Laparoscopic Roux-en-Y Gastric Bypass Research Articles

Ten-Year Outcomes Following Roux-en-Y Gastric Bypass vs Duodenal Switch for High Body Mass Index

Results from long-term follow-up after biliopancreatic diversion with duodenal switch (DS) are scarce. To compare weight loss, health outcomes, and quality of life 10 years or more after Roux-en-Y-gastric bypass (RYGB) and DS surgery in patients with severe obesity-that is, a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 50 to 60. This open-label randomized clinical trial was conducted at 2 academic bariatric centers in Sweden and Norway. Sixty patients with a BMI of 50 to 60 were included from March 1, 2006, to August 31, 2007. Data were analyzed from August 12, 2022, to January 25, 2023. Laparoscopic RYGB or laparoscopic DS. The main outcome was change in BMI after 10 or more years. Secondary outcomes included anthropometric measures, lipid and glycemic profiles, bone mass density, adverse events, gastrointestinal tract symptoms, and health-related quality of life. Forty-eight of the original 60 patients (80%) were assessed after a median of 12 (range, 9-13) years (mean [SD] age, 48.0 [6.0] years; 35 women [73%]). At follow-up, the mean BMI reductions were 11.0 (95% CI, 8.3-13.7) for RYGB and 20.3 (95% CI, 17.6-23.0) for DS, with a mean between-group difference of 9.3 (95% CI, 5.4-13.1; P < .001). Total weight loss was 20.0% (95% CI, 15.3%-24.7%) for RYGB and 33.9% (95% CI, 27.8%-40.0%) for DS (P = .001). Mean serum lipid levels, except high-density lipoprotein cholesterol and hemoglobin A1c, improved more in the DS group during follow-up. Bone mass was reduced for both groups from 5 to 10 years, with lower bone mass after DS at 10 years. Quality-of-life scores (Obesity-Related Problem Scale and the 36-Item Short Form Health Survey) were comparable across groups at 10 years. The total number of adverse events was higher after DS (135 vs 97 for RYGB; P = .02). More patients in the DS group developed vitamin deficiencies (21 vs 11 for RYGB; P = .008) including 25-hydroxyvitamin D deficiency (19 for DS vs 9 for RYGB; P = .005). Four of 29 patients in the DS group (14%) developed severe protein-caloric malnutrition, of whom 3 (10%) underwent revisional surgery. In this randomized clinical trial, BMI reduction was greater after DS, but RYGB had a better risk profile over 10 years. Biliopancreatic diversion with DS may not be a better surgical strategy than RYGB for patients with a BMI of 50 to 60. ClinicalTrials.gov Identifier: NCT00327912.

Comparison of long-term outcomes after laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass for morbid obesity

BackgroundLaparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the two most bariatric procedures in Asia. However, a comparison of long-term outcomes is still limited. ObjectivesTo compare the degree of long-term weight loss, remission of co-morbidities and complication rates after LRYGB and LSG procedures. MethodsA retrospective analysis was conducted for all patients who underwent LSG or LRYGB between May 2005 and May 2018 at a single institute with at least 1 to 5 years of follow up. Demographic data were collected. ResultsOf the total 342 patients, 159 underwent primary LSG and 183 patients underwent LRYGB. Preoperative BMI in the LSG group was significantly higher than the LRYGB group (54.7 ± 12.6 kg/m2 vs 48.2 ± 8.2 kg/m2, P = 0.001). Co-morbidities between LSG and LRYGB groups were similar. Mean percentage of total weight loss (%TWL) at 5 years after was 23.6±1.7% in the LSG group vs. 29.9±1.3% in the LRYGB group (P = 0.005) and LRYGB resulted in greater weight loss than LSG at all time points. Overall complications were 35.2% in the LSG group vs. 20.8% in the LRYGB group (P = 0.003). ConclusionsOur center revealed that LRYGB had better results than LSG in terms of percentage total weight loss at all time points. In the long term, LSG showed a higher overall complication rate compared to LRYGB.

Comparison between total weight loss and other metrics after bariatric surgery using a multilevel mixed-effects linear regression model.

Several tools are used to assess postoperative weight loss after bariatric surgery, including the percentage of excess body weight loss (%EWL), percentage of total weight loss (%TWL), and percentage of excess body mass index (BMI) loss (%EBMIL). A repeated series of measurements should be considered to assess weight loss as accurately as possible. This study aimed to test weight loss metrics. Data were obtained from a prospective database of patients with obesity who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) between 2016 and 2017 in a French tertiary referral bariatric center. A multilevel mixed-effects linear regression model with repeated measures was used to analyze repeated weight measurements over time. A total of 435 patients underwent LRYGB (n = 266) or LSG (n = 169). At 2years, the average %EWL, %EBMIL, and %TWL were 56.8%, 61.3%, and 26.6%, respectively. Patients who underwent LSG experienced lower weight loss (β: -4233 in %TWL model, β: -6437 in %EWL model, and β: -6989 in %EBMIL model) than those who underwent LRYGB. In multivariate mixed analysis, preoperative BMI was not significantly associated with %TWL at 2years (β, -0.09 [-0.22-0.03] p = 0.1). Preoperative BMI was negatively associated with both %EWL (β, -1.61 [-1.84--1.38] p < 0.0001) and %EBMIL (β, -1.91 [-2.16--1.66] p < 0.0001). This is the first study to assess %TWL use for postoperative weight measurement, using a multilevel mixed-effects linear regression model %TWL is the measure of choice to assess weight loss following bariatric surgery.

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

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

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

PurposeMost 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.MethodsIn 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.ResultsThe 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)).ConclusionMultiBypass140 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.

Long-term (11 Years) Results of Laparoscopic Gastric Bypass: Changes in Weight, Blood Levels of Sugar and Lipids, and Late Adverse Effects : Laparoscopic Gastric Bypass Results.

Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) remains the most effective procedure to treat severe obesity with proven short- and intermediate-term benefits. The main goal is to describe the effects on weight and biochemical laboratory tests after long-term follow-up (11 years). A prospective cohort of adults with obesity treated with LRYGB between 2004 and 2010 in one center were studied. Patients with prior bariatric or upper digestive tract surgery, hiatal hernia >4 cm, alcoholism, or decompensated conditions were excluded. The study enrolled 123 patients, with a mean follow-up of 133±29 months and a 14% loss of participants. The percentage of Total Weight Loss (%TWL) at one, five, and eleven years was 30.3±8.4%, 29.1±6.9%, and 23.4±7%, respectively. Of the patients, 61.3% (65/106) maintained a %TWL≥20 after eleven years. Recurrent Weight Gain (RWG) at five and eleven years was 2.6±11.4% and 11 ±11.5%, respectively. At the end of the follow-up, 31.1% (33/106) of patients had RWG≥15%. Hypercholesterolemia and hypertriglyceridemia improved in 85.7% (54/63) and 90.2% (7/61) of the cohort, respectively. Remission of diabetes occurred in 80% of this subgroup. Gallstones developed in 28% of patients, and bowel obstruction due to internal hernia occurred in 9.4%. Anemia due to iron deficiency appeared in 25 patients. After surgery, there is a significant and durable loss of weight, with a tendency for late Recurrent Weight Gain. Furthermore, the improvement in biochemical parameters is sustained over time, but surgery's adverse effects may appear later.

How Preoperative Investigations Affect the Management of Bariatric Patients - Results of a Cohort Study of 897 Patients

Abstract Background Poorly defined preoperative diagnostic protocols worldwide vary in their emphasis on comprehensive investigations, with some prioritizing patient safety while others question routine procedures. Aims This study explores how diverse preoperative findings, from inflammatory processes to structural abnormalities, significantly influence patients’ management and the choice of bariatric procedures, underscoring the complexity in decision-making for individualized surgical interventions based on a cohort study's findings. Methods In a retrospective analysis of prospective data of over 1000 bariatric surgery patients from January 2017 to December 2022, we specifically included those who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG). In all patients, preoperative upper endoscopy was performed, with selected candidates also undergoing additional procedures like upper GI series and esophageal manometry, especially when LSG was planned. The study primarily analyzed the impact of preoperative examinations on therapeutic approaches. Results In this study, 897 patients were included, with 741 undergoing laparoscopic LRYGB and 156 LSG. All patients underwent upper endoscopy, revealing common findings such as type C gastritis, gastroesophageal reflux disease, and detection of Helicobacter pylori. Upper endoscopy prompted a therapeutic change in 216 patients (24.3%), resulting in a number needed to screen (NNS) of 4.1, with no significant differences based on the initially scheduled procedure. Preoperatively, upper GI series were more frequently conducted before planned LSG, uncovering hiatal hernias and motility disorders. However, no change in the surgical procedure resulted from upper GI series findings. Esophageal manometry, primarily performed for LSG, indicated normal findings in 84.6%, with a procedural change in 3 patients (2.0%). Overall, 14 (1.6%) patients experienced a change in the planned procedure, with 12 changes prompted by preoperative findings and two by technical difficulties. Conclusion We recommend routine upper endoscopy for all bariatric surgery patients, with additional manometry for planned LSG. Upper GI series should be reserved for selected cases and specific clinical indications.

Advantages of the 3- vs. the 2-Dimensional Laparoscopic Technology in Bariatric Surgery

Abstract Background Bariatric surgery procedures as the laparoscopic Roux-en-Y-Gastric Bypass (RYGB) are highly standardized procedures. The difficulty in two-dimensional (2D) laparoscopic surgery is the loss of the depth perception which complicates surgical techniques as suturing and knotting. The development of three-dimensional (3D) laparoscopy has been shown to reduce operative times and surgeons’ performances errors. Aims To compare operative times, post-operative complications and the lengths of hospital stay of patients having undergone laparoscopic RYGB before and after the introduction of the 3D-technology. Methods We conducted a retrospective cohort study including patients having undergone RYGB (without cholecystectomy) at our institution by the same surgical team before and after the introduction of the 3D-laparoscopic technology (Karl Storz, Tuttlingen, Germany). The primary outcome was the operative time, the secondary outcomes the post-operative complications and lengths of hospital stay. Results 100 consecutive patients, operated on 2019-2021 were included; 50 were operated utilizing the 2D- and 50 the 3D laparoscopic technology. There were no statistically significant differences in age, gender, body mass index or comorbidities, however, patients in the 3D-group had significantly more previous interventions. Operative time and hospital length of stay were significantly reduced in the 3D-group (83 (± 20.8) vs. 91 (± 13.5) minutes; p &amp;lt; 0.05 and 2.1 (± 0.4) vs. 2.7 (± 1.1) nights; p &amp;lt; 0.05). There were no statistically significant differences found between groups concerning post-operative complications and re-interventions. Conclusion 3D technology may help reducing the operative time and length of hospital stay in laparoscopic RYGB surgery with similar post-operative complications. We cannot completely exclude reduced operative times by the still growing experience of the surgical team.

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&lt;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&gt;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.