Robotic Biliary Stricturoplasty and Roux-en-Y Hepaticojejunostomy After Hepatic Artery Infusion Pump Injury.

BACKGROUND: Hepatic artery infusion pump (HAIP) with floxuridine/dexamethasone and systemic chemotherapy is an established treatment regimen, which had been reported about converting 47% of patients with stage 4 colorectal liver metastasis from unresectable to resectable.1,2 To this effect, HAIP chemotherapy contributes to prolonged survival of many patients, which otherwise may not have other treatment options. Biliary sclerosis, however, is a known complication of the HAIP treatment, which occurs in approximately 5.5% of patients receiving this modality as an adjuvant therapy after hepatectomy and in 2% of patients receiving HAIP treatment for unresectable disease.3 While biliary sclerosis diffusely affects the perihilar and intrahepatic biliary tree, a dominant stricture maybe found in select cases, which gives an opportunity for a local surgical treatment after failure of endoscopic stenting/dilations. While the use of minimally invasive approach to biliary surgery is gradually increasing,4 there have been no descriptions of its application in this scenario. In this video, we demonstrate the use of minimally invasive robotic technique for biliary stricturoplasty and Roux-en-Y (RY) hepaticojejunostomy to treat persistent right hepatic duct stricture after HAIP chemotherapy. PATIENT: A 68-year-old woman with history of multifocal bilobar stage 4 colorectal liver metastasis presented to our office with obstructive jaundice and recurrent cholangitis that required nine endoscopic retrograde cholangiopancreatographies (ERCPs) and a placement of internal-external percutaneous transhepatic biliary drain (PTBD) by interventional radiology within the past 2 years. Her past surgical history was consistent with laparoscopic right hemicolectomy 3 years prior, followed by a left lateral sectorectomy with placement of an HAIP for adjuvant treatment. The patient had more than ten metastatic liver lesions within the right and left lobe, ranging from 2 to 3 cm in size at the time of HAIP placement. The patient had a histologically normal background liver parenchyma before the HAIP chemotherapy treatment. The patient did not have any history of alcohol use, diabetes mellitus, metabolic syndrome, nonalcoholic steatohepatitis, or other underlying intrinsic liver disorders, which are known to contribute to the development of hepatic fibrosis. Despite a radiologically disease-free status, the patient started to have episodes of acute cholangitis 1 year after the placement of HAIP that required multiple admissions to a local hospital. The HAIP was subsequently removed once the diagnosis of biliary sclerosis was made despite dose reductions and treatment with intrahepatic dexamethasone for almost 1 year. In addition to this finding, the known liver metastases have shown complete radiological resolution. Therefore further treatment with HAIP was deemed unnecessary, and pump removal was undertaken. Magnetic resonance imaging showed a dominant stricture at the junction of the right anterior and right posterior sectoral hepatic duct. The location of the dominant stricture was confirmed by an ERCP and cholangioscopy. Absence of neoplasia was confirmed with multiple cholangioscopic biopsies. Multiple endoscopic and percutaneous attempts with stent placement failed to dilate the area of stricture. Postprocedural cholangiographies showed a persistent significant narrowing, which led to multiple recurrent obstructive jaundice and severe cholangitis. While the use of surgical approach is rarely needed in the treatment of biliary sclerosis, a decision was made after extensive multidisciplinary discussions to perform a robotic stricturoplasty and RY hepaticojejunostomy with preservation of the native common bile duct. TECHNIQUE: The operation began with a laparoscopic adhesiolysis to allow for identification of HAIP tubing (which was later removed) and placement of robotic ports. A peripheral liver biopsy was obtained to evaluate the degree of hepatic parenchymal fibrosis. Porta hepatic area was carefully exposed without causing an inadvertent injury to the surrounding hollow organs. Biopsy of perihepatic soft tissues was taken as appropriate to rule out any extrahepatic disease. The common bile duct and common hepatic duct with ERCP stents within it were identified with the use of ultrasonography. Anterior wall of the common hepatic duct was then opened, exposing the two plastic stents. Cephalad extension of the choledochotomy was made toward the biliary bifurcation and the right hepatic duct. The distal common bile duct was preserved for future endoscopic access to the biliary tree. After lowering the right-sided hilar plate, dense fibrosis around the right hepatic duct was divided sharply with robotic scissors, achieving a mechanical release of the dominant stricture. An intraoperative cholangioscopy was performed to confirm adequate openings of the right hepatic duct secondary and tertiary radicles, as well as patency of the left hepatic duct. A 4-Fr Fogarty catheter was used to sweep the potential biliary debris from within the right and left hepatic lobe. Finally, a confirmatory choledochoscopy was performed to ensure patency and clearance of the right-sided intrahepatic biliary ducts and the left hepatic duct before fashioning the hepaticojejunostomy. A 40-cm antecolic roux limb was next prepared for the RY hepaticojejunostomy. A side-to-side double staple technique was utilized to create the jejunojejunostomy. The common enterotomy was closed in a running watertight fashion. Once the roux limb was transposed to the porta hepatic in a tension-free manner, a side-to-side hepaticojejunostomy was constructed in a running fashion by using absorbable barbed sutures. The index suture was placed at 9 o'clock location, and the posterior wall of the anastomosis was run toward 3 o'clock location. This stabilized the roux limb to the bile duct. The anterior wall of the anastomosis was next fashioned by using a running technique from both corners of the anastomosis toward the middle (12 o'clock), where both sutures were tied together. This completed a wide side-to-side hepaticojejunostomy anastomosis encompassing the upper common hepatic duct, biliary bifurcation, and the right hepatic duct. A closed suction drain was placed before closing.5 RESULTS: The operative time was approximately 4 hr with 60 ml of blood loss. The postoperative course was uneventful. The patient was discharged home on postoperative Day 5 after removal of the closed suction drain, confirming the absence of bile leak. The patient had developed periportal/periductal fibrosis, cholestasis, and moderate-severe parenchymal fibrosis (F3-F4) based on liver biopsy, often seen in patients treated with a long course of floxuridine HAIP chemotherapy. The patient is clinically doing well at 1 year outpatient follow-up without any evidence of recurrent cholangitis at the time of this manuscript preparation. CONCLUSIONS: Robotic biliary stricturoplasty with RY hepaticojejunostomy for treatment of biliary sclerosis after HAIP chemotherapy is safe and feasible. Appropriate experience in minimally invasive hepatobiliary surgery is necessary to achieve this goal.

Short-term effects of gastric bypass versus sleeve gastrectomy on high LDL cholesterol: The BASALTO randomized clinical trial.

BACKGROUND: There has been a substantial increase in the use of laparoscopic sleeve gastrectomy (SG) to treat morbid obesity despite observational evidence demonstrating the superiority of Roux-en-Y gastric bypass (RYGB) for reducing low-density lipoprotein (LDL) cholesterol. The main aim was to ascertain whether high LDL cholesterol levels should be considered when selecting the most appropriate surgical procedure for each patient (RYGB or SG). METHODS: In this single-center, randomized clinical trial using intention-to-treat analysis, 38 patients with severe obesity and elevated levels of LDL cholesterol were randomly assigned to undergo RYGB or SG. The primary outcome was LDL cholesterol remission at 12 months, defined as LDL cholesterol < 3.36 nmol/l without lipid-lowering medications. Secondary outcomes included changes in weight, other comorbidities, qualitative lipoprotein traits, cholesterol esters, glycoproteins, cholesterol absorption and synthesis metabolites and complications. RESULTS: Intention-to-treat analysis revealed that LDL cholesterol remission occurred in 66.6% of RYGB patients compared to 27.8% of SG patients (p = 0.019). Among patients completing follow-up, RYGB demonstrated superior remission (80.0% vs. 29.4%, p = 0.005). Exclusive benefits of RYGB included a reduction in large, medium, and small LDL particles. Cholesterol absorption markers showed differential behavior after both techniques: campesterol (Δ -15.2 µg/mg, 95% CI -30.2 to -0.1) decreased after RYGB, and sitosterol (Δ 21.1 µg/mg, 95% CI 0.9 to 41.2), cholestanol (Δ 30.6 µg/mg, 95% CI 14.8 to 57.9) and campesterol (Δ 18.4 µg/mg, 95% CI 4.4 to 32.3) increased after SG. No differences in weight loss, cholesterol esters, glycoproteins, cholesterol synthesis metabolites or postoperative complications were observed between techniques. CONCLUSION: In conclusion, RYGB is superior to SG in terms of short-term of high LDL cholesterol remission. Furthermore, RYGB also led to a greater improvement in lipoprotein parameters that confer an atherogenic profile. Therefore, the presence of elevated levels of LDL cholesterol should be considered when determining the optimal bariatric surgery procedure for each patient. TRIAL REGISTRATION: Clinicaltrials.gov number, NCT03975478).

Varying concentrations of tyrosine kinase inhibitors in chronic myeloid leukemia patients following bariatric surgery: a case series.

Bariatric surgery is increasingly performed to treat severe obesity. As a result of anatomical and physiological changes in the gastrointestinal tract, the pharmacokinetics (PK) of oral drugs can be altered, affecting their efficacy and safety. This includes the class of tyrosine kinase inhibitors (TKIs) which are used to treat chronic myeloid leukemia (CML). This case series describes the clinical course of four CML cases with a history of bariatric surgery. The patients used various TKIs (nilotinib, dasatinib, bosutinib, ponatinib, and imatinib) for which 15 drug levels were measured. The measured TKI concentrations were in part subtherapeutic, and highly variable when compared to mean levels measured in the general population. Multiple drug levels were measured in these patients, as the clinicians were aware of the possible impact of bariatric surgery. The drug levels were used as additional input for clinical decision-making. All four patients required TKI switches and/or dose modifications to achieve an effective and tolerable treatment. Eventually, adequate clinical and molecular remissions were achieved in all cases. In summary, TKI concentrations of patients undergoing bariatric surgery may be subtherapeutic. Moreover, there is substantial interindividual and intraindividual variation, which may be explained by the complex interference of bariatric surgery and associated weight loss. For clinical practice, therapeutic drug monitoring is advised in patients with a history of bariatric surgery in case of suboptimal response or loss of response.

How best to combine liver transplantation and bariatric surgery?-Results from a global, web-based survey.

BACKGROUND AND AIMS: Obesity is a growing healthcare challenge worldwide and a significant risk factor for liver failure as seen with non-alcoholic steatohepatitis (NASH). Combining metabolic-bariatric surgery (MBS) with liver transplantation (LT) appears as attractive strategy to treat both, the underlying liver disease and obesity. However, there is an ongoing debate on best timing and patient selection. This survey was designed to explore the current treatment practice for patients with NASH and obesity worldwide. METHODS: A web-based survey was conducted in 2022 among bariatric and LT surgeons, and hepatologists from Europe, North and South America and Asia. RESULTS: The survey completion rate was 74% (145/196). The average respondents were 41-50 years (38%), male (82.1%) and had >20 years of clinical experience (42.1%). Centres with a high LT-caseload for NASH were mainly located in the USA and United Kingdom. Almost 30% have already performed a combination of LT with MBS and 49% plan to do it. A majority of bariatric surgeons prefer MBS before LT (77.2%), whereas most of LT surgeons (52%) would perform MBS during LT. Most respondents (n = 114; 80%) favour sleeve gastrectomy over other bariatric techniques. One third (n = 42; 29.4%) has an established protocol regarding MBS for LT candidates. CONCLUSION: The most experienced centres doing LT for NASH are in the USA and United Kingdom with growing awareness worldwide. Overall, a combination of MBS and LT has already been performed by a third of respondents. Sleeve gastrectomy is the bariatric technique of choice-preferably performed either before or during LT.

Association of Sex Differences on Weight Loss and Complications Following Bariatric Surgery.

INTRODUCTION: Sex as a biologic variable remains largely understudied, even for the most commonly performed operations. The most effective treatment for obesity and obesity-associated comorbidities is bariatric surgery. There are limited data to describe potential differences in outcomes between male and female patients, particularly with regards to weight loss. Within this context, we examined weight loss and complications up to 1 y following sleeve gastrectomy or gastric bypass within a statewide bariatric quality improvement collaborative. METHODS: We performed a retrospective cohort study among patients who had bariatric surgery. Using a state-wide bariatric-specific data registry, all patients who underwent gastric bypass or sleeve gastrectomy between June 2006 and June 2022 were identified. The primary outcome was percent excess body weight loss and change in body mass index (BMI) at 1 y. The secondary outcome was 30-d risk-adjusted complications. RESULTS: Among 107,504 patients, the majority (n = 85,135; 79.2%) were female and most patients (n = 49,731; 58%) underwent sleeve gastrectomy. Compared to female patients, male patients were older (47.6 y versus 44.8 y; P < 0.0001), had higher baseline weight (346.6 lbs versus 279.9 lbs; P < 0.0001), had higher preoperative BMI (49.9 kg/m2versus 47.2 kg/m2; P < 0.0001), and higher prevalence of most comorbid conditions including hypertension, hyperlipidemia, diabetes, and sleep apnea (P < 0.0001). Compared to female patients, male patients experienced greater total body weight loss (105.1 lbs versus 84.9 lbs; P < 0.0001) and higher excess body weight loss (60.0% versus 58.8%; P < 0.0001) but had higher BMI overall (34.0 kg/m2versus 32.8 kg/m2; P < 0.0001) at 1-y follow-up. Males had higher rates of serious complications (2.5% versus 1.9%; P < 0.0001), leak and perforation (0.5% versus 0.4%; P < 0.0001), venous thromboembolism (0.7% versus 0.4%; P < 0.0001), and medical complications (1.5% versus 1%; P < 0.0001). CONCLUSIONS: In this study we found that both males and females experienced excellent weight loss with a low risk of complications following bariatric surgery. Male sex was associated with slightly greater weight loss and slightly higher incidence of complications. However, although statistically significant, clinically, the differences in weight loss was not. Due to males having higher prevalence of comorbidities, providers should consider referring males earlier for bariatric surgery which may improve outcomes for this population.

Can proximal gastrectomy with double-tract reconstruction replace total gastrectomy? a meta-analysis of randomized controlled trials and propensity score-matched studies.

BACKGROUND: According to the 5th edition of the Japanese Guidelines for the Treatment of Gastric Cancer, proximal gastrectomy is recommended for patients with early upper gastric cancer who can retain the distal half of the residual stomach after R0 resection. However, a large number of recent clinical studies suggest that surgical indications for proximal gastrectomy in the guidelines may be too narrow. Therefore, this meta-analysis included patients with early and advanced gastric cancer and compared short- and long-term postoperative outcomes between the two groups. At the same time, we only had high-quality clinical studies such as propensity score-matched studies and randomized controlled trials, which made our research more authentic and credible. METHODS: Data were retrieved from PubMed, EMBASE, Medline, and Cochrane Library up to June 2023, and included treatment outcomes after proximal gastrectomy with double-tract reconstruction and total gastrectomy with Roux-en-Y reconstruction. The primary results were Early-phase complications(Anastomotic leakage, Anastomotic bleeding, Abdominal abscess, Abdominal infection, Pulmonary infection, Incision infection, Intestinal obstruction, Dumping syndrome, Pancreatic fistula), Late-phase complications(Intestinal obstruction, Anastomosis stricture, Dumping syndrome, Reoperation, Internal hernia, Incidence of endoscopic gastroesophageal reflux), Serious complications (≥ Grade III C-D score), Quality of life[Gastroesophageal reflux symptom evaluation (Visick score)(≥ III), Los Angeles classification(C or D)], Nutritional status(Hemoglobin, Receipt of vitamin B12 supplementation), Oncologic Outcomes(The 5-year overall survival rates). Secondary outcomes were surgical outcomes (Operative time, Estimated blood loss, Postoperative hospital stay, Number of harvested lymph nodes, Gas-passing, Postoperative mortality).The Cochrane risk-of-bias tool and Newcastle‒Ottawa scale were used to assess the quality of the included studies. RESULTS: After screening, 11 studies were finally included, including 1154 patients. Results from the combined literature showed that total gastrectomy had a significant advantage over proximal gastrectomy with double-tract reconstruction in mean operating time (MD = 4.92, 95% CI: 0.22∼9.61 P = 0.04). However, meta-analysis results showed that Hemoglobin (MD = 7.12, 95% CI:2.40∼11.84, P = 0.003) and Receipt of vitamin B12 supplementation (OR = 0.12, 95% CI:0.05∼0.26, P < 0.00001) in the proximal gastrectomy with double-tract reconstruction group were better than those in the total gastrectomy with Roux-en-Y reconstruction group. There is no significant difference between the proximal gastrectomy with double-tract reconstruction and the total gastrectomy with Roux-en-Y reconstruction group in Early-phase complications(OR = 1.14,95% CI:0.79∼1.64, P = 0.50), Late-phase complications(OR = 1.37,95% CI:0.78∼2.39, P = 0.27), Gastroesophageal reflux symptom evaluation (Visick score)(≥ III)(OR = 0.94,95% CI:0.14∼1.07 P = 0.07), Los Angeles classification(C or D)(OR = 0.33,95% CI:0.01∼8.21, P = 0.50), the 5-year overall survival rates (HR = 1.01, 95% CI: 0.83 ~ 1.23, P = 0.89). CONCLUSION: Proximal gastrectomy with double-tract anastomosis is a safe and feasible treatment for upper gastric carcinoma. However, the operating time was slightly longer in the proximal gastrectomy with double-tract group compared to the total gastrectomy with Roux-en-Y group. The two groups were comparable to the total gastrectomy with Roux-en-Y group in terms of serious complications (≥ Grade III C-D score), early-phase complications, late-phase complications, and quality of life. Although the scope of proximal gastrectomy is smaller than that of total gastrectomy, it does not affect the 5-year survival rate, indicating good tumor outcomes for patients. Compared to total gastrectomy with Roux-en-Y group, proximal gastrectomy with double-tract reconstruction had higher hemoglobin levels, lower probability of vitamin B12 supplementation, and better long-term efficacy. In conclusion, proximal gastrectomy with double-tract reconstruction is considered one of the more rational surgical approaches for upper gastric cancer.

Gastric sleeve as an extra-anatomical roux for biliary reconstruction in a pediatric third liver transplant.

BACKGROUND: Sir Roy Calne in 1976 described "Biliary reconstruction is the Achilles heel of liver transplantation," and it remains true. In some patients, such as those with short-gut syndrome and concomitant biliary atresia, neither duct to duct nor Roux biliary reconstruction is feasible. METHODS: We present a case of child's third liver transplant (LT), where an innovative extra-anatomical biliary bypass was created using a sleeve from greater curvature of the stomach. RESULTS: The patient is well nearly 10 years following the LT. CONCLUSIONS: This technique could prove to be an important addition to the armamentarium of a surgeon in difficult retransplants and in patients with short-gut syndrome as it provides a viable option with good long-term outcome.

Late-"de novo" paraesophageal hernia after Roux-en-Y gastric bypass (RYGB)-should it be repaired?

BACKGROUND: This study presents a case series of "de novo" paraesophageal hernia (dnPEH) in post-Roux-en-Y gastric bypass (RYGB) patients and analyzes the predisposing factors, symptoms, and outcomes after repair. This is a lesser known complication after RYGB and when symptomatic, may warrant surgery. METHODS: A retrospective review of data from a single academic institution from 2002 to 2022 was performed identifying patients who developed dnPEH after RYGB and compared them to patients with primary RYGB without post-operative symptomatic dnPEH. Patient characteristics from initial RYGB were analyzed to identify predisposing factors for dnPEH development. Additional information analyzed included time to dnPEH repair, indications for surgery, types of herniation, type of surgical repair, and symptom resolution. RESULTS: There were 6975 RYGB in the study period of which 6619 underwent RYGB alone at index surgery, with 31 of those patients developing late stage PEH requiring repair. Patients with older age (51.8 years with dnPEH vs 45.2 years without, p = 0.001) and increased weight loss at 1 year (33.4% vs 30.5%, p = 0.048) from index RYGB were more likely to develop dnPEH. The incidence of dnPEH was 31/6619 (0.47%). Late dnPEH after RYGB took an average of 74 months (45-102 months IQR) to develop symptoms and undergo repair. The most common symptoms were heartburn/reflux 19/31 (61.3%) and epigastric pain 13/31 (41.9%). Symptom resolution rate after repair was highest with 100% for globus and 89.5% heartburn/reflux. The most common form of dnPEH was pouch herniation in 25/31. Surgical repair most commonly included primary cruroplasty alone in 25/31 with additional mesh in 1 case. Recurrence rate was 2/31 (6.54%). CONCLUSION: Late dnPEH after RYGB is an emerging entity typically occurring years after index RYGB. Symptomatic patients with dnPEH warrant hernia repair and responded well to surgical repair in this case series.

One anastomosis gastric bypass as a primary bariatric surgery: MBSAQIP database analysis of short-term safety and outcomes.

BACKGROUND: One anastomosis gastric bypass (OAGB) is described as a simpler, potentially safe, and effective bariatric-metabolic procedure that has been recently endorsed by the American Society of Metabolic and Bariatric Surgery. OBJECTIVES: First, we aim to compare the 30-day outcomes between OAGB and other bypass procedures: Roux-en-Y gastric bypass (RYGB) and single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S). Second, identify the odds between postoperative complications and each surgical procedure. METHODS: Patients who underwent primary OAGB, RYGB, and SADI-S were identified using the MBSAQIP database of 2020 and 2021. An analysis of patient demographics and 30-day outcomes were compared between these three bypass procedures. In addition, a multilogistic regression for overall complications, blood transfusions, unplanned ICU admissions, readmission, reoperation, and anastomotic leak stratified by surgical procedure was performed. RESULTS: 1607 primary OAGBs were reported between 2020 and 2021. In terms of patient demographics, patients who underwent RYGB and SADI-S showed a higher incidence of comorbidities. On the other hand, OAGB had shorter length of stay (1.39 ± 1.10 days vs 1.62 ± 1.42 days and 1.90 ± 2.04 days) and operative times (98.79 ± 52.76 min vs 125.91 ± 57.76 min and 139.85 ± 59.20 min) than RYGB and SADI-S. Similarly, OAGB showed lower rates of overall complications (1.9% vs 4.5% and 6.4%), blood transfusions (0.4% vs 1.1% and 1.8%), unplanned ICU admission (0.3% vs 0.8% and 1.4%), readmission (2.4% vs 4.9% and 5.0%), and reoperation (1.2% vs 1.9% and 3.1%). A multilogistic regression analysis was performed, RYGB and SADI-S demonstrated higher odds of 30-day complications. CONCLUSION: The incidence of primary OAGB has increased since its approval by ASMBS, from 0.05% reported between 2015 and 2019 to 0.78% between 2020 and 2021. OAGB had better 30-day outcomes and shorter operative times than RYGB and SADI-S and therefore, could be considered a viable alternative.

SAGES guidelines for the surgical treatment of hiatal hernias.

BACKGROUND: Hiatal hernia (HH) is a common condition. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of HH. METHODS: Systematic reviews were conducted for four key questions regarding the treatment of HH in adults: surgical treatment of asymptomatic HH versus surveillance; use of mesh versus no mesh; performing a fundoplication versus no fundoplication; and Roux-en-Y gastric bypass (RYGB) versus redo fundoplication for recurrent HH. Evidence-based recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluations methodology by subject experts. When the evidence was insufficient to base recommendations on, expert opinion was utilized instead. Recommendations for future research were also proposed. RESULTS: The panel provided one conditional recommendation and two expert opinions for adults with HH. The panel suggested routinely performing a fundoplication in the repair of HH, though this was based on low certainty evidence. There was insufficient evidence to make evidence-based recommendations regarding surgical repair of asymptomatic HH or conversion to RYGB in recurrent HH, and therefore, only expert opinions were offered. The panel suggested that select asymptomatic patients may be offered surgical repair, with criteria outlined. Similarly, it suggested that conversion to RYGB for management of recurrent HH may be appropriate in certain patients and again described criteria. The evidence for the routine use of mesh in HH repair was equivocal and the panel deferred making a recommendation. CONCLUSIONS: These recommendations should provide guidance regarding surgical decision-making in the treatment of HH and highlight the importance of shared decision-making and consideration of patient values to optimize outcomes. Pursuing the identified research needs will improve the evidence base and may allow for stronger recommendations in future evidence-based guidelines for the treatment of HH.

Robotic bariatric surgery reduces morbidity for revisional gastric bypass when compared to laparoscopic: outcome of 8-year MBSAQIP analysis of over 40,000 cases.

INTRODUCTION: Robotic-assisted metabolic and bariatric surgery (MBS) is gaining popularity. Revisional MBS is associated with higher perioperative morbidity compared to primary MBS. The optimal surgical approach to minimize complications in these complex cases is unclear. The goal of this study was to assess robot utilization in revisional MBS and compare laparoscopic and robotic revisional MBS outcomes in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. METHODS: A retrospective review of the MBSAQIP database was performed identifying revisional sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) cases from 2015 to 2022. Primary MBS, open/emergent cases, cases converted to another approach, and combined cases other than esophagogastroduodenoscopy were excluded. 30-Day outcomes for laparoscopic and robotic cases were compared using multivariate logistic regression adjusting for patient demographics, comorbidities, and operative variables. RESULTS: 41,404 Cases (14,474 SG; 26,930 RYGB) were identified. From 2015 to 2022, the percentage of revisional SG and RYGB cases performed robotically increased from 6.1% and 7.3% to 24.2% and 32.0% respectively. Laparoscopic SG had similar rates of overall morbidity, leak, bleeding, readmission, reoperation, and length of stay compared to robotic. Laparoscopic RYGB had significantly higher rates of overall morbidity (6.2% vs. 4.8%, p < 0.001, AOR 0.80 [0.70-0.93]), blood transfusion (1.5% vs. 1.0%, p < 0.05, AOR 0.74 [0.55-0.99]), superficial incisional SSI (1.2% vs. 0.4%, p < 0.001, AOR 0.30 [0.19-0.47]), and longer length of stay (1.87 vs. 1.76 days, p < 0.001) compared to robotic. Laparoscopic operative times were significantly shorter than robotic (SG: 86.4 ± 45.8 vs. 113.5 ± 51.7 min; RYGB: 130.7 ± 64.7 vs. 165.5 ± 66.8 min, p < 0.001). CONCLUSION: Robot utilization in revisional bariatric surgery is increasing. Robotic surgery has lower postoperative morbidity and shorter length of stay in revisional RYGB when compared to laparoscopic. Robotic platforms may have the capacity to improve the delivery of care for patients undergoing revisional bariatric surgery.

Conversion of one-anastomosis gastric bypass (OAGB) to Roux-en-Y gastric bypass (RYGB) for gastroesophageal reflux disease (GERD): who is more at risk? A multicenter study.

BACKGROUND: Although gastroesophageal reflux disease (GERD) affects 0.6% to 10% of patients operated on for one-anastomosis gastric bypass (OAGB), only about 1% require surgery to convert to Roux-en-Y gastric bypass (RYGB) [3-5]. The aim of the present study was to analyze the characteristics of OAGB patients converted to RYGB for GERD not responding to medical treatment. METHODS: This retrospective multicenter study included patients who underwent conversion from OAGB to RYGB for severe GERD. The conversion was performed with resection of the previous gastro-jejunal anastomosis and the use of the afferent loop as a new biliary loop. RESULTS: A total of 126 patients were included in the study. Of these patients, 66 (52.6%) had a past medical history of bariatric restrictive surgery (gastric banding, sleeve gastrectomy). A hiatal hernia (HH) was present in 56 patients (44.7%). The association between previous restrictive surgery and HH was recorded in 33 (26.2%) patients. Three-dimensional gastric computed tomography showed an average gastric pouch volume of 242.4 ± 55.1 cm3. Conversion to RYGB was performed on average 60 ± 35.6 months after OAGB. Seven patients (5.5%) experienced an early postoperative complication (4 patients grade IIIb and 3 grade IIb), and 3 (2.4%) a late complication. Patients showed further weight loss after RYGB conversion and an average of 24.8 ± 21.7 months after surgery, with a mean % of total weight loss (%TWL) of 6.9 ± 13.6 kg. From a clinical point of view, the problem of GERD was definitively solved in more than 90% of patients. CONCLUSIONS: Situations that weaken the esogastric junction appear to be highly frequent in patients operated on for OAGB and converted to RYGB for severe reflux. Similarly, the correct creation of the gastric pouch could play an important role in reducing the risk of conversion to RYGB for GERD.

Long-term results after transoral outlet reduction (TORe) of the gastrojejunal anastomosis for secondary weight regain and dumping syndrome after Roux-en-Y gastric bypass.

BACKGROUND: Bariatric surgery has been proven to be the most effective therapy for obesity and Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed procedure. However, weight regain and dumping syndrome occur over time. The transoral outlet reduction (TORe) procedure using an endoscopic suturing device may be an option to treat these conditions. We aimed to analyze outcome parameters and long-term results for this endoscopic technique. METHODS: A retrospective data analysis of patients who underwent TORe using an endoscopic suturing system at our institution from January 2015 to December 2020 was performed. A total of 71 subjects were included. Forty-five patients received the intervention for weight regain, 9 for dumping syndrome and 17 for both. The primary endpoint was weight stabilization or weight loss for subjects with weight regain, and resolution of symptoms for those with dumping syndrome. Secondary endpoints were intraoperative complications, procedure time, length of hospital stay and diameter of gastrojejunal anastomosis 1 year post-intervention. RESULTS: The median size of the gastrojejunal anastomosis was estimated at 30 mm before intervention, and after performing a median of 3 endoscopic sutures, the median estimated gastrojejunal anastomosis width was reduced to 9.5 mm. Eight perioperative complications occurred. Overall mean follow-up was 26.5 months. All interventions achieved weight stabilization or weight loss or resolution of dumping symptoms within the first 3 months, 98.2% at 12 months, 91.4% at 24 months and 75.0% at 48 months. In 22/26 subjects a persisting improvement of dumping syndrome was achieved. CONCLUSIONS: TORe is a safe and effective procedure in the treatment of patients with dumping syndrome after laparoscopic RYGB, the effect on weight stabilization is less significant. A prospective randomized trial should be conducted to compare the effects of TORe with other surgical methods like banding the gastrojejunal anastomosis.

Weight loss after Roux-en-Y gastric bypass and single anastomosis duodenoileostomy following failed sleeve gastrectomy.

OBJECTIVE: While sleeve gastrectomy (SG) results in sustained weight loss for the majority of patients, some will experience inadequate weight loss or weight regain requiring revision. The objective of this study was to evaluate differences in weight loss over time between patients undergoing Roux-en-Y gastric bypass (RYGB) or single anastomosis duodenoileostomy (SADI) after SG. METHODS: We queried a single institution's bariatrics registry to identify patients who underwent RYGB or SADI after previous SG over a three-year period. Demographics, operative characteristics, and post-operative complications were evaluated. Interval total body weight loss (TBWL) and excess body weight loss (EBWL) were calculated from available follow-ups within 2 years. RESULTS: We identified 124 patients who underwent conversion to RYGB (n = 61) or SADI (n = 63) following previous SG. There were no differences in sex, age, or medical comorbidities between groups. The median initial BMI was higher in the SADI group (44.9 vs. 41.9 for RYGB, p = 0.03) with greater excess body weight (56.7 vs. 64.3 kg, p = 0.04). The SADI group had a shorter median operative duration (157 vs. 182 min for RYGB, p < 0.01) and lower readmission rates (0 vs. 14.75%, p < 0.01). There was no difference in post-operative complications or need for rehydration therapy between the groups. Among 122 patients (98.4%) that had follow-up weights available, there were no differences in TBWL between groups. RYGB patients had a higher EBWL at 2, 3, and 6 months (p < 0.05 for all comparisons), but there were no differences between RYGB and SADI at 1 or 2 years. CONCLUSIONS: Both RYGB and SADI conversions proved effective for further weight loss following failed SG at our academic center. While neither demonstrated clear superiority in long-term (> 1 year) weight loss, RYGB's restrictive gastric pouch may explain its early weight loss advantage.

Outcomes of same-day discharge in bariatric surgery.

BACKGROUND: Restrictions during the COVID-19 pandemic influenced a shift to same-day discharge in bariatric surgery. Current studies show conflicting findings regarding morbidity and mortality. We aim to compare outcomes for same-day discharge versus admission after bariatric surgery. METHODS: Subjects included patients who underwent primary laparoscopic or robotic-assisted sleeve gastrectomy or Roux-En-Y gastric bypass at an academic center. The inpatient group included patients discharged postoperative day one, and the outpatient group included patients discharged on the day of surgery. Primary outcomes included the number of emergency room visits, reoperations, IV fluid treatments, readmissions, and mortality within 30 days. Secondary outcomes were morbidity, including skin and soft tissue infection, pulmonary embolism, and acute kidney injury. RESULTS: 1225 patients met the inclusion criteria. In the gastric sleeve group, 852 subjects were outpatients and 227 inpatients. In the gastric bypass group, 70 subjects were outpatients, and 40 were inpatients. The mean age was 44.63 (17.38-85.31) years, and the mean preoperative BMI was 46.07 ± 8.14 kg/m2. The subjects in the outpatient group had lower BMI with fewer comorbidities. The groups differed significantly in age, BMI, and presence of several chronic comorbidities. The inpatient and outpatient groups for each surgery type did not differ significantly regarding reoperations, IV fluid treatments, or 30-day mortality. The inpatient sleeve group demonstrated a significantly higher readmission percentage than the outpatient group (4.6% vs 2.1%; p = 0.02882). The inpatient bypass group showed significantly greater ER visits (21.7% vs 10%; p = 0.0108). The incidence of adverse events regarding the secondary outcomes was not statistically different. CONCLUSION: Same-day discharge after bariatric surgery is a safe and reasonable option for patients with few comorbidities.

Bariatric surgery and the diseased kidney: a 5-year assessment of safety and postoperative renal outcomes.

BACKGROUND: Obesity and its related medical conditions are well-established contributors to the development of chronic kidney disease (CKD). Metabolic and bariatric surgery (MBS), including procedures such as sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), is a potential intervention for these individuals. However, the heightened risk of postoperative complications casts doubts on the suitability of MBS in this population. Our aim is to evaluate the long-term safety, anthropometric and renal outcomes of MBS in patients with CKD. METHODS: A retrospective review of patients who underwent primary laparoscopic MBS with a BMI ≥ 35 kg/m2 and a preoperative diagnosis of stage 2 to 5 CKD. Criteria for CKD diagnosis and staging were based on estimated glomerular filtration rate measurements in accordance with established guidelines. Anthropometric and renal outcomes were measured at 3-, 6-, 12-, 24- and 60-months postoperatively. RESULTS: A total of 302 patients (177 SG, 125 RYGB) were included. RYGB was preferred for patients with stage 3 CKD, while SG was more common in stages 4 and 5. At 5-year follow-up, percentage of total weight loss was higher in the RYGB cohort compared to SG (25.1% vs. 18.6%, p = 0.036). Despite SG patients having more advanced CKD, the incidence of late complications was significantly higher following RYGB, with 11 incidents (8.8%), compared to the SG cohort with only 4 cases (2.3%) (p = 0.014). In those with preoperative CKD stage 3, 76 patients (43.2%) improved to stage 2, with another 9 patients (5.1%) improving further to stage 1. Of all patients, 63 (20.8%) eventually received a successful renal transplant. CONCLUSIONS: MBS is an effective strategy for sustained weight loss in patients with CKD with acceptable complications rates. RYGB leads to a higher percentage of overall weight loss, albeit with an elevated likelihood of late surgical complications. Future studies are needed to determine the safety of MBS in this demographic.

Laparoscopic Roux-Y-gastric bypass versus laparoscopic one-anastomosis gastric bypass for obesity: clinical & metabolic results of a prospective randomized controlled trial.

BACKGROUND: One anastomosis gastric bypass (OAGB) has been proposed as an effective alternative to the current standard procedure in Switzerland, Roux-en-Y gastric bypass (RYGB). Prospective data comparing both procedures are scarce. Therefore, we performed a non-inferiority randomized controlled trial assessing the effectiveness and safety of these 2 operative techniques. METHOD: Eighty patients were randomized 1:1. OAGB consisted of a very long gastric pouch with a 200 cm biliopancreatic limb, RYGB of a 150 cm ante-colic alimentary and a 60 cm biliopancreatic limb, respectively. Primary endpoint was the percent excess weight loss (%EWL) at 12 months after surgery. RESULTS: Mean %EWL at 12 months was 87.9% (SD24.4) in the RYGB group and 104.1% (SD24.6) in the OAGB group (p = 0.006). There was no mortality. The rate of marginal ulcers was higher in patients with OAGB compared to those with RYGB (p = 0.011), while the total number of late complications did not statistically differ between the two groups. Except for the remission of GERD, which was higher in the RYGB group compared to OAGB, there was no difference between the groups regarding the remission of comorbidities. OAGB showed improved glucose control compared to the RYGB after 1 year (p = 0.001). Furthermore, glucagon-like peptide-1 increase was significantly higher in OAGB at 6 weeks (p = 0.041) and 1 year after surgery (p = 0.029). Quality of life improved after both surgeries, without differences between the groups. CONCLUSIONS: %EWL 1 year after surgery was higher in OAGB than in RYGB. A better glycemic control with a higher increase in GLP-1 was observed after OAGB compared to RYGB. TRIAL REGISTRATION: This trial is registered on ClinicalTrials.gov under the identifier NCT02601092.

Contemporary trends in choledochal cyst excision: An analysis of the pediatric national surgical quality improvement program.

BACKGROUND: Choledochal cysts are rare congenital anomalies of the biliary tree that may lead to obstruction, chronic inflammation, infection, and malignancy. There is wide variation in the timing of resection, operative approach, and reconstructive techniques. Outcomes have rarely been compared on a national level. METHODS: We queried the Pediatric National Surgical Quality Improvement Program (NSQIP) to identify patients who underwent choledochal cyst excision from 2015 to 2020. Patients were stratified by hepaticoduodenostomy (HD) versus Roux-en-Y hepaticojejunostomy (RNYHJ), use of minimally invasive surgery (MIS), and age at surgery. We collected several outcomes, including length of stay (LOS), reoperation, complications, blood transfusions, and readmission rate. We compared outcomes between cohorts using nonparametric tests and multivariate regression. RESULTS: Altogether, 407 patients met the study criteria, 150 (36.8%) underwent RNYHJ reconstruction, 100 (24.6%) underwent MIS only, and 111 (27.3%) were less than one year old. Patients who underwent open surgery were younger (median age 2.31 vs. 4.25 years, p = 0.002) and more likely underwent RNYHJ reconstruction (42.7% vs. 19%, p = 0.001). On adjusted analysis, the outcomes of LOS, reoperation, transfusion, and complications were similar between the type of reconstruction, operative approach, and age. Patients undergoing RNYHJ had lower rates of readmission than patients undergoing HD (4.0% vs. 10.5%, OR 0.34, CI [0.12, 0.79], p = 0.02). CONCLUSIONS: In children with choledochal cysts, most short-term outcomes were similar between reconstructive techniques, operative approach, and age at resection, although HD reconstruction was associated with a higher readmission rate in this study. Clinical decision-making should be driven by long-term and biliary-specific outcomes.

Long-term weight loss of distal gastric bypass is moderately superior compared to proximal gastric bypass in patients with a BMI of 37-44 Kg/m2.

PURPOSE: The laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the standard procedures in metabolic surgery. Different limb lengths have been proposed in the past to maximize weight loss (WL) and reduce metabolic complications. Distal gastric bypass surgery with a very short common channel (CC) (up to 100 cm) has been often criticized due to frequent side effects such as malnutrition, bone weakening and short-bowel syndrome. We introduced a modified version of a distal LRYGB with a 50-70 cm long biliopancreatic limb (BPL) and an intermediate short CC (120-150 cm). Our primary goal was to compare the long-term WL between distal and proximal LRYGB in two cohorts of patients. Secondary outcomes were weight regain (WR), insufficient weight loss (IWL), postoperative complications and metabolic changes 5 years after surgery. METHODS: In this retrospective study we collected data from 160 patients operated between 2014 and 2015, with a BMI of 37-44 Kg/m2. 101 patients underwent a distal and 59 patients a proximal LRYGB in two bariatric centers. WL was calculated as percent of excess of BMI loss (%EBMIL), loss of body mass index (Delta-BMI), percent of excess weight loss (%EWL) and percent of total weight loss (%TWL). Data were collected 3, 6, 9, 12, 24, 48 and 60 months after surgery. RESULTS: The distal LRYGB resulted in significantly better 5-year-WL compared to the proximal bypass in terms of %EBMIL (median at 5 years: 83% vs. 65%, p = 0.001), %TWL (median at 5 years: 32% vs. 26%, p = 0.017) and %EWL (median at 5 years: 65% vs. 51%, p = 0.029), with equal major complications and metabolic alterations. In addition, WR was significantly lower in patients with distal bypass (18% vs. 35%, p = 0.032). CONCLUSIONS: Distal LYRGB with a 120-150 long CC results in better WL and WL-maintenance compared to proximal LRYGB without major side effects after five years.

Higher incidence of cholelithiasis with Roux-en-Y reconstruction compared with Billroth-I after laparoscopic distal gastrectomy for gastric cancer: a retrospective cohort study.

PURPOSE: Cholelithiasis occurs often after gastrectomy. However, no consensus has been established regarding the difference in the incidence of postgastrectomy cholelithiasis with different reconstruction methods. In this study, we examined the frequency of cholelithiasis after two major reconstruction methods, namely Billroth-I (B-I) and Roux-en-Y (R-Y) following laparoscopic distal gastrectomy (LDG) for gastric cancer. METHODS: Among 696 gastric cancer patients who underwent LDG between April 2000 and March 2017, after applying the exclusion criteria, 284 patients who underwent B-I and 310 who underwent R-Y were examined retrospectively. The estimated incidence of cholelithiasis was compared between the methods, and factors associated with the development of cholelithiasis in the gallbladder and/or common bile duct were investigated. RESULTS: During the median follow-up of 61.2 months, 52 patients (8.8%) developed cholelithiasis postgastrectomy; 12 patients (4.2%) after B-I and 40 (12.9%) after R-Y (p = 0.0002). Among them, choledocholithiasis was more frequent in patients who underwent R-Y (n = 11, 27.5%) vs. B-I (n = 1, 8.3%) (p = 0.0056). Univariate and multivariate analyses revealed that male sex, body mass index > 22.5 kg/m2, and R-Y reconstruction were significant predictors of the development of postLDG cholelithiasis. CONCLUSION: Regarding cholelithiasis development, B-I reconstruction should be preferred whenever possible during distal gastrectomy.