Redo fundoplication vs. Roux-en-Y gastric bypass conversion for failed anti-reflux surgery: which is better?

INTRODUCTION: Different techniques have been proposed for reoperation after failed anti-reflux surgery. However, there is no consensus on which should be preferred. We aim to report and compare the outcomes of different revisional techniques for failed anti-reflux surgery. METHODS: We performed a retrospective analysis of patients who underwent redo fundoplication (RF) or Roux-en-Y gastric bypass (RYGB) conversion after a failed fundoplication at our institution between 2016 and 2021. The primary outcome was long-term presence of reflux or dysphagia following revisional surgery. Secondary outcomes included 30-day perioperative complications as well as long-term use of anti-reflux medication and radiographic recurrence of hiatal hernia (HH). RESULTS: A total of 165 (median age 63 years, 73.9% female) patients were included. RF was performed in 120 (73 Toupet and 47 Nissen), RYGB in 38, and 7 patients had fundoplication takedown alone. The RYGB group had a significantly higher BMI, and more prior revisional surgeries compared to the other groups. Median operative time and length of stay were longer for RYGB. Twenty (12.1%) patients experienced postoperative complications, with the highest incidence in the RYGB group. Reflux and dysphagia improved significantly for the whole cohort, with the greatest improvement noted with reflux in the RYGB group (89.5% with preoperative reflux vs. 10.5% with postoperative reflux, p = < .001). On multivariable regression we found that prior re-operative surgery was associated with persistent reflux and dysphagia, whereas RYGB conversion was protective against reflux. CONCLUSION: Conversion to RYGB may offer superior resolution of reflux than RF, especially for obese patients.

Do sleeve gastrectomy and Roux-en-Y gastric bypass have different venous thromboembolism risk factors? Creation of 30-day Bariatric Hypercoagulation Score.

BACKGROUND: Venous thromboembolism (VTE) is a major cause of morbidity and mortality after bariatric surgery, most often occurring after discharge within 30 days after surgery. OBJECTIVES: To determine the risk factors associated with VTE after either sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) and to develop a Bariatric Hypercoagulation Score (BHS) to predict 30-day adverse postoperative outcomes. SETTING: University hospital. METHODS: Using 2015-2018 data from the Metabolic and Bariatric Surgery Quality Improvement Program, a BHS was created by performing a logistic regression of "venous thromboembolism." The variables with the highest odds ratio (OR) were selected for the SG and RYGB groups. Then, the 30-day outcomes of low-risk (0-1), average-risk (2-3), and high-risk (≥4) BHS were compared. RESULTS: Similar risk factors for VTE were found in both the SG and RYGB groups; the highest OR was shown by history of deep vein thrombosis (SG: 3.54, RYGB: 3.05). Other related factors in both groups were history of pulmonary embolism, prolonged length of stay, Black race, and male sex. Conversely, unique risk factors such as dialysis (OR 1.81) was found in the SG group; meanwhile, prolonged operative time (OR 1.50) and age >60 years (OR 1.28) were for the RYGB group. When comparing the 30-day outcomes, BHS ≥4 had a significantly higher rate of complications (P < .001). CONCLUSIONS: SG and RYGB have some risk factors in common for VTE; however, dialysis was associated only with SG, and prolonged operative time and age >60 years were associated only with RYGB. BHS ≥4 showed higher 30-day adverse outcomes. The VTE-correlated variables require special consideration when assessing patients undergoing SG and RYGB.

Experience of Robotic Complex Revisional Bariatric Surgery in a High-Volume Center.

PURPOSE: A revisional bariatric surgery (RBS) is necessary in about 28% of the patients. The role of robotic surgery in RBS is still a subject of debate. We aim to report the outcomes of robotic-assisted RBS at our institution. MATERIALS AND METHODS: We identified patients who underwent robotic-assisted RBSs between January 1, 2016, and May 31, 2022. We analyzed patient demographics and indications for surgery. Measured outcomes included peri- and postoperative morbidity, comorbidity management, and weight loss outcomes. RESULTS: A total of 106 patients were included. Primary procedures were adjustable gastric band 44 (41.5%), sleeve gastrectomy 42 (39.6%), Roux-en-Y gastric bypass (RYGB) 18 (17%), duodenal switch (DS) 1 (0.9%), and vertical banded gastroplasty 1 (0.9%). RBSs performed included 85 (78.7%) RYGB, 16 (14.8%) redo-gastrojejunostomy, and 5 (4.6%) DS. The median time to revision was 8 (range 1-36) years, and the main indication was insufficient weight loss (49%). Median length of hospital stay was 2 (range 1-16) days, and 9 (8.5%) patients were readmitted during the first 30 days. Only 4 (3.7%) patients had early Clavien-Dindo grade III or higher adverse events. No anastomotic leaks were documented. Median excess weight loss was 35.1%, 42.23%, and 45.82% at the 6-, 12-, and 24-month follow-up. Of 57 patients with hypertension, 29 (50.9%) reduced their medication dosage, and 20/27 (74.1%) reduced their diabetes mellitus medication dosage. Finally, of the 75 patients with symptoms, 64 (85.3%) reported an improvement after the RBS. CONCLUSION: Robotic-assisted RBS is feasible, significantly improves patients' comorbidities and symptoms, and leads to considerable weight loss.

Outcomes of Bariatric Surgery Before, During, and After Solid Organ Transplantation.

BACKGROUND: Bariatric surgery (BS) may help transplant patients by improving their comorbidities and graft function and reducing the recurrence of the disease that led to the transplant. Different timings for BS have been proposed. This study aims to describe the outcomes of BS before, during, and after solid organ transplantation. METHODS: We identified patients with history of solid organ transplantation that underwent BS between January 1, 2012, and April 31, 2022, at our hospital site. We analyzed patients' demographics, obesity-related comorbidities, and transplant history. Measured outcomes included post-operative morbidity; readmission; comorbidity management; weight loss at 6-, 12-, and 24-month follow-up; and survival. RESULTS: Seventy-eight patients were included in our analysis, with a median age of 57 (28-75) years and a median BMI of 40.91 (28.9-61) kg/m2. The most transplanted organ was the liver (53.6%), followed by the kidney (31.9%). Ten patients underwent BS before the transplant, 11 had simultaneous BS and liver transplant, and 57 underwent BS after the transplant. The median operative time, ICU requirement, length of hospital stay, and early post-operative complications were significantly higher in the simultaneous group. The median EBWL% at 6-, 12-, and 24-month follow-up was 47.51%, 57.89%, and 64.22%, respectively, with no significant difference between the three groups. Thirty-four (44.3%) and 40 (50.8%) patients reduced their HTN and DM medication dosage, respectively. One- and five-year survival rates were 98.2% and 87.4%. CONCLUSION: BS before, during, or after solid organ transplant is safe, leads to a significant weight loss and improvement of obesity-related comorbidities, and improves patient's survival.

Combined Sleeve Gastrectomy with Liver Transplant in Patients with Obesity: a Feasibility Study.

BACKGROUND: Nonalcoholic steatohepatitis (NASH) associated with obesity is one of the leading causes of liver failure requiring transplant, yet guidelines for the management of obesity in these scenarios are not always followed. In order to decrease incidence of NASH in the new liver, we studied the feasibility of simultaneous liver transplant and bariatric surgery. MATERIALS AND METHODS: We retrospectively identified patients who underwent simultaneous liver transplant and sleeve gastrectomy at our hospital site between November 24, 2019, and April 14, 2022. Demographics, surgical data, postoperative adverse events, and weight loss data were collected. RESULTS: Ten patients met inclusion criteria. Mean body mass index (BMI) at the time of transplant was 43.1 ± 5.3 kg/m2, and mean length of hospital stay was 10.8 ± 5.22 days. Within 30 days after surgery, 7 patients reported adverse effects, and 2 were readmitted. Mean BMI at 6-month follow-up was 30.6 ± 2.5 kg/m2. Mean percentage excess weight (in pounds) loss was 48.1 ± 11.4%, 58.6 ± 8.9%, and 66.1 ± 15.3% at 3-, 6-, and 12-month follow-up, respectively. Three patients had an increase in weight at 12-month follow-up when compared to 6-month follow-up. Most patients required fewer comorbidity-related medications, and none reported adverse effects related to sleeve gastrectomy. CONCLUSIONS: Bariatric surgery at the time of liver transplant is safe and has minimal adverse effects. Results include substantial postoperative weight loss, improvement in comorbidities, and decreased risk of NASH in the new liver. Further studies with larger cohorts are required to confirm the findings of this study.