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.

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.

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.

Does hemithyroidectomy still provide any benefit?

OBJECTIVES: Multinodular goiter is a common disorder, found in 5% of the general population. If only one thyroid lobe is affected, hemithyroidectomy may be preferred to total thyroidectomy, to limit the risk of complications and avoid hormone replacement therapy, but incurs a risk of subsequent completion thyroidectomy. The aim of the present study is to determine whether the arguments in favor of hemithyroidectomy are justified and whether it still provides real benefit. METHODS: A retrospective observational study based on prospective data included all patients who underwent surgery for goiter or nodule in our center between September 2010 and September 2014. Rates of hormone replacement 6 months after hemithyroidectomy, postoperative complications and completion thyroidectomy during the postoperative year due to the discovery of carcinoma were analyzed. RESULTS: Four hundred and ninety-three patients were studied: 335 with total thyroidectomy and158 with hemithyroidey. The rate of hormone replacement 6 months after hemithyroidectomy was 84.4%. The rate of definitive hypocalcemia was 6.3% in total thyroidectomy and zero in hemithyroidectomy (P<0.05). There was no significant difference between groups in terms of recurrent laryngeal nerve palsy (1.8% versus 1.9%; P=1) or hematoma (1.2% versus 3.5%; P=0.15). A total of 11.3% of hemithyroidectomies required completion due to discovery of carcinoma (mean interval between surgeries 3.58±2.5 months). CONCLUSIONS: This study suggests that hemithyroidectomy does not in fact avoid the risk of hormone replacement and places the patient at risk of completion thyroidectomy. However, it does avoid a 6% rate of hypocalcemia. We would recommend hemithyroidectomy only in case of single toxic or euthyroid nodule with healthy contralateral lobe and/or refusal of hormone replacement by the patient.

Assessment of the Aldosteronona resolution score as a predictive resolution score of hypertension after adrenalectomy for aldosteronoma in French patients.

PURPOSE: Aldosteronoma Resolution Score (ARS) is a predictive score for cure of hypertension after adrenalectomy for hyperaldosteronism and has been validated in American patients. The aim of the study was to validate this score in a French population. METHOD: Data concerning patients operated from 2002 to 2015 in 7 French University Hospitals were retrospectively collected. Diagnosis of Aldosterone-producing adenoma (APA) was confirmed with clinical and biochemical hyperaldosteronism and adrenal nodule on CT scan. Adrenal venous sampling was performed when CT failed to identify laterality. ARS is based on four variables: female sex, BMI ≤25 kg/m2, duration of hypertension ≤6 years, number of antihypertensive medications ≤2. One point is attributed for the first three and 2 points for the last. Patients were considered as cured if they had no hypertension and no antihypertensive medications at least 6 months after surgery. Patients with bilateral adrenal hyperplasia were excluded. RESULTS: This multicenter study included 310 patients with APA. ARS and follow-up were obtained in 257 patients. 46.6% of patients were cured and potassium serum level was normalized in 97.7%. In multivariate analysis, odds ratio for female sex, BMI ≤25 kg/m2, duration of hypertension ≤6 years, and number of antihypertensive medications ≤2 were 1.60 (p = 0.09), 1.77 (p = 0.04), 1.28 (p = 0.4), 3.41 (p < 0.001), respectively. Cure rate were, respectively, 22.2, 41.4 and 74% for patients with a score ARS 0-1, 2-3, 4-5. The area under the curve (AUC) of ARS was 0.715. CONCLUSION: ARS is not a predictive score efficient enough in a French population maybe due to different metabolic data and genetic conditions.