Previous Sleeve Gastrectomy Research Articles

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

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

Gastric Torsion following Sleeve Gastrectomy: A rare case and surgical management

Gastric torsion is a rare but potentially life-threatening complication that can occur following sleeve gastrectomy, characterized by the rotation of the stomach along its axis. This case report presents the clinical presentation, diagnostic approach, surgical management, and postoperative outcomes of a patient who developed gastric torsion after previous sleeve gastrectomy. Early recognition and prompt surgical intervention are crucial in effectively managing this uncommon complication.

A070 Treatment of Hiatal Hernia, Reflux, and Weight Regain in Patients with Previous Sleeve Gastrectomy

A070 Treatment of Hiatal Hernia, Reflux, and Weight Regain in Patients with Previous Sleeve Gastrectomy

Early postoperative complications after gastric bypass revisional surgery in patients with previous sleeve gastrectomy versus primary gastric bypass.

Revisional bariatric surgery (RS) is indicated if there is weight regain or insufficient weight loss, no improvement or reappearance of co-morbidities, or previous bariatric surgery complications. It has been associated with higher postoperative morbidity. To evaluate the early postoperative complications (&lt;30 d) of Roux-en-Y gastric bypass RS (RYGB-RS) after primary sleeve gastrectomy (SG-1) compared with primary RYGB (RYGB-1) at a bariatric surgery referral center. Department of General and Digestive Surgery of General Universitary Hospital of Alicante, Spain. Retrospective cohort study comparing RYGB-RS after SG-1 and RYGB-1 between January 2008 and March 2021. Postoperative complications, hospital stay, mortality, and readmissions were analyzed. Six hundred and twenty-eight RYGB surgeries (48 RYGB-RS, 580 RYGB-1) were studied. The mean age of patients undergoing RYGB-RS was 50 years, compared with 46 years in the RYGB-1 group (P = .017). Mean initial body mass index was 44.2 kg/m² (RYGB-RS) versus 47.6 kg/m² (RYGB-1; P = .004). Cardiovascular risk factors were higher in the RYGB-1 group (P &lt; .05). Indications for RS were weight regain or insufficient weight loss (72.9%), weight regain or insufficient weight loss plus gastroesophageal reflux disease (14.6%), and gastroesophageal reflux disease (12.5%). There were no differences in the frequency of complications (RYGB-RS 22.9% vs RYGB-1 20.5%) or in their severity (Clavien-Dindo ≥IIIa; RYGB-RS 10.4% vs RYGB-1 6.4%; P &gt; .05). There were no differences in emergency room visits (RYGB-RS at 12.5% vs RYGB-1 at 14.9%) or in readmissions (RYGB-RS at 12.5% vs RYGB-1 at 9.4%). No differences were observed between primary RYGB and revisional RYGB in early morbidity, mortality, emergencies, or readmissions. Revisional bariatric surgery is a safe procedure at referral centers and must be done by expert hands.

A110 FEASIBILITY OF EUS-GUIDED PORTAL PRESSURE GRADIENT MEASUREMENT WITHOUT DEEP SEDATION: A PATH TO ACCURATE PORTAL PRESSURE DETERMINATION

AimsHepatic venous pressure gradient (HVPG) is the gold standard for the diagnosis and staging of portal hypertension. Previous studies have shown that it underestimates pre-sinusoidal portal hypertension. Endoscopic ultrasound-guided portal pressure gradient (EUS-PPG) can safely measure direct portal vein pressure (PVP) and bridge this diagnostic gap. However, EUS-PPG has so far been performed with patients under deep sedation which can alter HVPG measurement and lead to misclassification of portal hypertension. Ketamine, a conscious sedation agent, has minimal effect on portal hemodynamics. We present our center’s experience with EUS-PPG under ketamine and low dose midazolam.MethodsWe retrospectively reviewed consecutive patients undergoing EUS-PPG with conscious sedation using ketamine and low-dose midazolam (<0.02 mg/kg) at the McGill University Health Centre from February to May 2021. Patients were placed in the left lateral position. Hepatic vein and portal vein were located through EUS via a trans-gastric/hepatic approach. A through the scope 25-gauge needle attached to a manometer was advanced through the liver to measure hepatic vein pressure (HVP) and portal vein pressure (PVP). Three measurements were sampled per vessel and mean pressure differences calculated to obtain PPG. PPG was considered reliable if the differences between the values was no more than 1mmHg.ResultsThree patients underwent EUS-PPG for evaluation of pre-sinusoidal portal hypertension. Cirrhosis was excluded in all patients based on recent liver biopsy or transient elastography. The first patient is a 69-year-old man with splenomegaly and recanalization of the paraumbilical vein on imaging. He received 80 mg of ketamine and no midazolam. HVPG measured was 1 mmHg. EUS-PPG was successful with PPG of 6 mmHg (HVP= 7 mmHg, and PVP= 13 mmHg). The second patient is a 42-year-old woman with previous sleeve gastrectomy and known with portal cavernoma. She received 120 mg of ketamine and 1 mg of midazolam. EUS-PPG was technically difficult due to respiratory movements. The measurement was not considered reliable as differences in PPG were as high as 2mmHg. In this case, PPG was 0mmHg (HVP= 15mmHg, and PVP= 15mmHg). The third patient, a 74-year-old man with hepatic steatosis and splenomegaly received 70 mg of ketamine and 1 mg of midazolam. EUS-PPG was successful (HVP= 3mmHg, PVP= 3mmHg) yielding a PPG 0mmHg. All patients tolerated the procedure well with no procedural or sedation-related complicationsConclusionsOur early experience suggests that EUS-PPG can be successfully and safely performed in patients under conscious sedation with ketamine and low-dose midazolam. This combination may avoid deep sedation with high dose midazolam or propofol which are known to alter accuracy of HVPG. Measurement of HVP (left) and PVP (right)Funding AgenciesNone

3D CAT Scan and Gastric Volumetry in the Planning of Revisional Bariatric Surgery.

Background: The planning of revisional bariatric surgery is a complex process. The availability of accurate anatomical information is especially important for the planning of such challenging surgical procedures, we present our initial experience using three-dimensional-computed tomography (3D-CT) images to preoperatively assess the anatomy of patients before bariatric revisional surgery. Methods: We used 3D reconstructed images of CT scans to assess the anatomy and plan revisional surgery in 144 patients 98 of them had a previous sleeve gastrectomy 41 had a previous gastric by-pass and 4 Vertical banded gastroplasties. An effervescent preparation was used to distend the stomach and the proximal bowel allowing volume estimation. Results: Eleven sleeve patients underwent a re-sleeve gastrectomy and 44 were revised to a "Roux-en-Y" gastric bypass (RYGBP). Forty-two patients with a previous gastric by-pass were revised due to weight regain or other issues and 4 patients with previous vertical banded gastroplasty (VBGP) were revised to RYGBP. 3D-CT scans provided valuable information for the planning of all revisional procedures by offering accurate information about the existing anatomy and measures of the volume of the gastric pouch, the size of the gastro-jejunal anastomosis in gastric by-pass cases, or the volume and shape of the gastric tube in gastric sleeve cases. Conclusion: 3D-CT is a fast, widely available, reliable, and accurate tool to assess the anatomy after bariatric procedures. This noninvasive method can be particularly useful for the evaluation of postbariatric patients with failures, suboptimal results, and complications, and for the planning of revisional surgery.

Delayed Splenic Abscess Post Splenic Arterial Embolization for Trauma in a Patient with Previous Sleeve Gastrectomy

In this report, we present a rare case of delayed splenic abscess formation with upper pole necrosis following proximal splenic artery embolization in a patient with impaired splenic collateral blood supply, having previously undergone sleeve gastrectomy surgery for weight loss. Consent was obtained from the patient for the writing of this case report.

Gastric volvulus after laparoscopic sleeve gastrectomy managed by conversion to Roux-en-Y gastric bypass. A case report and literature review.

Introduction and importanceOne of the most performed bariatric procedures, Laparoscopic sleeve gastrectomy (LSG) can be utilized not only as a primary bariatric procedure to achieve weight loss but also as a staged procedure, as it attains durable weight loss on long term follow up with remission of obesity-related comorbidities. There are several complications associated with LSG in the short and long terms, including hemorrhage, gastric leakage, and gastroesophageal reflux disease (GERD), yet gastric volvulus after sleeve gastrectomy is a rare entity.Case presentation and clinical discussionWe present a morbid obese female patient 32 years old -with no known medical comorbidity- presented to our bariatric outpatient clinic after laparoscopic sleeve gastrectomy with a chronic progressive history of vomiting, regurgitation, and heartburn of three months which started once/week then progress to 3 times/week duration. After a normal abdominal x-ray, Pelvi-abdominal ultrasound showed mild colonic gaseous distension. The CT virtual gastroscopy with 3D reconstruction revealed significant mid-body kinking with a wavy appearance. A decision was made on a multi-disciplinary approach to do a diagnostic laparoscopy for the patient with a revision of the previous sleeve gastrectomy. Upon entering the intra-abdominal there were extensive adhesions between the sleeved stomach, liver, and pancreas. Intra-operative upper endoscopy was done, and the scope didn't pass at the mid-portion of the sleeved stomach. Conversion to Roux-en-Y gastric bypass had been done with successful results.ConclusionGastric volvulus after sleeve gastrectomy is a rare entity presenting vague symptoms and signs and requires a high index of suspicion from the physicians for the proper diagnosis.

Robotic Revisional Single Anastomosis Duodenoileal Bypass After Sleeve Gastrectomy.

Introduction: Single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) is a metabolic operation emerging as an option for patients with morbid obesity. It is a promising revisional procedure for weight regain or suboptimal weight loss after sleeve gastrectomy (SG). Currently, there is limited literature describing robotic revisional SADI-S. This study describes the safety, feasibility, and early outcomes of robotic revisional SADI-S after previous SG. Methods: This is a retrospective review from May 26 2019 to January 31 2021. Perioperative outcomes were analyzed. Results: A total of 16 patients underwent the procedure. There were 11 females (69%) with a mean age of 39 ± 11 years. Mean body mass index (BMI) was 44.0 ± 5.1 kg/m2 and median ASA was two. Comorbidities included hypertension (25%), hyperlipidemia (19%), and obstructive sleep apnea (13%). Mean interval from primary to revisional surgery among patients was 5.5 ± 1.4 years. Median operative console time was 110 minutes (IQR = 103-137). There were no intraoperative complications. The median hospital stay was 2 days (IQR = 2-3). Perioperative outcomes included no reoperations, perioperative complications, or deaths. There were two (12.5%) emergency department visits for wound checks without infection but no readmissions. At a median follow-up of 4.5 months (IQR = 1-10), patients had a mean BMI of 38.3 ± 7.3 kg/m2 and a mean percent total body weight loss (%TBW) of 12.7%. Conclusions: Initial outcomes suggest that robotic revisional SADI-S after previous SG is feasible and safe. Future studies are needed to evaluate intermediate- and long-term postoperative outcomes.

Small bowel obstruction following laparoscopic Roux-en-Y gastric bypass: is it always necessary to operate? A 5-year, high volume center experience.

This study aims to describe the incidence, associated factors, etiology, and management of small bowel obstructions following laparoscopic Roux-en-Y gastric bypass (LRYGB). A retrospective analysis was conducted between January 15 and December 19 using the surgery database of our hospital. Included LRYGB patients were those that evolved with a prolonged length of stay; readmission; emergency room consult; and re-intervention due to small bowel obstruction (SBO) related symptoms with compatible radiological or intraoperative findings. The LRYGB technique implied an antecolic alimentary limb reconstruction and systematic closure of mesenteric defects. Descriptive and analytical statistics were carried out, using a parametric or non-parametric approach as needed. Nine hundred forty-one LRYGB were performed. 9.9% were revisional surgeries of patients with a laparoscopic sleeve gastrectomy. During the study period, 36 SBOs occurred, representing 3.8% of operated patients, with no mortality. 58.3% had successful non-operative management, while 41.7% required surgical exploration, of which 73.3% were treated laparoscopically and 20% needed conversion to open surgery. Etiologies of SBO were jejuno-jejunostomy (JJO) related stenosis (22, 61.1%), internal hernias (6, 16.7%), adherences (3, 8.3%), and other diagnoses (5, 13.9%). Regarding JJO stenosis and internal hernias, median time to diagnosis was 8days (IQR 7-11) and 12months (IQR 8.7-16) respectively. Previous sleeve gastrectomy, age, or sex was not associated to the incidence of small bowel obstruction. LRYGB is safe when performed by experienced surgeons. SBO due to internal hernias were scarce in this series. JJO stenosis could explain most cases of SBO; under this diagnosis, non-surgical management was successful frequently.

Efficacy and Drawbacks of Single-Anastomosis Duodeno-Ileal Bypass After Sleeve Gastrectomy in a Tertiary Referral Bariatric Center

BackgroundThe need for revisional procedures after sleeve gastrectomy (SG) for insufficient weight loss or weight regain, gastroesophageal reflux, or other complications is reported to be 18–36% in studies with 10-year follow-up. Single-anastomosis duodeno-ileal bypass (SADI) may be performed as a revisional procedure after SG. This study aims to evaluate the short- and mid-term outcomes of SADI after SG in a referral center for bariatric surgery.Materials and MethodsData of patients who underwent SADI between March 2015 and March 2020 were collected prospectively and analyzed retrospectively. Follow-up comprised clinical and biochemical assessment at 1, 3, 6, 12, 18, and 24 months postoperatively, and once a year thereafter.ResultsOverall, 106 patients underwent SADI after a previous SG. The timeframe between SG and SADI was 50 ± 31.3 months. Postoperative mortality was observed in two cases (1.8%) and morbidity in 15.1% of patients. At 24 months, %total weight loss was 37.6 ± 12.3 and %excess weight loss 76.9 ± 25.2 (64 patients). Three patients were treated for malnutrition during follow-up, two with medical treatment and one with SADI reversal.ConclusionSADI after SG provides effective weight loss results in the short-term, even if in the present series the postoperative complication rate was non-negligible. Further trials are needed to establish the more advantageous revisional bariatric procedure after failed SG.

Short-term results of single-anastomosis gastric bypass after failed sleeve gastrectomy

Background It is recognized that sleeve gastrectomy (SG) is one of the most common bariatric procedures worldwide. It is considered a relatively safe and effective option in the treatment of morbid obesity. However, SG operations may fail in the treatment of obesity. In cases of unsuccessful SG surgery, revisional bariatric surgery may be used. One anastomosis gastric bypass (OAGB) was considered as an outstanding choice for revision surgery. Objective To assess the efficacy and safety of OAGB as a redo surgery after the failure of previous sleeve gastrectomy operation. Patients and methods This study is a retrospective cohort study, conducted in Bariatric Surgery Unit, Ain Shams University Hospital, Cairo, Egypt, from February 2018 to July 2019, with 6 months of postoperative follow-up till January 2020. We included 50 patients who underwent OAGB who were adults fit for surgery, aged between 18 and 60 years, with a history of failed SG. Results A total of 50 patients with history of failed SG underwent OAGB surgery with excess body weight loss of 14.10% at 1 month, 28.85% at 3 months, and 45.43% at 6 months. Weight loss was 7.14–32.43 kg (SD 6.14). The type 2 diabetes mellitus remission rate was 100% by 6 months, with glycated hemoglobin level of 5.88±0.77 (range, 5.4–7.2). Hypertension resolution was 40%. Overall, 100% of patients with sleep apnea improved symptomatically. No morbidity or mortality cases were reported. Conclusion OAGB operation is considered to be an effective and safe revisional surgical procedure after a failed primary SG operation.

Fetal fractional limb volumes in pregnancies following bariatric surgery.

Obesity rates have reached an epidemic level and bariatric surgery is the most effective method of sustainable weight loss. Pregnancy following bariatric surgery is associated with an increased prevalence of small babies. The objective of the study is to compare the fetal fat distribution, as assessed by fractional arm and thigh volume using three-dimensional ultrasonography, in pregnancies following maternal bariatric surgery with those without such history. This is a prospective, longitudinal, observational study conducted in a Maternity Unit in the UK. The study included 189 pregnant women; 63 with previous bariatric surgery [27 restrictive (13 with gastric band, 14 with sleeve gastrectomy) and 36 malabsorptive procedures] and 126 with no previous surgery but similar maternal booking body mass index. Fetal arm and thigh volume were obtained at 30-33 and 35-37weeks' gestation and fractional limb volumes were calculated using a commercially available software. Women underwent a 75g, 2h oral glucose tolerance test at 28-31weeks of gestation. Overall, adjusted fetal arm and thigh volume were smaller in the post-bariatric, compared to the no surgery, group and this was more marked in women who had undergone a previous sleeve gastrectomy (P<.001 and P=.002, respectively) or a malabsorptive procedure (P<.001 for both). There was a strong positive correlation between maternal fasting/post-prandial (2h) glucose levels, at the time of the oral glucose tolerance test, and arm and thigh volume at both 30-33 and 35-37weeks (P<.01 for all). The study has demonstrated that in the third trimester of pregnancy, fetuses of women with previous bariatric surgery have smaller fractional limb volumes, therefore less soft tissue, compared to fetuses of women without such surgery and this may be related to the lower maternal glucose levels seen in the former pregnancies.

Laparoscopic Conversion of Sleeve Gastrectomy to One Anastomosis Gastric Bypass for Weight Loss Failure: Mid-Term Results.

Laparoscopic sleeve gastrectomy (SG) became the most performed surgical intervention for treating population with morbid obesity. However, revisional surgery after SG has been increasingly performed due to weight loss failure. We describe the results of a single surgeon's experience with conversion of SG to one anastomosis gastric bypass (OAGB) in patients with previous SG and weight loss failure. The aim of the study is to analyze the short- and mid-term results of conversion of SG to OAGB for failure of weight loss. Conversion of SG to OAGB was performed in 77 patients from May 2010 to June 2018. Vertical resleeving of the gastric tube was done in all patients. A chart review was conducted to determine the weight loss mid-term results and the occurrence of postoperative complications. Revisional surgery was completed by laparoscopy in all cases. The mean operative time was 42.0 ± 8.0min, and mean blood loss was 56.8 ± 56.7mL. A total complication rate of 3.9% was observed. Ninety-day mortality rate was 0%. Patients mean %EWL was 80.2 (36-128) at 12-month follow-up, mean percent total weight loss (%TWL) was 0.74 (range 0.03-1.8), and mean percent excess BMI loss (%EBMIL) was 70.7%. At 24-month follow-up, mean %EWL was 84.1 (41-128), mean %TWL 0.79 (range 0.32-1.6), and mean %EBMIL 79.9%. In patients with history of SG and weight loss failure, conversion from SG to OAGB is effective in terms of weight loss and has a low risk of surgical complications.

A560 Laparoscopic magnetic sphincter augmentation system for the treatment of severe GERD post Sleeve Gastrectomy

The laparoscopic Magnetic Sphincter Augmentation System (MSA) is a surgical technique with mid-term evidence demonstrating efficacy in the treatment of medically refractory or chronic gastroesophageal reflux disease (GERD). We present the first series of cases with severe GERD post Sleeve, that underwent this surgery. To verify the efficacy of the MSA for the treatment of pathological GERD in patients with previous sleeve gastrectomy, with no weight regain.

Cardiopexy with Ligamentum Teres in Patients with Hiatal Hernia and Previous Sleeve Gastrectomy: An Alternative Treatment for Gastroesophageal Reflux Disease.

Fifty percent of patients who have undergone sleeve gastrectomy have gastroesophageal reflux disease (GERD). Surgical reinforcement of the lower esophageal sphincter is necessary to prevent acid reflux. Here, we describe ligamentum teres cardiopexy, a surgical technique that reinforces the lower esophageal sphincter and restores its competence with a new valve, in patients with previous sleeve gastrectomy and hiatal hernia. Included in the study were 15 patients (age, 35.6 ± 15.2 years; 13 females [86.6 %]; mean pre-cardiopexy body mass index, 21.94 kg/m(2)) with sleeve gastrectomy who presented with hiatal hernia and gastroesophageal reflux disease and underwent ligamentum teres cardiopexy. In this procedure, the ligamentum teres is released from its umbilical connection and the hernia reduced by manual traction, freeing the last 3-5 cm of esophagus in the abdomen. The distal ligamentum teres is fixed with one stitch to the apex of the angle of His, one at the gastroesophageal junction, and one joining the gastric fundus to the esophagus. The remainder of the ligamentum teres is fixed over itself with four to six stitches, forming a necktie cardiopexy. The procedure concludes with diaphragmatic crus closure. After 6 months, 13 patients (86.6 %) achieved successful results, defined as resolution of GERD, no proton-pump inhibitor (PPI) use, and manometry measurement over 12 mmHg after surgery. Two patients (13.3 %) required continued proton-pump inhibition. Ligamentum teres cardiopexy combined with closure of the gastric crus is a good alternative treatment for gastroesophageal reflux disease in patients with previous sleeve gastrectomy and hiatal hernia.

Single-anastomosis duodenoileal bypass as a second step after sleeve gastrectomy

BackgroundAfter sleeve gastrectomy, many surgical options are available in patients with insufficient weight loss. Duodenal switch is typically considered the operation that results in higher weight loss, although it is, perhaps unjustly, considered technically difficult and may be accompanied by severe side effects. Single-anastomosis duodenoileal bypass with sleeve gastrectomy is a simplification of the duodenal switch that may behave as a standard biliopancreatic diversion but is easier and quicker to perform. Given its effectiveness as a primary surgery we hypothesized that it would be successful as a second-step operation. The objective of this study was to analyze the weight loss and co-morbidities resolution after a single-anastomosis duodenoileal bypass (SADI) performed as a second step after sleeve gastrectomy. MethodsSixteen patients with an initial body mass index of 56.4 kg/m2 and a mean excess weight loss of 39.5% after a sleeve gastrectomy were submitted to a single-anastomosis duodenoileal bypass with a 250-cm common channel. ResultsThere were no postoperative complications. The mean excess weight loss was 72% 2 years after the second-step surgery. The complete remission rate was 88% for diabetes, 60% for hypertension, and 40% for dyslipidemia. The mean number of daily bowel movements was 2.1. One patient suffered an isolated episode of clinical hypoalbuminemia. ConclusionSADI is a safe operation that offers a satisfactory weight loss for patients subjected to a previous sleeve gastrectomy. The side effects are well tolerated, and complications are minimal.