Factors associated with weight regain post-bariatric surgery: a systematic review.

INTRODUCTION: To systematically review the literature to assess the incidence and risk factors of weight regain (WR) after bariatric surgery. Bariatric surgery is the most effective intervention for sustained weight loss of morbidly obese patients, but WR remains a concern. MATERIALS AND METHODS: A PRISMA compliant systematic literature review was performed using the PubMed database, Embase and the Cochrane Library in July of 2019. Studies that reported ≥ 10% WR after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) were included. The Newcastle-Ottawa scale (NOS) was used for assessing study quality. RESULTS: Out of 2915 retrieved abstracts, 272 full papers were reviewed, and 32 studies included (25 of high and 7 of fair quality) reporting weight outcomes on 7391 RYGB and 5872 SG patients. 17.6% (95% CI 16.9-18.3) had a WR ≥ 10%. Risk factors related with WR fell into 5 categories, namely anatomical, genetic, dietary, psychiatric, and temporal. Specifically, gastrojejunal stoma diameter, gastric volume following sleeve, anxiety, time after surgery, sweet consumption, emotional eating, portion size, food urges, binge eating, loss of control/disinhibition when eating, and genetics have been positively associated with WR while postprandial GLP-1, eagerness to change physical activity habits, self-esteem, social support, fruit and zinc consumption, HDL, quality of life have been negatively associated. CONCLUSION: At least 1 in 6 patients after bariatric surgery had ≥ 10% WR. This review identified several factors related to WR that can be used to counsel patients preoperatively and direct postoperative strategies that minimize WR risk.

Short-term outcomes of revisional surgery after sleeve gastrectomy: a comparative analysis of re-sleeve, Roux en-Y gastric bypass, duodenal switch (Roux en-Y and single-anastomosis).

BACKGROUND: Sleeve gastrectomy (SG) is the most common primary bariatric surgery. Long-term, up to 20% of patients may need revisional surgery. We aimed to evaluate the short-term outcomes of various revisional bariatric surgeries after a failed primary SG. METHODS: This is a single-center retrospective study of a prospectively collected database of obese patients who underwent revisional bariatric surgery during 2010-2018 for a failed previous SG. Failure was defined as inadequate weight loss (< 50% excess weight loss), ≥ 20% weight regain of the weight lost, and presence of refractory non-reflux obesity-related comorbidities ≥ 1 year after SG. Revisions included were re-sleeve, Roux en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD/DS), and single-anastomosis duodenal switch (SADS). The primary outcome was weight loss after revision. Secondary outcomes included postoperative complications. Due to varying follow-up rates, short-term outcomes (≥ 6 and ≤ 18 months) were assessed. Descriptive statistics are expressed as count(percentage) or median(interquartile range). RESULTS: Ninety-four patients met inclusion criteria. Forty-one underwent conversion to RYGB, 33 had BPD/DS, 7 had SADS, and 13 underwent re-sleeve surgery. Median interval between SG and revision was 31(27) months. At a median of 14(18) months, follow-up rate was 76% for the study cohort. Prior to revision, median BMI was 41.9(11.7) kg/m2 and 1 year after decreased by 6.3(5.1) kg/m2. BPD/DS resulted in the largest total weight loss of 21.8(10.9) kg followed by RYGB 13.2(11.3), SADS 12.2(6.1), and re-sleeve 12.0(11.9) kg; p = 0.023. Major 90-day and long-term complications occurred only after RYGB and BPD/DS and were similar (7.3% vs. 3.0%; p = 0.769 and 9.8% vs. 24.2%; p = 0.173, respectively). CONCLUSIONS: At 1 year, revisional procedures offer further weight loss after a failed primary SG. Bypass-type revisions are preferred over re-sleeve surgery. In the absence of refractory reflux symptoms, duodenal switch-type procedures are safe and effective options especially in patients with severe obesity before SG.

Five-year results of endoscopic gastrojejunostomy revision (transoral outlet reduction) for weight gain after gastric bypass.

BACKGROUND: The study aim is to determine if patients who have undergone endoscopic gastrojejunostomy revision (EGJR) maintain weight loss up to 5 years postoperatively. METHODS: This is a retrospective review of patients who underwent EGJR with a full-thickness endoscopic suturing device between April 2009 and June 2018. Percent of excess body weight loss (%EBWL) was calculated using the weight on day of EGJR consult as baseline. The paired t test and McNemar's test were used to compare weight and comorbidities between preoperative and postoperative time points. RESULTS: A total of 70 patients regained a mean of 42.8 ± 18.7% of the weight lost after gastric bypass. On day of EGJR consult, average was 116.1 ± 25.2 kg and BMI of 42.3 ± 8.5. Weight loss and %EBWL at follow-up was as follows: 10.7 ± 11.6 kg and 18.5 ± 18.2% at 6 months, 8.5 ± 11.5 kg and 14.9 ± 20.6% at 1 year, 6.9 ± 10.7 kg and 12.2 ± 19.8% at 2 years, 5.3 ± 9.1 kg and 8.7 ± 14.9% at 3 years, 3.1 ± 12.0 kg and 3.2 ± 21.6% at 4 years, and 3.9 ± 13.1 kg and 7.0 ± 23.8% at 5 years. The percentage of patients with obstructive sleep apnea, hypertension, hyperlipidemia, and diabetes did not change over time. Patients who received a pursestring revision or had a greater percent reduction in stoma diameter had more significant %EBWL. CONCLUSIONS: Weight loss after EGJR is sustained up to 5 years after revision with little effect on medical comorbidities. Patients with a greater reduction in stoma diameter experienced superior weight loss.

Awakening: a qualitative study on maintaining weight loss after bariatric surgery.

AIMS AND OBJECTIVES: To describe the experiences of adults who were successful in maintaining weight loss after bariatric surgery. BACKGROUND: The majority of studies examine a homogenous demographic group of postbariatric surgical patients who have gone through initial weight loss, which occurs within the first 12-24 months post surgery. Maintenance of weight loss begins 24 months after bariatric surgery; however, there is a paucity of research examining experiences during this period. The lack of conclusive research related to interactions between intrapersonal, behavioural and environmental influences suggests a need to develop a better understanding of patients' experiences related to weight loss maintenance post bariatric surgery. DESIGN: Bandura's Social Cognitive Theory provided the framework for the semi-structured interviews for this qualitative descriptive study. METHODS: In-person interviews with n = 14 participants who were able to maintain weight loss at least 24 months after a bariatric surgery. RESULTS: Participants experienced an awakening and gained a new perspective on their life. They identified negative attitudes, influences and behaviours and modified their environment to support their desired healthy behaviour. CONCLUSIONS: To maintain weight loss, an individual must seek out and be surrounded by positive family and peer support influences. Positive support may provide the opportunity for an individual to place personal health needs as a priority. RELEVANCE TO CLINICAL PRACTICE: Therapeutic education and counselling for individuals, couples and families should occur during all phases of bariatric surgery. Communication techniques may empower clients to deflect negative comments and influences in a constructive manner. Support groups should accommodate the various phases of bariatric surgery. Clients should be prepared for how to work through emotions associated with weight fluctuations.

Benefits of Adjuvant Medical Weight Loss Intervention in Setting of Weight Regain and Inadequate Weight Loss After Weight Loss Surgery.

BACKGROUND: Currently, there is no nationally accepted protocol for addressing weight regain or inadequate weight loss after MBS. OBJECTIVES: To devise, implement, and evaluate a protocol targeting weight regain or inadequate weight loss in MBS patients at our institution. SETTING: Vanderbilt University Medical Center, Nashville, TN, United States. METHODS: Patients at least 6 months following primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) who achieved or were trending toward <50% excess body weight loss or who regained ≥10% of their lowest postoperative weight, were identified and referred for medical weight loss (MWL) intervention. Exclusion criteria were body mass index (BMI) ≤ 27 kg/m2, treatment with adjustable gastric banding, and conversion from SG to RYGB. RESULTS: 2274 patients who were >6 months out from surgery were evaluated over 12 months. 93 patients (86% female) met criteria for inclusion. 69 (74%) patients agreed to intervention and were followed for an average of 165 days (SD 106.89 days), demonstrating a mean weight change of -5.11 kg (SD 6.86 kg), and BMI change of -1.81 kg/m2 (SD 2.37 kg/m2). Patients who spent <90 days in a MWL program demonstrated less average weight loss (1.75 kg vs 6.48 kg) (P = .0042), and less change in BMI (-.63 kg/m2 vs -2.29 kg/m2) (P = .0037) when compared to patients who spent >90 days in the MWL intervention. CONCLUSIONS: This study identifies criteria for intervention in patients suffering weight regain or inadequate weight loss after MBS and demonstrates that standardized identification and referral for treatment results in modest weight loss.

Revision Endoscopic Gastroplasty: An Overview and Review of Literature.

The main aim of this paper was to examine the efficacy and safety of revision endoscopic gastroplasty and some of the adverse events likely to arise from the procedure, as well as the implications for future scholarly research. The study is a systematic review in which the PRISMA protocol was used to govern the article's inclusion and exclusion criteria. The selected studies include those on revising endoscopic gastroplasty's effectiveness and safety. The studies were selected based on multiple parameters. The outcome included weight recidivism, excessive BMI loss, and absolute, total, or percentage weight loss. The outcome of this review confirmed that revision endoscopic gastroplasty is effective and safe. Mainly, revision endoscopic gastroplasty (R-EG) was found to counter-weight recidivism, especially short-term and mid-term. However, there is a need for additional scholarly investigations that would last several years to decades to inform the long-term efficacy of R-EG with precision.

Current state of the definition and terminology related to weight recurrence after metabolic surgery: review by the POWER Task Force of the American Society for Metabolic and Bariatric Surgery.

Bariatric surgery continues to be the most reliable treatment for the disease of obesity. Despite excellent results, some patients experience weight recurrence with or without concomitant recurrence of co-morbidities. There is currently no standard definition for clinically significant weight recurrence after bariatric surgery so that patients and clinicians have a platform from which to plan treatment. The Post-Operative Weight Recurrence (POWER) Task Force was formed by the American Society for Metabolic and Bariatric Surgery to address this aspect of the disease of obesity. This article reviews the literature of existing definitions for weight recurrence and their limitations. Furthermore, the term weight recurrence is introduced to replace weight regain or recidivism, and the term nonresponder is introduced to replace inadequate weight loss after surgery.

Patterns of Weight Loss Medication Utilization and Outcomes Following Bariatric Surgery.

BACKGROUND: Bariatric surgery is the most effective treatment for obesity; however, some patients experience significant weight regain. Weight loss medications (WLM) are being increasingly used in surgery patients with limited evidence. We examine weight loss outcomes in patients using WLM after bariatric surgery. METHODS: In a retrospective study, 197 bariatric surgery patients who started WLM between 2016 and 2019 at a single center were analyzed. Patients were categorized into 3 groups based on outcomes of the initial surgery: (1) Weight regainers (WR) = achieved goal weight loss after surgery (15% total body weight loss (TBWL) for sleeve gastrectomy (SG) and 25% TBWL for Roux-en-Y gastric bypass (RYGB)) with subsequent regain of > 20% of weight lost; (2) Adequate weight loss (AWL) = achieved goal weight loss without > 20% weight regain; (3) Non-responders (NR) = never achieved goal weight loss. Weight loss and medication use patterns were analyzed. RESULTS: Among the three categories, there was no significant difference in duration of medical therapy or %TBWL with medications. RYGB patients lost more weight than SG patients using WLM (p = 0.03). Of the medications used, patients treated with phentermine + topiramate had the highest likelihood of achieving 5%, 10%, and 15% weight loss. Compared to other 2 groups, AWL group initiated WLM earlier and experienced more weight loss when compared to their pre-operative weight or post-operative nadir. CONCLUSIONS: RYGB patients respond better to WLM than SG patients. Those who had started WLM before regaining weight (AWL) experienced greater overall weight loss, suggesting that proactive medical therapy at the time of weight plateau can help with greater total weight loss. Phentermine + topiramate is the most effective WLM in post-bariatric surgery patients.

Short-term Results of Transit Bipartition to Promote Weight Loss After Laparoscopic Sleeve Gastrectomy.

Objective: To evaluate (1) the efficacy of transit bipartition (TB) as revisional bariatric surgery (RBS) after laparoscopic sleeve gastrectomy (LSG); (2) the impact of the length of the common channel (CC) on weight loss. Background: LSG in combination with TB has been shown to be highly efficacious for treating morbid obesity. The role of TB as RBS to address the problem of primary failure or weight recidivism after LSG is less well defined. Methods: Observational study of outcomes in 100 morbidly obese patients who received a TB following LSG. Follow-up examinations (FE) were performed at 1, 3, 6, and 12 months. Variables analyzed included BMI, percent excess weight loss (%EWL), total body weight loss (%TBWL), effect on obesity-related conditions and complications. Results: The mean BMI before LSG was 49.9 ± 8.5 kg/m2. A nadir of 32.7 ± 6.1 kg/m2 was reached 22.1 ± 16.9 months after LSG (%EWL 70.0 ± 14.5). The time interval between LSG and TB was 52.2 ± 26.6 months at which the BMI had increased to 37.6 ± 7.1 kg/m2 and %EWL decreased to 49.4 ± 19.7. Following TB, the BMI decreased continuously to 31.4 ± 5.7 kg/m2 after 12 months with a parallel increase in %EWL to 74.7 ± 20.3 and %TWL reaching 36.3 ± 10.5. Weight loss was significantly higher for CC length of 250 versus 300 cm after 12 months (BMI 29.4 ± 5.3/33 ± 5.3 kg/m2, P = 0.002; %EWL 79.8 ± 26.6/70.4 ± 17; P = 0.009). Improvement of comorbidities was observed in a high proportion of patients. Major early complications occurred in 3% of the patients. Conclusion: TB is an effective second-step procedure to address insufficient weight loss or weight recidivism after LSG. CC length of 250 versus 300 cm had a significant impact. While most improvements of obesity-related comorbidities are likely linked to weight loss, amelioration of GERD is largely mediated by accelerated gastric emptying. Major complications were observed in 3% of patients and managed without fatalities.

Short- to medium-term results of single-anastomosis duodeno-ileal bypass compared with one-anastomosis gastric bypass for weight recidivism after laparoscopic sleeve gastrectomy.

BACKGROUND: Single-anastomosis duodeno-ileal bypass (SADI) and the one-anastomosis gastric bypass (OAGB) are 2 revisional procedures to address the problem of weight recidivism after laparoscopic sleeve gastrectomy (LSG). OBJECTIVES: To evaluate the efficacy and safety of SADI and OAGB as revisional bariatric surgery (RBS) in initially super-obese patients (body mass index [BMI] >50 kg/m2). SETTING: Academic hospital, bariatric center of excellence, Germany. METHODS: Observational study of outcomes in 84 initially super-obese patients who had undergone RBS after LSG (SADI n = 42, OAGB n = 42) between July 2013 and April 2018. Follow-up examinations were performed at 1, 6, 12, 24, and 36 months after RBS. The variables analyzed included time between LSG and RBS, BMI, excess weight loss, total weight loss, operation time, and complications. RESULTS: The time interval between LSG and RBS was 45.5 ± 22.8 and 43.5 ± 24.2 months for SADI and OAGB, respectively. At the time of RBS, the mean BMI was 42.8 ± 7.9 kg/m2 for SADI and 43.4 ± 9.2 kg/m2 for OAGB. The follow-up examinations rates (%) after SADI were 97.6, 92.8, 90.5, 78.6, 57.1, and 100, 97.6, 95.2, 85.7, and 59.5 after OAGB. The BMI at the follow-up examinations were 39.1 ± 7.2, 34.2 ± 6.9, 31.2 ± 5.8, 30.2 ± 5.3, 29.3 ± 5.1 for SADI, and 39.5 ± 8.1, 36.6 ± 7.4, 34.7 ± 7.9, 32.9 ± 6.3, and 31.6 ± 5.9 for OAGB. The mean operating times for SADI and OAGB were 138 ± 40 and 123 ± 39 minutes, respectively. Three patients in the SADI group and 1 patient in the OAGB group developed a major complication within the first 30 postoperative days. CONCLUSION: SADI and OAGB were effective second-step procedures for further weight reduction after LSG in initially super-obese patients after short to medium follow-up. There was a trend toward higher weight loss for SADI though this did not reach statistical significance. Substantial differences concerning surgery time and complications between the 2 procedures were not observed.

Modifiable factors associated with weight regain after bariatric surgery: a scoping review.

Background: Although bariatric surgery is the most effective treatment for severe obesity, weight regain may still occur. While non-modifiable factors associated with weight regain have been explored, modifiable factors responsible for weight regain are understudied. This scoping review aimed to identify modifiable behaviors associated with weight regain after bariatric surgery. Methods: A systematic search was conducted in Medline, Google Scholar, Cochrane, National Collaborating Centre for Methods and Tools (NCCMT) and Practice-based Evidence in Nutrition (PEN) which included articles published between January 1990 and February 2 2017, for studies examining "weight regain" after bariatric surgery. A total of 293 citations were retrieved. Eligible articles must have examined modifiable factors and addressed weight regain, or a long-term post-operative phase in which weight regain may occur. After removing duplicates, 22 studies were included for thematic analysis. Results: Key modifiable factors associated with weight regain were identified and categorized under the following themes: poor dietary adherence (e.g. excessive calorie, carbohydrate, and alcohol intake), maladaptive eating behaviors (e.g. grazing, binging), lack of on-going follow-up with the bariatric team and insufficient physical activity. Conclusions:  Health professionals and self-monitoring tools for patients who have undergone bariatric surgery may benefit from these findings to direct their education and interventions to target behavior change.

A Specialized Medical Management Program to Address Post-operative Weight Regain in Bariatric Patients.

INTRODUCTION: Although bariatric surgery results in massive weight loss, weight regain over time up to as much as 25% is not uncommon. Weight regain in this population often leads to long-term weight loss failure and non-compliance in clinical follow-up and program recommendations. METHODS: We analyzed early weight outcomes at 3 and 6 months of 48 bariatric patients referred to an individualized, multidisciplinary medical management program at the Center for Obesity Medicine (COM) to address weight regain in 2015 and compared to a group of matched non-bariatric patients. The medical management center, under the direction of a medical obesity specialist and complementary to the surgical program and multidisciplinary team, addressed weight regain with intensive lifestyle (diet, activity, anti-stress therapy, behavioral counseling, sleep) and with medical intervention (one or more anti-obesity medications). RESULTS: According to early findings, the average percentage post-operative weight regain of patients entering the weight management program was 20% above nadir and time since surgery averaged 6 years (range = 1 to 20 years) with a mean weight loss of - 2.3 kg after 3 months and - 4.4 kg at 6 months into the program. Individuals most successful with weight loss were those treated with anorexigenic pharmaceuticals. Weight and percent weight loss were significantly greater for the non-surgical than the surgical patients at 3 and 6 months (p < 0.05). CONCLUSIONS: A medically supervised weight management program complementary to surgery is beneficial for the treatment of weight regain and may prove important in assisting the surgical patient achieve long-term weight loss success.

Conversion of standard Roux-en-Y gastric bypass to distal bypass for weight loss failure and metabolic syndrome: 3-year follow-up and evolution of technique to reduce nutritional complications.

BACKGROUND: Standard proximal Roux-en-Y gastric bypass (RYGB) fails to achieve long-term weight maintenance and/or control of metabolic syndrome in up to 35% of patients. OBJECTIVES: To improve the performance of the standard proximal gastric bypass by increasing the biliopancreatic limb length at the expense of the common channel. SETTINGS: Academic-affiliated private practice. METHODS: A retrospective review of all patients who underwent conversion to distal RYGB from 2010 to 2016 was performed. RYGB was modified by dividing the Roux limb at the jejunojejunostomy and transposing it distally to create a shortened total alimentary limb length (TALL) of 250 to 300 cm in the initial 11 patients. Of these, 7 developed protein calorie malnutrition and diarrhea requiring a second procedure to lengthen the common channel an additional 100 to 150 cm (TALL 400-450 cm), leading to resolution of all symptoms. The subsequent 85 patients were converted to distal RYGB with TALL 400 to 450 in a single-stage operation. RESULTS: Ninety-six RYGB patients underwent conversion to distal RYGB. The mean body mass index and mean excess weight loss at the time of distalization was 40.6 kg/m2 and 33.6%. At 1, 2, and 3 years after distalization, the mean body mass index was reduced to 34.4, 33.1, and 32.2 kg/m2, respectively, and excess weight loss improved to 41.9%, 53.7%, and 65.7%, respectively. Diabetes resolved in 66.7%, hypertension resolved in 28.6%, hyperlipidemia resolved in 40%, and sleep apnea resolved in 50% at 1 year. The 30-day complication rate and reoperation rates were 6.3% and 5.2%; an additional 7.3% (7/96) required reoperation for limb lengthening. Hypoalbuminemia developed in 21% at 3 years, but no increase in iron deficiency was observed. Calcium metabolism was affected by the distalization procedure to a greater degree as 21% of patients had low corrected calcium levels, 77% were deficient in vitamin D, and parathyroid hormone levels were above normal in 64% at 3 years. CONCLUSION: Revision of proximal RYGB to distal RYGB results in substantial improvement in weight loss and resolution of co-morbidities at 3 years. Diarrhea and protein calorie malnutrition were seen frequently in patients with TALL of 250 to 300 cm, whereas patients with TALL 400 to 450 cm demonstrated a lower incidence of nutritional issues, but the effect on calcium, parathyroid hormone, and the fat soluble vitamins A and D is still a major concern.

Long-term results for gastric banding as salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass.

BACKGROUND: Studies reporting revisionary options for weight loss failure after Roux-en-Y gastric bypass (RYGB) have been underpowered and lacking long-term data. We have previously shown that short-term (12 mo) and midterm (24 mo) weight loss is achievable with laparoscopic adjustable gastric banding (LAGB) for failed RYGB. The present study represents the largest published series with longest postoperative follow-up of patients receiving salvage LAGB after RYGB failure. OBJECTIVE: To investigate long-term results of salvage gastric banding. SETTING: University Hospital, New York, United States. METHODS: Data were prospectively collected with retrospective review. Baseline characteristics were evaluated and weights at multiple time intervals (before RYGB, before LAGB, each year of follow-up). Additional data included approach (open or laparoscopic), operative time, hospital length of stay, and postoperative complications. RESULTS: A total of 168 patients underwent statistical analysis with 86 patients meeting inclusion for RYGB failure. The mean body mass index before RYGB was 48.9 kg/m2. Before LAGB, patients had an average body mass index of 43.7 kg/m2, with 10.4% total weight loss and 21.4% excess weight loss after RYGB. At 5-year follow-up, patients (n = 20) had a mean body mass index of 33.6 kg/m2 with 22.5% total weight loss and 65.9% excess weight loss. The long-term reoperation rate for complications related to LAGB was 24%, and 8% of patients ultimately had their gastric bands removed. CONCLUSION: The results of our study have shown that LAGB had good long-term data as a revisionary procedure for weight loss failure after RYGB.

Validation of a new method for the endoscopic measurement of post-bariatric gastric outlet using a standard guidewire: an observer agreement study.

BACKGROUND AND AIMS: Between 10 and 20% of all patients undergoing bariatric surgery procedures regain weight secondary to a gastrojejunostomy enlargement. The aim of this study was to validate the interobserver agreement while measuring gastric outlet diameters using a new standard guidewire. METHODS: We selected thirty-five videos of consecutive endoscopic procedures on patients undergoing esophagogastroduodenoscopy after a Roux-en-Y gastric bypass procedure. All videos were evaluated by four raters: two expert endoscopists and two trainees. We excluded videos having a slipped Fobi ring or a strictured gastric outlet. Anastomosis diameter was measured using a novel device with standardized markings on a guidewire (Hydra jagwire, Boston Scientific, Natick. MA) as well as the current gold standard defined as a calibrated endoscopic measuring instrument (Olympus America, Center Valley, PA). RESULTS: We obtained 272 measurements of the gastric outlet. Overall agreement measured through intra-class correlation coefficients for the gold standard was 0.84 (p < 0.01) and 0.83 (p < 0.01) for the new guidewire. Agreement among experts was 0.699 (p < 0.01), while among trainees it was 0.822 (p < 0.01). CONCLUSION: The new guidewire demonstrated a high degree of observer reliability, also presenting similar results between expert endoscopists and trainees.

Laparoscopic Wedge Resection of Gastrojejunostomy for Weight Recidivism after Gastric Bypass.

BACKGROUND: Weight recidivism after Roux-en-Y gastric bypass (RYGB) is a common problem. Often, this weight loss failure or regain may be due to a wide gastrojejunostomy (GJ). We evaluated the feasibility and safety of a novel approach of laparoscopic wedge resection of gastrojejunostomy (LWGJ) for a wide stoma after RYGB associated with weight recidivism. METHODS: This is a single-center retrospective study of a prospectively collected database. We analyzed outcomes of patients with weight recidivism after RYGB and a documented wide GJ (>2 cm) on imaging, who underwent LWGJ between 11/2013 and 05/2016. RESULTS: Nine patients underwent LWGJ for dilated stomas. All patients were female with a mean ± SD age of 53 ± 7 years. Mean interval between RYGB and LWGJ was 9 ± 3 years. All cases were performed laparoscopically with no conversions. Mean operative time and hospital stay were 86 ± 9 min and 1.2 ± 0.4 days, respectively. The median(IQR) follow-up time was 14(12-18) months. During follow-up, there were no deaths, postoperative complications, or unplanned readmissions or reoperations. The mean and median(IQR) BMI before RYGB and LWGJ were 55.4 ± 8.1 kg/m2 and 56.1(47.9-61.7) and 43.4 ± 8.6 kg/m2 and 42.1(38.3-47.1), respectively. One year after LWGJ, mean and median(IQR) BMI significantly decreased to 34.9 ± 7.3 kg/m2 and 33.3(31.7-35.0) corresponding to a mean %EWL of 64.6 ± 19.9 (P < 0.05). CONCLUSIONS: LWGJ is safe and can lead to further weight loss in patients experiencing weight recidivism after RYGB with a wide GJ (>2 cm). Long-term follow-up is needed to determine the efficacy and durability of LWGJ and compare its outcomes with other endoscopic/surgical approaches for weight recidivism after RYGB with a documented wide GJ.

Pouch Reshaping for Significant Weight Regain after Roux-en-Y Gastric Bypass.

BACKGROUND: Significant weight regain after Roux-en-Y gastric bypass (RYGB) occurs in around 20 % of patients in the long term. Anatomical reasons include dilatation of the gastric pouch and/or the pouch-jejunal anastomosis, leading to loss of restriction. Pouch reshaping (PR) aims at reestablishing restriction with a subsequent feeling of satiety. This study reports the outcome of PR embedded in a multidisciplinary treatment pathway. METHODS: Twenty-six patients after PR for weight regain >30 % following RYGB in a university hospital between October 2010 and March 2016 were analyzed. Excluded were patients with PR for gastro-gastric fistulae, hypoglycemia, candy cane syndrome, and concomitant alteration of limb lengths. PR consisted in laparoscopic lateral resection of the gastric pouch, the anastomosis and the proximal 5 cm of the alimentary limb over a 32F bougie. RESULTS: Median follow-up after PR was 48 months (range 24-60). Median BMI at PR was 39.1 kg/m2 (32.7-59.1). Median operation time was 85 min (25-190), and median length of stay was 3 days (1-35). Minor complications (grade ≤ 2) occurred in seven (27 %) patients and major complications (grade ≥ 3) in four patients (15 %). Nadir BMI and %EBMIL after PR were 32.9 kg/m2 and 43.3 %, reached after a median of 12 months (3-48). Comorbidities were resolved in 81 %. After 48 months, median BMI was 33.8 kg/m2 (20.4-49.2) and %EBMIL was 61.4 (39.1-121.2). CONCLUSIONS: Used selectively in a multidisciplinary treatment pathway, PR leads to prolonged weight stabilization around the previous nadir. However, its associated perioperative morbidity must not be disregarded.

Pharmacotherapy in Conjunction with a Diet and Exercise Program for the Treatment of Weight Recidivism or Weight Loss Plateau Post-bariatric Surgery: a Retrospective Review.

BACKGROUND: Bariatric surgery is an effective therapeutic option for management of obesity. However, weight recidivism (WR) and weight loss plateau (WLP) are common problems. We present our experience with the use of two pharmacotherapies in conjunction with our standard diet and exercise program in those patients who experienced WR or WLP. METHODS: From June 2010 to April 2014, bariatric surgery patients who experienced WR or WLP after undergoing Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB), and who were treated with phentermine (Ph) or phentermine-topiramate (PhT), were reviewed retrospectively. Generalized estimating equations were used to compare patient weights through 90 days between initial surgery type and medication type. Patient weights, medication side effect, and co-morbidities were collected during the first 90 days of therapy. RESULTS: Fifty-two patients received Ph while 13 patients received PhT. Overall, patients in both groups lost weight. Among those whose weights were recorded at 90 days, patients on Ph lost 6.35 kg (12.8% excess weight loss (EWL); 95% confidence interval (CI) 4.25, 8.44) and those prescribed PhT lost 3.81 kg (12.9% EWL; CI 1.08, 6.54). Adjusting for baseline weight, time since surgery, and visit through 90 days, patients treated with Ph weighed significantly less than those on PhT throughout the course of this study (1.35 kg lighter; 95% CI 0.17, 2.53; p = 0.025). There were no serious side effects reported. CONCLUSIONS: Phentermine and phentermine-topirimate in addition to diet and exercise appear to be viable options for weight loss in post-RYGB and LAGB patients who experience WR or WLP.

Early Weight Recidivism Following Laparoscopic Sleeve Gastrectomy: A Prospective Observational Study.

BACKGROUND: Although weight loss following laparoscopic sleeve gastrectomy (LSG) can be substantial, weight recidivism is still a major concern. The aim of our work is to study early weight recidivism following LSG and to evaluate the role of gastric computed tomography volumetry (GCTV) in the assessment of patients experiencing early weight regain. METHODS: One-hundred and one morbidly obese patients undergoing LSG were prospectively studied. Patients were followed up for 2 years. Those who presented with weight recidivism were counseled for dietary habits and assessed for the amount of weight regain. Patients who regained weight were scheduled for GCTV. RESULTS: Twelve patients were excluded from the study. Weight recidivism was reported in 9/89 patients (10.1 %) [weight loss failure (n = 1), weight regain (n = 8)] and was almost always first recognized 1½-2 years after LSG. The amount of weight regain showed negative correlations with preoperative body weight and body mass index (r = -0.643, P = 0.086 and r = -0.690, P = 0.058; respectively) and positive correlations with the distance between the pylorus and the beginning of the staple line (r = 0.869, P = 0.005), as well as with the residual gastric volume (RGV) on GCTV 2 years after LSG (r = 0.786, P = 0.021). CONCLUSIONS: In the small group of patients who regained weight, a longer distance between the pylorus and the beginning of the staple line, as well as a higher RGV on GCTV 2 years after LSG, were both associated with increased weight regain. Gastric computed tomography volumetry with RGV measurement holds promise as a useful research tool after LSG.

Revision of Roux-En-Y Gastric Bypass for Weight Regain: a Systematic Review of Techniques and Outcomes.

BACKGROUND: Weight regain has led to an increase in revision of Roux-en-Y gastric bypass (RYGB) surgeries. There is no standardized approach to revisional surgery after failed RYGB. We performed an exhaustive literature search to elucidate surgical revision options. Our objective was to evaluate outcomes and complications of various methods of revision after RYGB to identify the option with the best outcomes for failed primary RYGB. METHOD: A systematic literature search was conducted using the following search tools and databases: PubMed, Google Scholar, Cochrane Clinical Trials Database, Cochrane Review Database, EMBASE, and Allied and Complementary Medicine to identify all relevant studies describing revision after failed RYGB. Inclusion criteria comprised of revisional surgery for weight gain after RYGB. RESULTS: Of the 1200 articles found, only 799 were selected for our study. Of the 799, 24 studies, with a total of 866 patients, were included for a systematic review. Of the 24 studies, 5 were conversion to Distal Roux-en-y gastric bypass (DRYGB), 5 were revision of gastric pouch and anastomosis, 6 were revision with gastric band, 2 were revision to biliopancreatic diversion/duodenal switch (BPD/DS), and 6 were revision to endoluminal procedures (i.e., stomaphyx). Mean percent excess body mass index loss (%EBMIL) after revision up to 1 and 3-year follow-up for BPD/DS was 63.7 and 76 %, DRYGB was 54 and 52.2 %, gastric banding revision 47.6 and 47.3 %, gastric pouch/anastomosis revision 43.3 and 14 %, and endoluminal procedures at 32.1 %, respectively. Gastric pouch/anastomosis revision resulted in the lowest major complication rate at 3.5 % and DRYGB with the highest at 11.9 % when compared to the other revisional procedures. The mortality rate was 0.6 % which only occurred in the DRYGB group. CONCLUSION: All 866 patients in the 24 studies reported significant early initial weight loss after revision for failed RYGB. However, of the five surgical revision options considered, BPD/DS, DRYGB, and gastric banding resulted in sustained weight loss, with acceptable complication rate.