Laparoscopic Roux-en-Y Gastric Bypass Research Articles

Challenges in multi-centric generalization: phase and step recognition in Roux-en-Y gastric bypass surgery.

Most studies on surgical activity recognition utilizing artificial intelligence (AI) have focused mainly on recognizing one type of activity from small and mono-centric surgical video datasets. It remains speculative whether those models would generalize to other centers. In this work, we introduce a large multi-centric multi-activity dataset consisting of 140 surgical videos (MultiBypass140) of laparoscopic Roux-en-Y gastric bypass (LRYGB) surgeries performed at two medical centers, i.e., the University Hospital of Strasbourg, France (StrasBypass70) and Inselspital, Bern University Hospital, Switzerland (BernBypass70). The dataset has been fully annotated with phases and steps by two board-certified surgeons. Furthermore, we assess the generalizability and benchmark different deep learning models for the task of phase and step recognition in 7 experimental studies: (1) Training and evaluation on BernBypass70; (2) Training and evaluation on StrasBypass70; (3) Training and evaluation on the joint MultiBypass140 dataset; (4) Training on BernBypass70, evaluation on StrasBypass70; (5) Training on StrasBypass70, evaluation on BernBypass70; Training on MultiBypass140, (6) evaluation on BernBypass70 and (7) evaluation on StrasBypass70. The model's performance is markedly influenced by the training data. The worst results were obtained in experiments (4) and (5) confirming the limited generalization capabilities of models trained on mono-centric data. The use of multi-centric training data, experiments (6) and (7), improves the generalization capabilities of the models, bringing them beyond the level of independent mono-centric training and validation (experiments (1) and (2)). MultiBypass140 shows considerable variation in surgical technique and workflow of LRYGB procedures between centers. Therefore, generalization experiments demonstrate a remarkable difference in model performance. These results highlight the importance of multi-centric datasets for AI model generalization to account for variance in surgical technique and workflows. The dataset and code are publicly available at https://github.com/CAMMA-public/MultiBypass140.

Effect of bariatric surgery on obstructive sleep apnea: using the STOP-Bang score as a screening tool

Background Obstructive sleep apnea (OSA), the most prevalent major sleep disorder in the world, has been associated with obesity. Besides reducing weight, bariatric surgery has been reported to improve OSA. Data on the effects of bariatric surgery on OSA are scarce in Egypt. This study aimed to evaluate the short-term effects of bariatric surgery on OSA. Patients and methods This is a prospective study that was conducted on patients who were candidates for bariatric surgery at our institution who completed the STOP-Bang questionnaire before the surgery with a score greater than or equal to 4 and underwent re-evaluation 6 months after surgery. All patients underwent a standardized clinical assessment. The 6-month follow-up data were recorded and analyzed. Results The present study included 30 patients, with a mean baseline BMI of 54.32±9.77 kg/m2. The surgeries performed were Laparoscopic Sleeve Gastrectomy (LSG) (n=21, 70%) and Laparoscopic Roux en Y gastric bypass (LRYGB) (n=9, 30%). The mean baseline STOP-Bang score was 5.3±1.09. At the 6-month follow-up, the mean 6-month postoperative STOP-Bang score was 1.13±1.04 (P<0.001). No statistically significant differences were noted in the BMI or the STOP-Bang score before and after surgery according to the surgery type (P>0.05). There was a statistically significant positive correlation between the 6-month BMI reduction and the Snoring, Tiredness, Observed apnea, Pressure, BMI, Age, Neck, Gender (STOP-Bang) score improvement (r=0.397, P=0.0298). Conclusion This study demonstrated the bariatric surgery-initiated evident improvement and even complete resolution of OSA in patients with obesity, as measured by the STOP-Bang score.

Early Marginal Ulcer After Roux-en-Y Gastric Bypass: MBSAQIP Database Analysis of Trends and Predictive Factors.

Marginal ulcer (MU) is a known complication after Roux-en-Y gastric bypass (RYGB) that carries significant morbidity. First, we aimed to determine the trends and the rates of readmission, reintervention, and reoperation of 30-day MU. Second, we aim to determine the predictive factors associated with this complication. Patients who had 30-day marginal ulcer (MU) after LRYGB were identified using the 2015-2021 MBSAQIP database. Those who had a 30-day complication other than MU were excluded. Bivariate and logistic regression analyses were performed. Among 213,104 patients undergoing laparoscopic RYGB, 638 (0.3%) showed 30-day MU. This group of patients required endoscopic interventions, readmissions, and reoperations at rates of 88%, 72%, and 9%, respectively. Predictive factors for 30-day MU after RYGB were renal insufficiency, history of DVT, previous cardiac stent, African American race, chronic steroid use, COPD, therapeutic anticoagulation, anastomotic leak test, GERD, and operative time > 120min. Additionally, patients who had 30-day MU showed significantly higher rates of overall complications such as pulmonary, cardiac and renal complications, unplanned ICU admission, blood transfusions, venous thromboembolism (VTE), and non-home discharge (p < 0.05). The MU group showed similar rates of 30-day mortality as those without this complication (0.2% vs 0.1%, p = 0.587). The incidence of 30-day MU following RYGB was 0.3%. Patients with MU required endoscopic interventions, readmissions, and reoperations at rates of 88%, 72%, and 9%, respectively. Some preoperative and intraoperative factors contributed to an increased risk of 30-day MU.

A New Procedure-Based Assessment of Operative Skills in Gastric Bypass Surgery, Evaluated by Video Fragment Rating

PurposeFeedback on technical and procedural skills is essential during the training of residents and fellows. The aim of this study was to assess the performance of a newly created instrument for the assessment of operative skills using laparoscopic Roux-en-Y gastric bypass (LRYGB) video fragments.Materials and MethodsA new procedure-based assessment (PBA) was created by combining LRYGB key steps with a 5-point independence scale. LRYGB performed by residents and surgeons with different levels of expertise were video recorded. Fragments of the pouch creation, gastro-jejunostomy and jejunojejunostomy, were review by 12 expert bariatric surgeons and the operative skills assessed with the PBA, Objective Structured Assessment of Technical Skill (OSATS), and the Bariatric OSATS (BOSATS). The PBA was compared to the OSATS and BOSATS. Mean scores for all items of the different assessments were summarized and compared using a T-test.ResultsThe scores of the procedural steps were combined and compared for all levels. The mean scores for beginner, intermediate, and expert level were 2.71, 3.70, and 3.90 for the PBA; for the OSATS 1.84, 2.86, and 3.44; and for the BOSATS 2.78, 3.56, and 4.19. Each of these assessments differentiated between the three skill levels (all p < 0.05).ConclusionThe PBA discriminates well between different levels of operative skills. Similar patterns were found for the OSATS and BOSATS, showing that the randomly selected video fragments are representative samples for assessing skill level. Future research will demonstrate whether these results can be extrapolated to clinical training, and which scores allow for procedure certification.Graphical

Safety and Efficacy of LSG Versus LRYGB on Patients with Obesity: a Systematic Review and Meta-analysis from RCTs.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the two most frequently performed techniques in treating obesity and its related comorbidities. We aimed to compare the clinical efficacy and safety of LSG with LRYGB in terms of short- and mid-term outcomes of weight loss, obesity-related comorbidities, and post-operative complications via a meta-analysis of RCTs. Clinical comparative RCTs on LSG and LRYGB were searched through PubMed, MEDLINE, and Web of Science databases from inception to August 2022. Pooled outcomes from the selected studies were discussed by the random-effect meta-analysis method. Quality assessment and risk of bias for selected RCTs were implemented, and all the statistical analyses were performed. Twenty studies, including 1270 patients, were enrolled. Meta-analysis results indicated the great superior efficacy of LRYGB to LSG in BMI loss at 6 (MD -1.35kg/m2, 95% CI: -2.07 to -0.62, p = 0.0003), 12months (MD -1.09kg/m2, 95% CI: -1.86 to -0.33, p = 0.005), and 36months (MD -1.47kg/m2, 95% CI: -2.77 to -0.16, p = 0.03) as well as %EWL gaining at 36months. Significantly higher remission rates of T2DM and dyslipidemia were achieved by LRYGB at 12months. Besides, better improvements for T2DM-related and lipid biochemical parameters were found favoring LRYGB. However, LSG resulted in a lower post-operative complication rate and shorter operating time. Present meta-analysis results suggested that LRYGB was superior to LSG concerning short- and mid-term weight loss, short-term T2DM remission efficacy, and related biochemical parameters. LSG is favored for obviously fewer complications and shorter operating time.

Comparison of Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass

Laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB) are widely used bariatric procedures for which comparative efficacy and safety remain unclear. To compare perioperative outcomes in SG and RYGB. In this registry-based, multicenter randomized clinical trial (Bypass Equipoise Sleeve Trial), baseline and perioperative data for patients undergoing bariatric surgery from October 6, 2015, to March 31, 2022, were analyzed. Patients were from university, regional, county, and private hospitals in Sweden (n = 20) and Norway (n = 3). Adults (aged ≥18 years) eligible for bariatric surgery with body mass indexes (BMIs; calculated as weight in kilograms divided by height in meters squared) of 35 to 50 were studied. Laparoscopic SG or RYGB. Perioperative complications were analyzed as all adverse events and serious adverse events (Clavien-Dindo grade >IIIb). Ninety-day mortality was also assessed. A total of 1735 of 14 182 eligible patients (12%; 1282 [73.9%] female; mean (SD) age, 42.9 [11.1] years; mean [SD] BMI, 40.8 [3.7]) were included in the study. Patients were randomized and underwent SG (n = 878) or RYGB (n = 857). The mean (SD) operating time was shorter in those undergoing SG vs RYGB (47 [18] vs 68 [25] minutes; P < .001). The median (IQR) postoperative hospital stay was 1 (1-1) day in both groups. The 30-day readmission rate was 3.1% after SG and 4.0% after RYGB (P = .33). There was no 90-day mortality. The 30-day incidence of any adverse event was 40 (4.6%) and 54 (6.3%) in the SG and RYGB groups, respectively (odds ratio, 0.71; 95% CI, 0.47-1.08; P = .11). Corresponding figures for serious adverse events were 15 (1.7%) for the SG group and 23 (2.7%) for the RYGB group (odds ratio, 0.63; 95% CI, 0.33-1.22; P = .19). This randomized clinical trial of 1735 patients undergoing primary bariatric surgery found that both SG and RYGB were performed with a low perioperative risk without clinically significant differences between groups. ClinicalTrials.gov Identifier: NCT02767505.

Comparative evaluation of early diabetic outcomes in southeast asian patients with type 2 diabetes mellitus undergoing Roux-en-Y gastric bypass (RYGB) versus sleeve gastrectomy (LSG)

Obesity and type 2 diabetes mellitus (T2DM) is an alarming problem globally and a growing epidemic. Metabolic surgery has been shown to be successful in treating both obesity and T2DM, usually after other treatments have failed. This study aims to compare Roux-Y gastric bypass and sleeve gastrectomy in determining early diabetic outcomes in obese Malaysian patients with T2DM following surgery. A total of 172 obese patients with T2DM who were assigned to either laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) were analysed up to a year post-procedure. The patients’ T2DM severity were stratified using the Individualized Metabolic Surgery (IMS) score into mild, moderate and severe. Remission rates of diabetes were compared between surgical techniques and within diabetic severity categories. T2DM remission for patients who underwent either surgical technique for mild, moderate or severe disease was 92.9%, 56.2% and 14.7% respectively. Both surgical techniques improved T2DM control for patients in the study. Comparing baseline with results 1 year postoperatively, median HbA1c reduced from 7.40% (IQR 2.60) to 5.80% (IQR 0.80) (p < 0.001), mean total antidiabetic medications use reduced from 1.48 (SD 0.99) to 0.60 (SD 0.86) [p < 0.001], insulin usage reduced from 27.9 to 10.5% (p < 0.001), and T2DM control improved from 27.9 to 82% (p < 0.001). The patients had a median excess BMI loss of 69.4% (IQR 34%) and 53.2% (IQR 36.0%) for RYGB and SG respectively (p = 0.016). At one year following surgery, there is no difference between LRYGB and LSG in terms of diabetic remission. LSG is not inferior to LRYGB in terms of early diabetic outcomes. Milder T2DM shows a better response. LSG is a simpler procedure with a lower risk profile and should be considered as an early treatment option for obese patients with T2DM.

Gastric bypass - 10 years' results.

Gastric bypass has not gained as much popularity in the Czech Republic as technically simpler restrictive bariatric procedures, frequently with a fading long-term effect. The aim of the presentation is to point out the long-term results after two types of gastric bypasses. Retrospective analysis of prospectively collected data in an initial set of patients after laparoscopic RYGB (Roux Y gastric bypass) and OAGB/MGB (one anastomosis/mini gastric bypass) performed at Breclav Hospital in 2010-2013. Evaluation based on the BAROS system, according to weight development, comorbidities, psychological aspects, complications and reoperations. Data available for evaluation are from 32 patients out of a total of 60; the follow-up rate is 53%. The patients are lighter by 34 kg on average (0-64 kg); TBWL (total basic weight loss): 25.7%. The majority of operated diabetics are free of signs of diabetes, and all others have a reduced need for antidiabetic medication. Hypertension, sleep apnea and psychological assessment of life in 6 domains improved. Eight of the 32 followed patients underwent reoperation during 10 years; only 2 of these procedures were acute for complications (anastomotic ulceration), both in smokers; further elective reoperations included 2 conversions of OAGB/MGB to RYGB due to reflux, 2 corrective surgeries, and 2 procedures for a suspected internal hernia. There was no conversion from laparoscopic to open surgery, no peritonitis associated with a leak, and no mortality within 30 days. The BAROS score (5.56) indicates a "very good result" of the gastric bypasses after 10 years. Gastric bypasses are safe and provide a high and lasting metabolic effect that meets the general expectations of an invasive intervention that can fundamentally improve the quality of treatment for otherwise incurable chronic diseases related to adiposity (so-called ABCD), especially type 2 diabetes.

Comparative nutritional, metabolic and body composition effect in patients of Roux-en-Y Gastric Bypass with Long or Short Pancreato-Biliary Limb

Introduction: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common techniques for the treatment of morbid obesity. However, evidence for the metabolic effects caused by the measures of intestinal limbs that are used in LRYGB is limited. The present study was conducted to assess the metabolic impact of using a long biliopancreatic limb (LBP-limb) versus a short biliopancreatic limb (SBP-limb) in patients with obesity undergoing LRYGB at six, nine and twelve months after the surgery to compare changes from baseline between the two procedures. Methods: Sixty-four patients with obesity participated in this study and underwent gastric bypass with either a 100-cm biliopancreatic limb (SBP-limb) and 150-cm alimentary limb (n = 31) or a 200-cm biliopancreatic limb (LBP-limb) and 50-cm alimentary limb (n = 33). Body weight, body fat (%), lean mass (%), total weight loss (%) and biochemical parameters glucose, glycosylated hemoglobin (HbA1c), total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides, albumin and glycated hemoglobin were compared at the time of surgery and at six, nine and twelve months after surgery. Results: After surgery was observed in the LBP-limb group greater total weight loss (P = 0.004) at twelve months after surgery and a significant increase in HDL-C levels at six months (P = 0.001) compared with the SBP-limb group. However, no differences in the remission of comorbidities were found between the two groups. Conclusions: At the end of the first year after surgery the LBP-limb technique generated greater weight loss.

IBC-Oxford University2023_BJSOral_18The Use of Indocyanine Green (ICG) Fluorescence Angiography in Laparoscopic Roux-en-Y Gastric Bypass for Perfusion Assessment and Structure Visualisation

Abstract Introduction Indocyanine green (ICG) fluorescence angiography (FA) has been utilised in bariatric surgery for assessment of tissue perfusion and blood supply in laparoscopic sleeve gastrectomy (LSG). However, there is limited literature on its use in laparoscopic Roux-en-Y gastric bypass (LRYGB). The aim of this study was to evaluate the use of ICG-FA in LRYGB for qualitative assessment of tissue perfusion and structure identification. These are the first cases utilising ICG-FA in LRYGB to be performed in the United Kingdom. Methods Thirty-five patients (12 male, 34%, 23 females, 66%) with median (IQR) age of 45 (38 – 52) years and preoperative median (IQR) BMI 45 (37 – 49) kg/m2 underwent LRYGB with ICG-FA. ICG was administered intravenously according to an agreed protocol. Karl Storz® Image 1 Rubina system with overlay and monochromatic modes was utilised for perfusion assessment. ICGFA was utilised for qualitative assessment of gastric pouch perfusion before and after linear stapled gastro-jejunal anastomosis and visualisation of key anatomical landmarks. The perfusion pattern was assessed by the operating team based on a ICG scoring system (ICG-S), which ranged from 1 (no perfusion) to 4 (excellent perfusion) based on timing following ICG injection and intensity of fluorescence detected in the anatomical structures. Results From April 2021 to August 2022, 34 patients underwent primary LRYGB with use of ICG- FA. ICG was utilised in one revisional case. No adverse effects to ICG were observed. ICG-S was 4 in 33 patients. (94%). In two patients (6%), operative strategy was modified based on focal area of no perfusion (ICG score 1) in gastric pouch. ICG-FA helped improve operative safety during division of omentum and in recognition of duodeno-jejunal flexure with fluorescence detection in epiploic vessels and inferior mesenteric vein (IMV) respectively. There were no leaks at a median follow up of 9 months. Conclusion ICGFA imaging allows for qualitative assessment of perfusion and identification of critical anatomical landmarks during LRYGB. The technology is safe and its utilisation in LRYGB provides a “real-time image” of gastric pouch perfusion, helping to demonstrate ischaemic or poorly perfused areas with an opportunity to modify operative strategy.

IBC-Oxford University2023_BJSOral_22Long Term Results of Conversion of Failed Laparoscopic Sleeve Gastrectomy into Four Different Bariatric Procedures, with a Follow-up of up to 14 Years

Abstract Background Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric operation. Its main downside is the high long term weight loss failure, necessitating re-operation and conversion. The optimal conversion technique is yet unknown, and reported long term data after conversion is lacking. Here we report the long-term results of our experience with conversion of failed LSG to four different bariatric procedures, laparoscopic Roux-Y Gastric Bypass (RYGB), laparoscopic Duodenal Switch (LDS), laparoscopic One Anastomosis Gastric Bypass (OAGB), and laparoscopic Single Anastomosis Duodeno-Ileal Bypass (SADIS), with a follow up of up to 14 years. Methods We analyzed data from 160 conversion procedures done for failed LSG, between the years 2007 to 2023. The procedure selection has changed over time, but the indication for conversion for weight related reasons was the same (BMI ≥34 kg/m²). Most patients were operated for weight loss failure. Patients operated for early strictures, stenosis and early dysfunction were excluded from the weight analysis. In almost all cases where sleeve dilatation was encountered, re-sleeve or pouch trimming were performed. The subgroup of patients with a follow up longer than 5 years was analyzed separately, to produce the long-term data. Results All operations were done laparoscopically, 6 patients suffered postoperative complications, no perioperative deaths were reported. Three patients required a corrective procedure due to severe malabsorption, from the LDS group. RYGB: 58 patients underwent conversion to RYGB, of those, 31 patients had pre-conversion BMI of ≥34kg/m², with a mean BMI of 40.4±5.5kg/m² and mean excess weight before conversion was 40.6kg. After a mean follow up of 7.7 years, mean BMI, excess weight loss and mean total weight loss were 32.8±5.3kg/m², 50.35%, and 18.1%, respectively. Long-term follow up (mean 9.2 years) of 23 patients, revealed mean BMI, excess weight loss and mean total weight loss were of 33±5.6kg/m², 52.1% and 19.24%, respectively. LDS: 20 patients underwent conversion to DS, all had pre-conversion BMI of ≥34kg/m², with a mean BMI of46.48±6.8kg/m², their mean excess weight before conversion was 59.22kg. After a mean follow up of 8 years, mean BMI, excess weight loss and mean total weight loss were 31.4±5.6kg/m², 71.6% and 31.9%, respectively. Long-term follow up (9.3 years) of 15 patients showed a mean BMI, excess weight loss and mean total weight loss were BMI of 30.9±5.1kg/m², 73.9%, 33.8%, respectively. Mean bowel movements per day was 3.2. OAGB: 45 patients underwent conversion to OAGB, of those, 39 patients had pre-conversion BMI of ≥34kg/m², with a mean BMI of 40±3.2kg/m², their mean excess weight before conversion was 42.2kg. After a mean follow-up of 2.4 years, mean BMI, excess weight loss and mean total weight loss were 30.4±5.5kg/m², 65.18%, 23.9%, respectively. Long-term follow up (6 years) of 9 patients showed mean BMI, excess weight loss and mean total weight loss of 27.1±4.3kg/m, 84.5% and 30%, respectively. Mean bowel movements per day was 3.2. SADI-S: 37 patients underwent conversion to SADI-S, all patients had pre-conversion BMI of ≥34kg/m², with a mean BMI of 43.2±7kg/m², their mean excess weight before conversion was 52.6kg. After a mean follow up of 1.2 years, mean BMI, excess weight loss and mean total weight loss were 28.7±5.5kg/m², 78.5%, and 32.2%, respectively. The mean bowel movements per day was 4. Long-term follow up for these patients is underway. Conclusion Conversion of failed LSG to either RYGB, DS, MGB or SADI-S, are all safe and feasible options without significant perioperative complications. Even with different preoperative characteristics of the groups (intrinsic to all non-randomized studies) our long-term results suggest for weight loss failure or weight regain stronger malabsorptive procedures produce a better long term weight loss, comparatively to RYGB. Long-term results after conversion to SADI are still pending and may seem as a very effective conversion technique.

BS O04 Can virtual reality exercise games improve compliance with preoperative prescriptive exercise programs in patients awaiting bariatric surgery?

Abstract Background Despite the recognised benefits of increased activity prior to any surgery, non-compliance rate with prescribed exercise regimens is perceived to be higher amongst patients with obesity. Virtual-reality is becoming more recognised as an adjunctive tool within the healthcare setting. In this setting the platform enables exercise games to be played and enjoyed in the comfort of the patient’s own home, either sitting or standing depending on physical disability. The study aims to identify whether VR exercise games could be considered part of the pre-operative exercise program in patients awaiting bariatric surgery and the effects of this technology on compliance. Methods A pilot study using block randomisation, patients with obesity planned for laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG) between December 2020 and December 2023 were recruited to a 6-week pre-operative regular exercise (REG) programme of either regular walking activity (RWA) or exercise using Virtual Reality device (VRX). Patients who later decided not to follow the exercise protocol were included as control (NEG). Patients with epilepsy, uncontrolled arrhythmias, heart failure or those unable to use VR systems were excluded. Pre- and post-trial demographic and progress data and follow up survey using the New Zealand Physical Activity Questionnaire were collected. Results 43 patients were recruited, 46.4kg/m2 mean referral BMI (33.8 – 65.6, SD 6.4) and 84% female. Exercise non-compliance was comparable between RWA and VRX groups (40 vs 43% respectively). 56% of NEG had their operation during short day light season (44% of REG). NEG group reported higher rate of chronic pain, poor motivation, and higher incidents of changes to surgery date (33, 33 and 22% respectively vs. none in REG). While weight loss achieved in REG prior to the operation was higher than in NEG, there was no significant difference in weight loss between the groups at 3 months follow up. Conclusions While the role of prehabilitation exercise prior to major elective surgery is well documented, the search for the ideal approach to achieve this is still ongoing. This pilot study demonstrates the limitations certain chronic conditions in patients with obesity have on the success of a pre-operative exercise programme. While more data is needed, it is important to bear these limitations in mind when recruiting patients to any exercise programme. The compliance rate remains unfavourable despite the use of VR technology.

BS P01 Case Report: Emergency Laparotomy for Retrograde Intussusception after Roux-en-Y Gastric Bypass

Abstract Background Roux-en-Y gastric bypass (RYGB) is a common operation performed to treat obesity and associated co-morbidities. When done with weight management programs, it is associated with 60% excess weight loss. A rare complication is retrograde intussusception (RI), which can require emergency surgery due to risk of bowel ischaemia and necrosis. We report a case of a 66-year-old female who developed intermittent then acute RI, requiring urgent laparotomy for reduction of the intussusception and small bowel resection of the perforated invaginated segment. Her case is compared to the literature available, and a pathophysiological mechanism aiming to explain post-RYGB RI is proposed. Methods We compare the case of a patient with RI post-RYGB, to the available literature. The literature search was done on PubMed: “retrograde intussusception AND Roux-en-Y”. Results were limited to English language and human species. Paediatric and Maternity journals were excluded. The patient is a 66-year-old female who had a laparoscopic RYGB for obesity in 2018; and lost 106% excess weight. In 2022, she presented with laparoscopic evidence of a resolved intussusception. In 2023, she was re-admitted with CT and laparotomy-confirmed RI and small bowel obstruction at the jejuno-jejunal anastomosis. She was managed with small bowel resection and anastomosis. Results The non-specific clinical presentation of RI makes prompt diagnosis challenging. Usually, patients have abdominal pain and lack peritonism. Severe cases may present with bowel ischaemia, as the intussuscepted segment can have compromised vascularity. Hence, prompt diagnosis and timely management is essential to reduce morbidity and mortality. CT-AP is the diagnostic imaging test of choice, but delay in diagnosis of &amp;gt;48h may increase mortality to 50% due to delayed intervention. The surgical management is emergency surgery with gentle reduction of the intussusception. Resection of the invaginated small bowel segment with anastomosis may be indicated if there is bowel ischaemia. Conclusions We report the case of a patient with RI post-RYGB, with evidence of gut dysmotility prior to intussusception. The literature suggests that dysmotility disorders could underpin RI, as 80% of cases are anti-peristaltic. Obesity has a strong association with slow gastric and intestinal motility, likely due to impaired gut-brain biochemical messaging and altered gut microbiota. RYGB will disrupt these pathways, and we hypothesize that this may lead to further motility dysregulation. However, further research is necessary to provide supporting evidence. Nevertheless, this report provides a helpful reminder to prompt urgent investigation in patients who present with non-specific abdominal pain post-RYGB.

PROMISE: effect of protein supplementation on fat-free mass preservation after bariatric surgery, a randomized double-blind placebo-controlled trial

IntroductionProtein malnutrition after bariatric surgery is a severe complication and leads to significant morbidity. Previous studies have shown that protein intake and physical activity are the most important factors in the preservation of fat-free mass during weight loss. Low protein intake is very common in patients undergoing bariatric surgery despite dietary counseling. Protein powder supplements might help patients to achieve the protein intake recommendations after bariatric surgery and could therefore contribute to preserve fat-free mass. This double-blind randomized placebo-controlled intervention study aims to assess the effect of a daily consumed clear protein powder shake during the first 6 months after bariatric surgery on fat-free mass loss in the first 12 months after laparoscopic Roux-en-Y gastric bypass (LRYGB).Methods and analysisInclusion will take place at the outpatient clinic of the bariatric expertise center for obesity of the Maasstad Hospital. Patients will be randomly assigned to either the intervention or control group before surgery. The intervention group will receive a clear protein powder shake of 200 ml containing 20 g of whey protein dissolved in water which should be taken daily during the first 6 months after LRYGB on top of their normal postoperative diet. The control group will receive an isocaloric, clear, placebo shake containing maltodextrine. Postoperative rehabilitation and physiotherapeutical guidance will be standardized and similar in both groups. Also, both groups will receive the same dietary advice from specialized dieticians. The main study parameter is the percentage of fat-free mass loss 6 months after surgery, assessed by multi-frequency bioelectrical impedance analysis (MF-BIA).Ethics and disseminationThe protocol, version 2 (February 20, 2022) has been approved by the Medical Research Ethics Committees United (MEC-U) (NL 80414.100.22). The results of this study will be submitted to peer-reviewed journals.Trial registrationClinicalTrials.gov NCT05570474. Registered on October 5, 2022.

Gastroesophageal reflux disease following laparoscopic vertical sleeve gastrectomy and laparoscopic roux-en-Y gastric bypass: meta-analysis and systematic review of 5-year data.

To compare 5-year gastroesophageal reflux outcomes following Laparoscopic Vertical Sleeve Gastrectomy (LVSG) and Laparoscopic Roux-en-Y gastric bypass (LRYGB) based on high quality randomized controlled trials (RCTs). We conducted a sub-analysis of our systematic review and meta-analysis of RCTs of primary LVSG and LRYGB procedures in adults for 5-year post-operative complications (PROSPERO CRD42018112054). Electronic databases were searched from January 2015 to July 2021 for publications meeting inclusion criteria. The Hartung-Knapp-Sidik-Jonkman random effects model was utilized to estimate weighted mean differences where meta-analysis was possible. Bias and certainty of evidence was assessed using the Cochrane Risk of Bias Tool 2 and GRADE. Four RCTs were included (LVSG n = 266, LRYGB n = 259). An increase in adverse GERD outcomes were observed at 5 years postoperatively in LVSG compared to LRYGB in all outcomes considered: Overall worsened GERD, including the development de novo GERD, occurred more commonly following LVSG compared to LRYGB (OR 5.34, 95% CI 1.67 to 17.05; p = 0.02; I2 = 0%; (Moderate level of certainty); Reoperations to treat severe GERD (OR 7.22, 95% CI 0.82 to 63.63; p = 0.06; I2 = 0%; High level of certainty) and non-surgical management for worsened GERD (OR 3.42, 95% CI 1.16 to 10.05; p = 0.04; I2 = 0%; Low level of certainty) was more common in LVSG patients. LVSG is associated with the development and worsening of GERD symptoms compared to LRYGB at 5 years postoperatively leading to either introduction/increased pharmacological requirement or further surgical treatment. Appropriate patient/surgical selection is critical to minimize these postoperative risks.

Efficacy and Safety of Sleeve Gastrectomy with Jejunoileal Bypass Compared with Roux-en-Y Gastric Bypass: Results from a Cohort Study.

Background: We previously described sleeve gastrectomy with jejunoileal bypass (SGJIB) as promising novel technique for the surgical treatment of obesity Methods: A retrospective analysis of a prospective database in a Private Practice of Alimentary Tract Surgery in São Paulo, Brazil. We analyzed 176 patients with 60 months of follow-up, 74 of whom underwent Vertical Sleeve Gastrectomy with Jejunoileal Bypass (VSG-JIB) (50 women and 24 men) with a mean age of 38 years and a mean body mass index (BMI) of 40 kg/m2, and 102 patients underwent Roux-en-Y gastric bypass (RYGB) (90 women and 12 men) with a mean age of 36.5 years and a mean BMI of 39.73 kg/m2. Results: There was no statistically significant difference in long-term weight loss between the two groups. The rate of postoperative complications immediately after surgery was similar, but there was a tendency toward less severe complications in the SGJIB cohort. Conclusion: Sleeve gastrectomy with jejunoileal bypass is a novel surgical procedure for weight loss with comparable efficacy and safety compared with laparoscopic RYGB.

Shifting paradigms: protocol implementation to reduce length of stay for bariatric surgery following the pandemic at a high volume bariatric center.

With the Covid-19 pandemic reducing the capacity to perform elective bariatric surgical cases, a multidisciplinary approach to reducing length of stay has been essential to continue providing this service. In conjunction with the use of our local ERAS protocols, same day discharge (SDD) and early next day discharge (NDD) for bariatric surgery is becoming more of a reality. To evaluate the effectiveness of our new protocols targeted at reducing length of stay (LOS) for our bariatric surgery patients during the pandemic. Secondary outcomes included comparisons of readmission and complications compared to baseline data. The MBSAQIP data set was analyzed identifying patients who underwent laparoscopic roux-en- Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (SG) from April to November 2021. Mean LOS and complication rates including re-admission in this baseline group were documented. This was compared to a cohort who underwent the surgeries between December 2021 and February 2022 under our new protocols for early discharge. 195 patients underwent bariatric surgery in the baseline group and 87 patients in the early discharge cohort were included. There was a statistically significant decrease in mean LOS comparing baseline group (34.5h) and next day PACU discharges (25h) with P = 0.004. No increase in complication rate from the early discharge cohort against the baseline group. (P = 0.014). SDD and NDD in carefully selected bariatric surgery patients is feasible with good outcomes. With ERAS protocols as a foundation and a multidisciplinary approach, this can be achieved in spite of pressures placed on bariatric units by the pandemic.

Diabetes Remission After LRYGBP With and Without Fundus Resection: a Randomized Clinical Trial

BackgroundGlycemic control, after metabolic surgery, is achieved in two stages, initially with neuroendocrine alterations and in the long-term with sustainable weight loss. The resection of the gastric fundus, as the major site of ghrelin production, is probably related with optimized glucose regulation. The aim of the present study is to investigate whether the modification of laparoscopic Roux-en-Y gastric bypass (LRYGBP) with fundus resection offers superior glycemic control, compared to typical LRYGBP.Materials and MethodsParticipants were 24 patients with body mass index (BMI) ≥40kg/m2 and type II diabetes mellitus (T2DM), who were randomly assigned to undergo LRYGBP and LRYGBP with fundus resection (LRYGBP+FR). Gastrointestinal (GI) hormones [ghrelin, glucagon-like-peptide-1 (GLP-1), peptide-YY (PYY)] and glycemic parameters (glucose, insulin, HbA1c, C-peptide, insulinogenic index, HOMA-IR) were measured preoperatively, at 6 and 12 months during an oral glucose tolerance test (OGTT).ResultsNinety-five percent of patients showed complete remission of T2DM after 12 months. LRYGBP+FR was not related with improved glycemic control, compared to LRYGBP. Ghrelin levels were not significantly reduced at 6 and 12 months after LRYGBP+FR. GLP-1 and PYY levels were remarkably increased postprandially in both groups at 6 and 12 months postoperatively (p<0.01). Patients who underwent LRYGBP+FR achieved a significantly lower BMI at 12 months in comparison to LRYGBP (p<0.05).ConclusionFundus resection is not associated with improved glycemic regulation, compared to typical LRYGBP and the significant decrease in BMI after LRYGBP+FR has to be further confirmed with longer follow-up.Graphical

Early Bowel Obstruction after Bariatric Surgery: An Analysis of the 2020-2021 MBSAQIP Database.

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program evaluates 30-day outcomes of bariatric cases performed in the United States. The Participant Use File in 2020 introduced bowel obstruction (BO). We compared the rates of BO, risk factors, and postoperative outcomes after laparoscopic Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and duodenal switch (DS). Retrospective analysis of patients who underwent laparoscopic RYGB, SG, or DS obtained from the 2020-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Patients who underwent either as a primary procedure with a body mass index >35kg/m2 were selected. Baseline characteristics, operative details, and postoperative complications were collected. The outcome of interest was BO occurring within 30 days. A total of 205,533 cases of which 148,944 were SG (72.4%), 54,606 were RYGB (26.5%), and 1983 were DS (1%). BO occurred in 0.74%, 0.4%, and 0.03% of patients who underwent an RYGB, DS, or SG, respectively. Patients with a BO in the RYGB group were more likely to be on immunosuppressive therapy (5.4% vs. 1.9%, P<0.001) with longer operative time (136.2min±58.0min vs. 117.4min±53.6min, P<0.001). SG patients with a BO were older (47.5±13.6 vs. 41.9±11.6, P=0.011) with longer operating times (98.6±63.8 vs. 68.9±33.4, P=0.002). Patients in the RYGB group with a BO had the highest rates of readmissions (71.9%) and reoperations (58.4%). Early bowel obstruction is rare after bariatric surgery. It is more common after RYGB and least common after SG. Readmission and reoperation rates were highest in patients with BO in the RYGB group.

Evaluation of Alternate Laparoscopic Stapling Device for Bariatric Surgery.

As laparoscopic bariatric surgical techniques have matured, the incidence of complications has decreased over time. Surgical stapling devices are commonly used for resection and anastomosis of gastric tissue during bariatric surgery. The purpose of this study is to assess and compare complication rates and clinical outcomes between patient cohorts using 2 different approved stapling devices. Clinical outcomes were retrospectively compared for patients undergoing bariatric surgery between April 2019 and December 2020 using laparoscopic surgical stapling device A (LSSD-A) against outcomes between January 2017 and September 2018 using laparoscopic surgical stapling device B (LSSD-B). Tradenames for LSSD-A and LSSD-B were AEON Endostapler and Endo GIA with Tri-Staple Technology, respectively. In all, 814 patients underwent laparoscopic bariatric operation using LSSD-A and 1034 using LSSD-B. Laparoscopic surgery included sleeve gastrectomy (n=1359, 73.5%), Roux-en-Y gastric bypass (RYGB) (n=425, 23.0%), and single anastomosis duodenoileostomy with gastric sleeve (n=64, 3.5%). Stapler-related complications were evenly distributed over the 20.9-month LSSD-B study period. No stapler-related complications were seen in the last 13 months of the LSSD-A study period, during which time 428 (52.5%) laparoscopic bariatric operations were performed. One staple line leak was observed, occurring in the LSSD-B group. Patients undergoing laparoscopic RYGB with LSSD-A had fewer overall complications, fewer transfusions, and fewer reoperations for staple line bleeding. Both LSSD-A and LSSD-B were safe and effective in the performance of laparoscopic bariatric operations with low complication rates and comparable clinical performance in sleeve gastrectomy and single anastomosis duodenoileostomy with gastric sleeve. Statistically significant differences in complication rates were observed in RYGB favoring LSSD-A.