnea in 84% and 78% of the TB and BPD-DS patients, respectively. CONCLUSIONS: Although 1-year weight loss was significantly lower when BMI was ≥50, the real benefit of TB is the reduction of the side effects and protein malnutrition compared with BPD-DS. TB represents a much simpler alternative to BPD-DS for treating superobesity with less risk of major complications, but prospective studies and longer follow-up are required to confirm the maintenance of the weight loss in the long term.

Bariatric surgery in adolescents with severe obesity: Review and state of the art in France.

Severe obesity (body mass index>120% of BMI IOTF-30 cut off) and morbid obesity (BMI>140% of BMI IOTF-30 cut off) affect 5 to 10% of obese adolescents in France. Organic complications can be found in about 50% of these patients, and depressive symptoms in one-third of them. Finally, over 70% will suffer from adult morbid obesity associated with a marked increase in morbidity and mortality. However, the reversion of obesity strongly decreases, and may even cancels, these risks. In controlled randomized studies, lifestyle interventions have limited effectiveness on BMI in children (and none in adolescents). Bariatric surgery has been shown to have short-term effectiveness in adolescents with severe and morbid obesity: the average BMI loss after gastric banding was 11.6kg/m2 (95% confidence interval from 9.8 to 13.4), 16.6kg/m2 (95% confidence interval from 13.4 to 19.8) after bypass, and 14.1kg/m2 (95% confidence interval 10.8 to 17.5) after sleeve gastrectomy. The resolution of comorbidities was the main aim, as well as the improvement of quality of life. This is not a simple surgical intervention, and minor side effects have been reported in approximately 10-15% of teenagers who underwent surgery (more common with the gastric band), and severe side effects in nearly 1-5% (mainly with bypass). In France, recommendations regarding indications, the care pathway, multidisciplinary meetings, reference management structures and postoperative care have been published by the French National Health Authority (HAS) in 2016 to provide a framework for bariatric surgery in underage patients.

The single anastomosis duodenal switch modifications: a review of the current literature on outcomes.

BACKGROUND: The single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) was designed in 2007 to reduce the side effects of biliopancreatic diversion with duodenal switch (BPD-DS) by replacing the Roux-en-Y construction with a single duodeno-ileal anastomosis and combining the common channel with the alimentary limb. Several variants using different channel lengths were published. The objective of this study was to identify the published cases of SADI-S and variants and assess the results regarding potential benefits on side effects and revisions. METHODS: PubMed, ClinicalTrials.gov, and the databases of 3 relevant surgical journals were searched for any publication from 2007 to date. RESULTS: In all, 19 studies were analyzed. After identifying overlaps, 1,041 patients among 9 institutions were identified: 304 with SADI-S, 667 with stomach intestinal pylorus sparing surgery, and 70 with single anastomosis duodenojejunal bypass with sleeve gastrectomy. There were no postoperative deaths and the early complication rate was 7.3% (range 1.6-14%). The mean operative time was 100.8 minutes (range 69.9-181.7 min). The mean 1-year percentage of excess weight loss (%EWL) was 78.7% (range 61.6-87%) and percentage of total weight loss (%TWL) was 36.8% (range 32.7-41.1%). Two studies reported a 2-year %TWL of 38.7% and a single study reported a 5-year %TWL of 37%. A total of 50% of patients had biological data at 1 year. One retrospective study found no difference between BPD-DS and SIPS for vitamin deficiency at 2 years, but there was less severe diarrhea and malnutrition after SIPS. The revision rate increased from 2% to 7% after SADI-S between 2- and 5-year follow-up. CONCLUSION: There are still limited long-term data available for single anastomosis duodenal switch. In the absence of published prospective randomized trials, no evidence exists in favor of this variant of the BPD-DS despite a possible trend in less malabsorption side effects.

Weight Loss and Nutritional Outcomes 10 Years after Biliopancreatic Diversion with Duodenal Switch.

BACKGROUND: Biliopancreatic diversion with duodenal switch (BPD/DS) is the most effective bariatric surgical procedure, but major concerns exist about the nutritional consequences. OBJECTIVES: The study reported weight loss and nutritional outcomes of 80 patients with a follow-up of at least 10 years. SETTING: The follow-up was conducted at a university hospital as well as in a private practice institution in France. METHODS: Eighty patients operated on between February 2002 and May 2006 were reviewed. Weight outcomes were analyzed as well as complete biological status. Revisions were reported as well as the number of patients taking vitamin supplementation. RESULTS: A follow-up of 141 ± 16 months was available for 87.7% of the patients at least 10 years from surgery. Preoperative BMI decreased from 48.9 ± 7.3 to 31.2 ± 6.2 kg/m2 with an EWL of 73.4 ± 26.7% and a TWL of 35.9% ± 17.7%. Despite weight regain ≥10% of the weight loss in 61% of the cases, 78% of the patients maintained a BMI <35. Fourteen percent of the patients had a revision. Normal vitamin D levels were found in 35.4%. The overall PTH level was 91.9 ± 79.5 ng/mL, and 62% of the patients had hyperparathyroidism. Other deficiencies were less frequent but fat-soluble deficiencies as well as a PTH >100 ng/mL were significantly associated with the absence of vitamin supplementation. CONCLUSION: BPD/DS maintains a significant weight loss, but remains associated with side effects leading to revision and multiple vitamin deficiencies. The most severe deficiencies are related to the lack of supplementation compliance.

Early postpartum gastric band slippage after bariatric surgery in an adolescent obese girl.

We report here a case of a rarely described complication of laparoscopic adjustable gastric banding (LAGB), slippage during the postpartum period, after LAGB had been performed in an adolescent obese girl. The LAGB had been placed after one year of clinical survey initiated at the age of 16. Maximal pre-operative body mass index (BMI) was 48.5 kg.m(-2) and obesity was associated with insulin resistance. Before pregnancy, there was a loss of 17 Kg (final BMI = 41.5 kg.m(-2)) and a resolution of insulin resistance. The patient became pregnant 21 months after LAGB, and whole pregnancy and delivery were uneventful for both mother and fetus. Six weeks after delivery, the patient suddenly complained for total food intolerance, due to a band slippage, leading to removal of the band. Slippage is now a rare complication of LAGB, but can happen during pregnancy and the postpartum period as well.

One-stage conversion of Roux-en-Y gastric bypass to a modified biliopancreatic diversion with duodenal switch using a hybrid sleeve concept.

BACKGROUND: Insufficient weight loss (percentage of excess weight loss [%EWL]<50%) is observed in approximately 20% of patients after Roux-en-Y gastric bypass (RYGB). Surgical revision can be performed by various procedures including malabsorptive techniques. Conversion to a biliopancreatic diversion with duodenal switch (BPD/DS) remains a complex technique which cannot always be performed as a one-stage procedure. OBJECTIVES: This study evaluates the conversion of RYGB to BPD/DS using a novel gastric reconstruction technique based on a "hybrid sleeve" using the existing gastrojejunal anastomosis of the RYGB. SETTING: All the procedures were performed at a private hospital. METHODS: The consecutive patients who were eligible for conversion since 2010 were reviewed; eligibility included %EWL≤50% and normal gastric pouch. The gastrojejunal anastomosis of the RYGB was untouched and the gastric fundus was resected. The gastric continuity was restored by an anastomosis between a short segment of the alimentary limb and the gastric antrum. A standard BPD/DS was then performed without restoration of the jejunal continuity. RESULTS: Fourteen patients were converted to BPD/DS for a mean body mass index (BMI) of 44.3±6.0 kg/m2, a mean %EWL of 33.4%, and a percentage of total weight loss (%TWL) of 15.3±11.7%. The BMI before RYGB was 54.4±13.1 kg/m2, with half of the patients being super-obese. All but 3 conversions were completed as a single stage and laparoscopically in a mean of 177 minutes. The 30-day complication rate was 28.5%. No patient was lost to follow-up over a mean 25.8 months and the BMI of the 12 patients with a follow-up≥3 months is 33.2±7.2 kg/m2. With reference to the initial weight of the patients, the mean %EWL is 73.5% and %TWL is 37.6±16.0%. On average, patients benefited from a 21.1% TWL through the conversion of their RYGB. CONCLUSIONS: This procedure allows for an easier conversion of RYGB to BPD/DS and appears to be the most effective procedure for resuming weight loss. Nutritional consequences and weight loss are similar to the primary BPD/DS results. However, the benefits and risks must be carefully assessed according to the definition of weight loss failure.

Gastric Bypass in Older Patients: Complications, Weight Loss, and Resolution of Comorbidities at 2 Years in a Matched Controlled Study.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) has recently been authorized for use in older patients. The objective of this single-center study was to evaluate 2-year weight loss in patients ≥60 years compared with younger matched patients undergoing RYGB. Secondary aims were to record complications and the resolution of comorbidities in a 2-year follow-up. METHODS: Of 722 patients with at least 2 years follow-up data, 48 elderly patients were matched with 92 young (<40 years) and 96 middle-aged (40-59 year) patients, according to sex, baseline body mass index, and date of surgery. Weight loss, remission of comorbidities, death, and early (30-day) and 2-year complication rates were compared. RESULTS: There were three deaths in the elderly group and none in the other groups. The early complication rate was not significantly different in the elderly group (17.8 %) compared with the young (11.5 %, p = 0.637) and middle-aged (13.7 %, p = 1.000) groups. The 2-year complication rates were not significantly different in the elderly group (9.3 %) compared with the young (23.5 %, p = 0.107) and middle-aged (13.2 %, p = 1.000) groups. The 2-year weight loss was lower in the elderly group (31.8 ± 7.2 %; p < 0.001) than in the young group (38.3 ± 6.9 %) but was not significantly different from that in the middle-aged group (34.4 ± 8.0 %; p = 0.145). Remission rates for diabetes and obstructive sleep apnea were lower in the elderly than in the two younger groups. CONCLUSION: After bariatric surgery, major weight loss was observed in patients older than 60, but remission of metabolic comorbidities was less marked than in younger subjects.

Laparoscopic adjustable gastric banding in adolescents: Results at two years including psychosocial aspects.

BACKGROUND/PURPOSE: Obesity now affects 3%-4% of the pediatric population and contributes to the increase in cardiac mortality in adulthood. Bariatric surgery is the best treatment for weight loss and the obesity-associated comorbidities in adults. We report here our experience of laparoscopic adjustable gastric banding (LAGB) in adolescents. METHODS: The medical charts of the first 16 patients operated on in our center were reviewed. Data were compiled concerning weight loss, physical and biological comorbidities, health-related quality of life (QOL) and surgical complications before surgery and during 24months of follow-up. RESULTS: The maximal pre-operative median body mass index was 43.0kg·m(-2), decreasing to 33.0kg·m(-2) at 2years post-LAGB, which corresponded to a 49.2% excess body weight loss (p<0.001). Most comorbidities (glucose intolerance, hypertension and sleep apnea) resolved within the first year post-LAGB and QOL was improved on the PedsQL™ scales. No severe surgical complications were noted, with only three re-interventions for device failure (2) or band removal (1). CONCLUSION: LAGB is well tolerated in adolescents and shows a beneficial impact on weight loss and obesity-related comorbidities. Associated with global management, it may have a positive impact on patients' QOL and social and psychological status.

Revision and reversal after biliopancreatic diversion for excessive side effects or ineffective weight loss: a review of the current literature on indications and procedures.

BACKGROUND: Biliopancreatic diversion is a powerful bariatric procedure that relies on gastric restriction combined with a large malabsorptive component. This can lead to excessive side effects and/or weight loss. Despite this, long-term weight regain can also occur. OBJECTIVES: To determine the rate of and options for revision in patients who experience excessive side effects and weight loss. To explore the revisional procedures available to overcome weight regain. METHODS: A PubMed search was conducted of all reports published between 1979 and August 31, 2014. Series and case reports on revision or reversal after biliopancreatic diversion with duodenal switch (BPD/DS) or without (BPD) were included. RESULTS: Revision rates for excessive malabsorption ranges from .5%-4.9% and 3%-18.5% after BPD/DS and BPD respectively. Revisions increase common channel by up to 150 cm. Reversal is necessary in .2%-7% of cases, with an increased risk when the common channel is ≤ 50 cm. In most instances, reversal (of the malabsorptive component only) is indicated after the revision failure. A proximal, side-to-side anastomosis between the biliopancreatic and alimentary limbs is the preferred option. Most reoperations are performed within 2 years of the initial procedure and for protein malnutrition in about half of the cases. Revision for insufficient weight loss is reported in .5%-2.78% of cases. Except inadequate channel lengths, little is to be gained by common channel shortening. Additional gastric restriction, which results in an average 9-14 kg weight loss, is another option. CONCLUSIONS: Biliopancreatic diversion can be relatively easily revised to control excessive side effects and protein malnutrition. Early diagnosis is essential and warrants a close nutritional monitoring. In case of weight regain, limited results can be obtained by reducing the gastric volume provided the lengths of the small bowel channels are adequate.