Biliopancreatic Limb Research Articles

ID: 3527179 SWITCHING THE SWITCH: ENDOSCOPIC REVERSAL OF A BILIOPANCREATIC DIVERSION

Biliopancreatic diversion (also known as duodenal switch) is a complex bariatric surgery that includes a sleeve gastrectomy and long Roux-en-Y intestinal bypass. The jejunojejunal anastomosis is very distal resulting in the bypass of two-thirds or more of the intestine. Patients lose weight not only because nutrients bypass most of the intestine, thereby reducing the absorption area, but also because nutrients join the biliopancreatic secretions and enzymes only distally leading therefore to their reduced digestion and absorption. This is a very effective surgery for weight loss, but can be complicated by severe malnutrition. In such cases, surgical reversal of the duodenal switch is done by creating a proximal anastomosis between the alimentary and biliopancreatic limbs. To our knowledge, endoscopic reversal of the duodenal switch has not been reported previously.

Different limb lengths in gastric bypass surgery: study protocol for a Swiss multicenter randomized controlled trial (SLIM)

BackgroundObesity and type 2 diabetes mellitus are reaching epidemic proportions. In morbidly obese patients, bariatric operations lead to sustained weight loss and relief of comorbidities in the majority of patients. Laparoscopic Roux-Y-gastric bypass (RYGB) is one of the most frequently performed operations, but it is still unknown why some patients respond better than others. Therefore, a number of variations of this operation have been introduced. Recent evidence suggests that a longer bypassed biliopancreatic limb (BPL) has the potential to be more effective compared to the standard RYGB with a shorter BPL length. This article describes the design and protocol of a randomized controlled trial comparing the outcome of a RYGB operation with a long versus short BPL.Methods/designThe trial is designed as a multicenter, randomized, patient- and observer-blinded trial. The relevant ethics committee has approved the trial protocol. To demonstrate that long BPL RYGB is superior compared to short BPL RYGB in terms of weight loss and resolution of T2DM, the study is conducted as a superiority trial. Postoperative percent total weight loss and nutritional deficiency rate are the primary endpoints, whereas morbidity, mortality, remission of obesity-related comorbidities and quality of life are secondary endpoints. Eight hundred patients, between 18 and 65 years and with a body mass index (BMI) from 35 to 60 kg/m2 who meet the regulatory rules for bariatric surgery in Switzerland, will be randomized. The endpoints and baseline measurements will be assessed pre-, intra-, and postoperatively.DiscussionWith its high number of patients and a 5-year follow-up, this study will answer questions about effectiveness and safety of long BPL RYGB and provide level I evidence for improvement of the standard RYGB. These findings might therefore potentially influence global bariatric surgery guidelines.Trial registrationClinicalTrials.gov NCT04219787. Registered on 7 January 2020.

Natural orifice transluminal endoscopic one-anastomosis gastric bypass: a feasibility study using porcine model.

Endoscopic bariatric therapies (EBT) are emerging as effective therapies in the management of overweight patient with or without metabolic syndrome. Unfortunately most procedures only restrict the gastric volume without altering the underlying metabolism which is seen in surgical patients. The aim of this study was to investigate the feasibility and limitations of a natural orifice trans-luminal endoscopic surgery (NOTES) one anastomosis gastric bypass (OAGB). NOTES OAGB was performed in three porcine models. The steps of the procedure can be divide as follows: (1) Endoscopic sleeve gastroplasty. (2) Trans-gastric access to peritoneal cavity. (3) Identification of a loop of jejunum. (4) Introduction of the jejunal loop into the stomach. (5) Creation of the gastro-jejunostomy with lumen-apposing metal stent (LAMS). (6) Closure of gastric pylorus with overstitch system. All the animals underwent successful NOTES of OAGB. The mean weight for the animals was 34.3 kg (32-37 kg). The mean procedure time was 250 min (300 min for first animal and 180 min for third animal). The average bypassed bilio-pancreatic limb was 98 cm (range 65-130 cm). This study has provided proof-of-principle in a preclinical model that a NOTES approach can be used to perform OAGB and, therefore, merits additional evaluation and consideration.

Roux-en-Y Gastric Bypass with Long Biliopancreatic Limb Compared to Single Anastomosis Sleeve Ileal (SASI) Bypass in Treatment of Morbid Obesity.

Bariatric surgery is the most effective treatment of morbid obesity. Bariatric procedures employ different mechanisms of action to induce weight loss. The present study aimed to compare single-anastomosis sleeve ileal (SASI) bypass and roux-en-Y gastric bypass RYGB with long biliopancreatic limb (BPL) in terms of weight loss, remission of comorbidities, complications, and nutritional status. This was a single-center cohort study on patients with morbid obesity who underwent RYGB with long BPL of 150 cm or SASI bypass. The main outcome measures were weight loss and improvement in comorbidities at 12 months, nutritional status, and complications. The present study included 92 patients (59.8% females) of a mean age of 38.4 years and mean BMI of 42 kg/m2. RYGB and SASI bypass were followed by a significant decrease in body mass index at 12 months and were comparable in terms of excess and total weight loss. Improvement in comorbidities after the two procedures was similar. The serum albumin levels showed a significant decline after RYGB, but not after SASI bypass. The postoperative serum iron levels were higher after SASI bypass than after RYGB. There was no significant difference in regard to complication rates (13% vs 4.3%, p = 0.27). RYGB with long BPL and SASI bypass achieved satisfactory weight loss and improvement in comorbidities that were comparable among the two groups. Long BPL RYGB was followed by a significant decrease in serum albumin and iron levels at one year, which was not observed after SASI bypass.

The Effect of Standard Versus Longer Intestinal Bypass on GLP-1 Regulation and Glucose Metabolism in Patients With Type 2 Diabetes Undergoing Roux-en-Y Gastric Bypass: The Long-Limb Study.

OBJECTIVERoux-en-Y gastric bypass (RYGB) characteristically enhances postprandial levels of glucagon-like peptide 1 (GLP-1), a mechanism that contributes to its profound glucose-lowering effects. This enhancement is thought to be triggered by bypass of food to the distal small intestine with higher densities of neuroendocrine L-cells. We hypothesized that if this is the predominant mechanism behind the enhanced secretion of GLP-1, a longer intestinal bypass would potentiate the postprandial peak in GLP-1, translating into higher insulin secretion and, thus, additional improvements in glucose tolerance. To investigate this, we conducted a mechanistic study comparing two variants of RYGB that differ in the length of intestinal bypass.RESEARCH DESIGN AND METHODSA total of 53 patients with type 2 diabetes (T2D) and obesity were randomized to either standard limb RYGB (50-cm biliopancreatic limb) or long limb RYGB (150-cm biliopancreatic limb). They underwent measurements of GLP-1 and insulin secretion following a mixed meal and insulin sensitivity using euglycemic hyperinsulinemic clamps at baseline and 2 weeks and at 20% weight loss after surgery.RESULTSBoth groups exhibited enhancement in postprandial GLP-1 secretion and improvements in glycemia compared with baseline. There were no significant differences in postprandial peak concentrations of GLP-1, time to peak, insulin secretion, and insulin sensitivity.CONCLUSIONSThe findings of this study demonstrate that lengthening of the intestinal bypass in RYGB does not affect GLP-1 secretion. Thus, the characteristic enhancement of GLP-1 response after RYGB might not depend on delivery of nutrients to more distal intestinal segments.

Correction to: One Anastomosis Gastric Bypass with a Biliopancreatic Limb of 150 cm: Weight Loss, Nutritional Outcomes, Endoscopic Results, and Quality of Life at 8-Year Follow-Up

Correction to: One Anastomosis Gastric Bypass with a Biliopancreatic Limb of 150 cm: Weight Loss, Nutritional Outcomes, Endoscopic Results, and Quality of Life at 8-Year Follow-Up

Long versus short biliopancreatic limb in Roux-en-Y gastric bypass: short-term results of a randomized clinical trial.

The Roux-en-Y gastric bypass continues to be one of the most performed bariatric surgeries because of its adequate balance of outcomes, complications, and durability. Recently, the role of the biliopancreatic limb on weight loss and co-morbidity control has gained attention because it seems to have a positive impact based on limb length. To compare results at 12 months of a "standard" (group 1) versus a long (group 2) biliopancreatic limb bypass. Biliopancreatic limbs were 50 cm and 200 cm, and alimentary limbs were 150 cm and 50 cm, respectively. Academic Referal Center; Mexico City; Public Seeting. Randomized study with patients undergoing both types of surgeries at a single academic center from 2016 to 2018. The analysis included weight loss, co-morbidity control (diabetes and hypertension), biochemical panel, operative outcomes, and complications. Two-hundred ten patients were included (105 in each group). Almost all data were homogenous at baseline. Female sex comprised 86.1% of cases, with a mean body mass index of 43.5 kg/m2. Excess weight loss (77.6 ± 15.7% versus 83.6 ± 16.7%; P = .011) and total weight loss (33.5 ± 6.4% versus 37.1 ± 7.1%; P < .001) was higher in group 2; better HbA1C levels were also observed. Co-morbidity outcomes, operative data, and complications were similar between groups. The Roux-en-Y gastric bypass with 200 cm of biliopancreatic limb length induces more weight loss at 12 months than a 50 cm limb length. Better HbA1C levels were also observed, but similar effects on co-morbidities and complications were noted.

P45 Effect of One Anastomosis Gastric Bypass on Liver Function Tests: A comparison between 150 cm and 200 cm Bilio-Pancreatic Limb

IntroductionThe effect of One Anastomosis Gastric Bypass (OAGB) on Liver Function Tests (LFTs) is unclear. The purpose of this study was to find out the effect of OAGB on LFTS and also if a Bilio-Pancreatic Limb (BPL) of 150 cm (OAGB-150) would deliver better outcomes than that with a BPL of 200 cm (OAGB-200).MethodsWe investigated our prospectively maintained records to obtain information on patients who underwent an OAGB-200 or OAGB-150 until 31st July 2018 in our unit.ResultsA total of 405 patients underwent an OAGB-200 (n = 234) or OAGB-150 (n = 171) in our unit between October 2012 -July 2018. There were significant improvements in Gamma-Glutamyl-Transpeptidase (GGT) levels at 1 and 2 years after OAGB-200 and significant worsening in the levels of Alkaline Phosphatase (ALP) and albumin at 1 and 2 years follow up. There was a significant improvement in GGT levels at 1 and 2 years after OAGB-150, and in Alanine Transaminase (ALT) levels at 1 year follow up. There was a significant worsening in ALP and albumin levels at both follow-up points in this group. There was no significant increase in the number of abnormal values for any of the tests in either group at both follow-up points. OAGB-150 group had a significantly lower bilirubin level at 1 year and significantly fewer abnormal ALP values at 2 years in comparison with OAGB-200 patients.ConclusionThis study demonstrates the overall safety of OAGB with regards to its effect on LFTs with no remarkable difference between OAGB-150 and OAGB-200.

Internal Hernia After One Anastomosis Gastric Bypass (OAGB): Lessons Learned from a Retrospective Series of 3368 Consecutive Patients Undergoing OAGB with a Biliopancreatic Limb of 150 cm

BackgroundInternal hernia (IH) represents a relatively common and well-known complication after Roux-en-Y gastric bypass. IH after one anastomosis gastric bypass (OAGB) is less frequent and rarely reported in the literature. This study presents a series of IH after OAGB observed in a high-volume bariatric center.MethodsData of patients who underwent OAGB with an afferent limb of 150 cm between May 2010 and September 2019 were prospectively collected and retrospectively analyzed. Data of patients undergoing surgery for IH during follow-up were collected and analyzed.ResultsNinety-six patients out of 3368 with a history of OAGB had intestinal incarceration in the Petersen’s orifice (2.8%). Specificity and sensitivity of computed tomography scans in the diagnosis of IH were 59% and 76%, respectively. The mean timeframe between OAGB and surgery for IH was 21.9±18.3 months. Mean body mass index at the time of IH surgery was 24.7 ± 3.6. Surgery was completed laparoscopically in 96.8% of cases. Nine patients (9.3%) had signs of bowel hypovascularization. In all patients, the herniated bowel was repositioned, and the Petersen’s orifice was closed, without the need for bowel resection. Mean hospital stay was 1.9 ± 4.8 days. The postoperative morbidity rate was 8.3%. Long-term IH relapse was observed in 14 patients; signs of bowel hypovascularization due to incarceration in a small orifice was observed in eight of these patients (57%).ConclusionsIncidence of IH after OAGB is 2.8%. IH is associated with a low rate of bowel ischemia and the need for intestinal resection.

Technical Considerations In Performing One Anastomosis Gastric Bypass In Case of Intestinal Malrotation

Intestinal malrotation is a rare congenital anomaly that originates from the failure of the normal rotation and fixation of the midgut during embryologic development. There are different types of Midgut Malrotation which includes non-rotation, incomplete rotation, reverse rotation, or anomalous fixation of the mesentery. Methods: We present a case of a 58-year-old woman with a BMI of 45.3 kg/m2. The patient underwent laparoscopic appendectomy 15 years ago and was diagnosed with a partial situs inversus. She has no other past medical conditions. Results: At the operation, four meters of small bowel were counted backward from the ileocaecal valve until the duodenum. We performed a one anastomosis gastric bypass with three meters of common limb and one meter of biliopancreatic limb, gastro-intestinal anastomosis made with a linear stapler, and the defect sutured with absorbable suture. Conclusion: One anastomosis gastric bypass is a feasible and safe alternative for morbidly obese patients with intestinal malrotation or multiple intestinal adhesions.

Safety and feasibility of laparoscopic sleeve gastrectomy with loop duodenojejunal bypass for obesity.

PurposeLaparoscopic sleeve gastrectomy (SG) with loop duodenojejunal bypass (LDJB) is a combination of SG and one anastomosis gastric bypass surgeries. This study was intended to evaluate the safety and feasibility of SG-LDJB surgery.MethodsThis was a retrospective study analyzing SG-LDJB surgery using 250-cm length biliopancreatic limbs that was performed between May 2013 and December 2017 in 113 Indians with obesity. All demographic, clinical, operative, and follow-up data were analyzed for weight loss and diabetes remission efficacy. Weight-loss success was defined as percentage of total weight loss (%TWL) ≥ 25%. Diabetes remission was defined as hemoglobin A1c < 6% without the need for antidiabetic medications. Safety and feasibility were analyzed in terms of intraoperative and postoperative complications and serum albumin, iron, and calcium levels.ResultsThe %TWL was 35.0% and 31.0% at the 1-year and 3-year follow-ups, respectively. The weight-loss success rate was 91.3% and 78.1% at the 1-year and 3-year follow-ups, respectively. Sixty-six out of 113 patients had type 2 diabetes. Diabetes remission was 80.0% and 75.4% at the 1-year and 3-year follow-ups, respectively. Major perioperative complications occurred in 0.9% of the patients. The 30-day mortality rate was zero. None of the patients had serum albumin levels of <3 g/dL at the 1-year and 3-year follow-ups or symptoms of hypoproteinemia.ConclusionSG-LDJB surgery using a 250-cm biliopancreatic limb is a safe and effective procedure to treat obesity. It is technically complex but has the advantages of endoscopic access to the stomach and negligible postoperative complications or hypoproteinemia.

Effect of one anastomosis gastric bypass on liver function tests: A comparison between 150 cm and 200 cm biliopancreatic limbs.

Context:Some studies have shown that one anastomosis gastric bypass (OAGB) results in the derangement of liver function tests (LFTs). We wanted to study this in our patients.Aims:The aims are to study the effect of OAGB on LFTs and to compare the effect of a biliopancreatic limb (BPL) of 150 cm (OAGB-150) to a BPL of 200 cm (OAGB-200).Settings and Design:The study was a retrospective cohort study conducted at a university hospital.Materials and Methods:Information was obtained from our prospectively maintained database and hospital's computerised records.Statistical Analysis:A P < 0.05 was regarded statistically significant; however, given the number of variables examined, findings should be regarded as exploratory.Results:A total of 405 patients underwent an OAGB-200 (n = 234) or OAGB-150 (n = 171) in our unit between October 2012 and July 2018. There were significant improvements in gamma-glutamyl transpeptidase (GGT) levels at 1 and 2 years after OAGB-200 and significant worsening in the levels of alkaline phosphatase (ALP) and albumin at 1 and 2 years. There was a significant improvement in GGT levels at 1 and 2 years after OAGB-150 and in alanine transaminase levels at 1 year. There was a significant worsening in ALP and albumin levels at both follow-up points in this group. OAGB-150 group had a significantly lower bilirubin level at 1 year and significantly fewer abnormal ALP values at 2 years in comparison with OAGB-200 patients.Conclusions:This exploratory study demonstrates the overall safety of OAGB with regard to its effect on LFTs, with no remarkable difference between OAGB-150 and OAGB-200.

Effect of One Anastomosis Gastric Bypass on Haematinics, Vitamin D and Parathyroid Hormone Levels: a Comparison Between 150 and 200 cm Bilio-Pancreatic Limbs.

There is little data on the effect of one anastomosis gastric bypass (OAGB) on haematinics, vitamin D and parathyroid hormone levels. It is further unclear if an OAGB with a bilio-pancreatic limb (BPL) of 150 cm (OAGB-150) would deliver better outcomes than that with a BPL of 200 cm (OAGB-200). We investigated our records to obtain information on patients who underwent an OAGB-200 or OAGB-150 until 31st July 2018 in our unit. A total of 405 patients underwent either an OAGB-200 (n = 234) or OAGB-150 (n = 171). The mean age was 46 ± 10.98 years and 276 (68.1%) were females. The mean preoperative weight and the body mass index (BMI) were 139 ± 29.96 kg and 49 ± 8.14 kg/m2 respectively. With OAGB-200, there was a significant increase in anaemia rates at 1 and 2 years compared to preoperative levels with a significant fall in haemoglobin levels. After OAGB-150, there was a significant fall in haemoglobin levels at 1 and 2 years but the increase in anaemia rate was only significant at 2 years. There was a significant increase in PTH levels and the number of abnormal values at 1 and 2 years with OAGB-200. With OAGB-150, PTH changes were significant at 2 years only. We found that both OAGB-200 and OAGB-150 are associated with a significant increase in anaemia and secondary hyperparathyroidism. Our findings should prompt the evaluation of supplementation protocols with higher dosages than we recommend for iron, folate and calcium. Consideration should also be given to evaluating shorter BPL lengths than 150 cm with OAGB.

Long limb compared with standard limb Roux-en-Y gastric bypass for type 2 diabetes and obesity: the LONG LIMB RCT

Background Roux-en-Y gastric bypass is recognised as a standard of care in the treatment of diabetes mellitus and obesity. However, the optimal length of the Roux-en-Y gastric bypass limbs remains controversial, with substantial variation in practice. Specifically, a longer biliopancreatic limb length of 150 cm (‘long limb’) has been hypothesised to be better for the treatment of diabetes mellitus because it increases the postprandial secretion of gut hormones, such as glucagon-like peptide 1, and increases insulin sensitivity, compared with the Roux-en-Y gastric bypass utilising a standard biliopancreatic limb length of 50 cm (‘standard limb’). Objective To evaluate the mechanisms, clinical efficacy and safety of long limb versus the standard limb Roux-en-Y gastric bypass in patients undergoing metabolic surgery for obesity and diabetes mellitus. Design A double-blind, mechanistic randomised controlled trial was conducted to evaluate the mechanisms, clinical efficacy and safety of the two interventions. Setting Imperial College London, King’s College London and their associated NHS trusts. Participants Patients with obesity and type 2 diabetes mellitus who were eligible for metabolic surgery. Interventions Participants were randomly assigned (1 : 1) to 150-cm (long limb) or 50-cm (standard limb) biliopancreatic limb Roux-en-Y gastric bypass with a fixed alimentary limb of 100 cm. The participants underwent meal tolerance tests to measure glucose excursions, glucagon-like peptide 1 and insulin secretion, and hyperinsulinaemic–euglycaemic clamps with stable isotopes to measure insulin sensitivity preoperatively, at 2 weeks after the surgery and at matched 20% total body weight loss. Clinical follow-up continued up to 1 year. Main outcome measures Primary – postprandial peak of active glucagon-like peptide 1 concentration at 2 weeks after intervention. Secondary – fasting and postprandial glucose and insulin concentrations, insulin sensitivity, glycaemic control and weight loss at 12 months after surgery, and safety of participants. Results Of the 53 participants randomised, 48 completed the trial. There were statistically significant decreases in fasting and postprandial glucose concentrations, increases in insulin, glucagon-like peptide 1 secretion and insulin sensitivity, and reductions in the levels of glycated haemoglobin (i.e. HbA1c) and weight in both long and standard limb groups. However, there were no significant differences between trial groups in any of these parameters. Limitations The main limitations of this trial include the relatively short follow-up of 12 months and elongation of the biliopancreatic limb to a fixed length of 150 cm. Conclusion Patients undergoing both types of Roux-en-Y gastric bypass benefited metabolically from the surgery. The results have not demonstrated that elongation of the biliopancreatic limb of the Roux-en-Y gastric bypass from 50 to 150 cm results in superior metabolic outcomes in terms of glucose excursions, insulin and incretin hormone secretion, and insulin sensitivity, when assessed at up to 12 months after surgery. Future work Continued longitudinal follow-up of the long and standard limb cohorts will be necessary to evaluate any differential effects of the two surgical procedures on patients’ metabolic trajectories. Trial registration Current Controlled Trials ISRCTN15283219. Funding This project was funded by the Efficacy and Mechanism Evaluation programme, a Medical Research Council and National Institute for Health Research (NIHR) partnership. This will be published in full in Efficacy and Mechanism Evaluation; Vol. 8, No. 3. See the NIHR Journals Library website for further project information. The section in the report on endocrinology and investigative medicine is funded by grants from the Medical Research Council, the Biotechnology and Biological Sciences Research Council, NIHR, an Integrative Mammalian Biology Capacity Building Award and a FP7-HEALTH-2009-241592 EuroCHIP grant. This section is also supported by the NIHR Biomedical Research Centre Funding Scheme.

The IFSO Worldwide One Anastomosis Gastric Bypass Survey: Techniques and Outcomes?

One anastomosis gastric bypass (OAGB) has become one of the most commonly performed gastric bypass procedures in some countries. To assess how surgeons viewed the OAGB, perceptions, indications, techniques, and outcomes, as well as the incidence of short- and long-term complications and how they were managed worldwide. A questionnaire was sent to all IFSO members in all 5 chapters to study the pattern of practice and outcomes of OAGB. Seven hundred and forty-two surgeons responded. The most commonly performed procedures were sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and OAGB. Preoperatively, 70% of the surgeons performed endoscopy routinely. In regards to weight loss, 83% (570 surgeons) responded that OAGB produces better weight loss than SG, and 49% (342 surgeons) responded that OAGB produces better weight loss than RYGB. The most common length of the biliopancreatic limb (BPL) utilized was 200 cm. Sixty-seven percent of surgeons did not measure the total length of the small bowel. In patients with reflux disease and history of smoking, 53% and 22% of surgeons respectively still offered OAGB as a treatment option. Postoperatively, leak was documented in 963 patients, and it was the leading cause for mortality. Leak management was conservative in 35%. Conversion to RYGB was performed in 31%. In 16% the anastomosis was reinforced, 6% of the patients were reversed, and other procedures were performed in 12%. Revision of OAGB for malnutrition/steatorrhea or severe bile reflux was reported at least once by 37% and 45% of surgeons, respectively (200 cm was the most commonly encountered biliopancreatic limb BPL in those revised for malnutrition). Most common strategy for revision was conversion to RYGB (43%), reversal to normal anatomy (32%), shortening of the BPL (20%), and conversion to SG (5%). Nevertheless, 5 out of 98 mortalities (5%) were due to liver failure/malnutrition. There are infrequent but potentially severe specific complications including malnutrition, liver failure, and bile reflux that may require surgical correction after OAGB.

Can Metabolite and Hormone Profiles Provide a Rationale for Choosing Between Bariatric Procedures?

There are no formal guidelines for choosing among different bariatric surgery procedures for obesity treatment. So, our aim was to evaluate whether post-absorptive metabolite and hormone profiles could aid the surgeon decision when considering bariatric surgery interventions. Subjects (N=38) previously submitted to biliopancreatic diversion with duodenal switch (BPD-DS, n=9), single anastomosis duodenal-ileum bypass with sleeve gastrectomy (SADI-S, n= 9), long biliopancreatic limb Roux-en-Y gastric bypass (RYGB-M, n= 11), and classic RYGB (RYGB-C, n= 9) underwent a mixed meal test to evaluate post-absorptive glucose, total amino acid (AA), insulin, and GLP-1 profiles. Glucose, AA, insulin, and GLP-1 excursions were lower after BPD-DS when compared to other surgeries. SADI-S resulted in lower glucose but similar AA and insulin excursions when compared to RYGB-M. The highest GLP-1 excursion was observed after RYGB-M. There were no significant differences in glucose or AA post-prandial excursions between RYGB procedures, yet insulin excursion was higher after RYGB-C when compared to RYGB-M. Post-prandial metabolite excursions diverge across bariatric procedures being lowest after BPD-DS, intermediate after SADI-S, and highest after RYGB, in parallel with the anti-diabetic efficacy and malabsorption risk reported for each type of intervention. SADI-S and RYGB-M seem to elicit similar post-prandial hormonal profiles, with potentially lower risk of protein malnutrition when compared to BPD-DS. Post-absorptive metabolite and hormone profiles could provide a rationale as decision-aid when choosing among bariatric surgery interventions, as long as these findings are validated in future trials.

The Hardship of Recovering a Patient from Liver Failure after One Anastomosis Gastric Bypass

The one anastomosis gastric bypass (OAGB) was first described in 2001 as a safe and effective procedure that meets the criteria for the "ideal" weight loss operation. However, revisions for malnutrition and liver failure were reported. We report a patient who was transferred to our institution with protein calorie malnutrition and liver failure after undergoing OAGB. A 42-year-old morbidly obese female patient underwent a laparoscopic sleeve gastrectomy (LSG) in 2012 followed by conversion to OAGB in 2018 for weight regain at another institution. Nine months after conversion, she was transferred to our institution with dehydration, vomiting, dysphagia, generalized edema, and steatorrhea (7 times/day). She had become wheelchair bound. On examination, there was gross edema, protein-calorie malnutrition, dermatitis, and muscle wasting. She had anemia (8g/dl) reference range (11.5-15.5g/dl), bilirubin (1.8mg/dl) (0.2-1.2mg/dl), hypoalbuminemia (1.4g/dl) (3.5-5g/dl), and elevated international normalized ratio (INR). The patient was admitted to the hospital and was started on total parenteral nutrition (TPN), with thiamine, vitamins, iron injections, and trace mineral replacement. Her course was complicated by multiple episodes of line sepsis and bacteremia. After 6weeks, we succeeded in raising her albumin to 2.9g/dl and proceeded with surgery. Laparoscopic exploration started with identifying the anatomy and measuring the biliopancreatic limb (BPL = 430cm) and the common channel (CC = 380cm). First, we restored the continuity of the small bowel. Then the long gastric pouch was trimmed. Finally, the patient was converted to a Roux-en-Y gastric bypass (RYGB) with a 30cm BP limb and 70cm Roux limb. The patient had an uneventful recovery and was discharged home on the fourth postoperative day. At 3months of follow-up, her symptoms resolved, her laboratory work up normalized, and she regained mobility. Malnutrition and liver failure after OAGB are not uncommon. It is encountered with configurations of longer BP limb. BPL length of 150 to 200cm seems to reduce such complications. Preoperative nutritional optimization is key. Conversion to a proximal RYGB is a safe and feasible approach.

Role of Gastrointestinal Hormones as a Predictive Factor for Long-Term Diabetes Remission: Randomized Trial Comparing Metabolic Gastric Bypass, Sleeve Gastrectomy, and Greater Curvature Plication.

Long-term studies comparing the mechanisms of different bariatric techniques for T2DM remission are scarce. We aimed to compare type 2 diabetes (T2DM) remission after a gastric bypass with a 200-cm biliopancreatic limb (mRYGB), sleeve gastrectomy (SG), and greater curvature plication (GCP), and to assess if the initial secretion of gastrointestinal hormones may predict metabolic outcomes at 5years. Forty-five patients with mean BMI of 39.4(1.9)kg/m2 and T2DM with HbA1c of 7.7(1.9)% were randomized to mRYGB, SG, or GCP. Anthropometric and biochemical parameters, fasting concentrations of PYY, ghrelin, glucagon, and AUC of GLP-1 after SMT were determined prior to and at months 1 and 12 after surgery. At 5-year follow-up, anthropometrical and biochemical parameters were determined. Total weight loss percentage (TWL%) at year 1 and GLP-1 AUC at months 1 and 12 were higher in the mRYGB than in the SG and GCP. TWL% remained greater at 5years in mRYGB group - 27.32 (7.8) vs. SG - 18.00 (10.6) and GCP - 14.83 (7.8), p= 0.001. At 5years, complete T2DM remission was observed in 46.7% after mRYGB vs. 20.0% after SG and 6.6% after GCP, p< 0.001. In the multivariate analysis, shorter T2DM duration (OR 0.186), p= 0.008, and the GLP-1 AUC at 1month (OR 7.229), p= 0.023, were prognostic factors for complete T2DM remission at 5-year follow-up. Long-term T2DM remission is mostly achieved with hypoabsortive techniques such as mRYGB. Increased secretion of GLP-1 after surgery and shorter disease duration were the main predictors of T2DM remission at 5years.

Long Term Outcomes after Laparoscopic Assisted Trans-Gastric Endoscopic Retrograde Cholangiopancreatography.

Background:The gastric bypass is a commonly performed bariatric procedure. The stomach is divided into a small pouch as well as leaving a larger remnant that is bypassed by the gastrojejunal anastomosis. This makes access to the biliary system difficult as an endoscope cannot transverse the esophagus, roux limb, and biliopancreatic limb. Therefore, a transgastric approach (endoscopic retrograde cholangiopancreatography [t-ERCP]) through the abdominal wall and remnant stomach is necessary. This involves the surgical team providing access to the remnant stomach for the gastroenterologist to perform the t-ERCP. We have performed a number of these for biliary pathology that ranges from cancer to retained gallstones. We evaluated these patients with at least a 3-year follow-up to determine long term outcomes.Methods:We conducted a chart review of patients who underwent a t-ERCP with at least a 3-year follow-up. We collected de-identified data including demographics, operative details, complications, and postoperative courses.Results:There were 12 patients who underwent t-ERCP. Eleven patients had at least a 3-year follow-up with a mean follow-up of 68.1 months (excluding one death from pancreatic cancer). The most common pathology was benign biliary stricture (n = 6), followed by retained gallstones (n = 4), with one pancreatic cancer, and one normal examination. Two patients still had epigastric pain at long term follow-up after 3 years.Conclusion:T-ERCP is safe and efficacious with good long-term results.

Analysis of Weight-Loss Outcomes Following Laparoscopic One Anastomosis Duodenal Switch.

Background: Laparoscopic one anastomosis duodenal switch (OADS) is one of the most effective bariatric surgeries aimed at simplifying duodenal switch procedure and reducing malabsorption without compromising weight-loss efficacy. This study analyzed weight-loss outcomes following OADS surgery with a common channel 300 cm. Methodology: Between June 2016 and November 2020, 150 patients who underwent OADS surgery with a common channel 300 cm were included in the study. The weight-loss outcomes of these patients at six months and one year after surgery were retrospectively studied with respect to various perioperative variables including biliopancreatic limb (BPL) and common channel lengths. Results: At six months and one year after surgery, %TWL was 30%, 39.4%, and %EWL was 75%, 98.8%, respectively. The BMI loss, weight loss and %TWL were directly proportional to preoperative BMI and weight, while the %EWL was inversely proportional to these variables. Preoperative BMI was found to be an independent predictor of BMI loss and %EWL. The BMI loss, and weight loss were also directly proportional to BPL length. The %TWL was directly proportional to BPL length at one year after surgery. Age, gender and diabetes did not have significant effects on the weight-loss outcomes. The success rate (%TWL 25%) was 88.9% and 99.2% at six months and one year after surgery, respectively. Conclusions: OADS surgery using a common channel 300 cm appears to be highly effective for weight loss. Preoperative BMI, weight and BPL length were found to be significant predictors of weight-loss outcomes following this surgery.