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Revisional Surgery for Insufficient Loss or Regain of Weight After Roux-en-Y Gastric Bypass: Biliopancreatic Limb Length Matters

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Abstract

Introduction

Weight regain after laparoscopic Roux-en-Y gastric bypass (RYGB) occurs in up to 35% of patients. Revisional surgery may be applied. Conversion from RYGB to a long biliopancreatic limb (BPL) RYGB is a potential option for revisional surgery and short-term results are promising.

Methods

All patients who underwent conversion to long BPL RYGB due to weight loss failure, defined as excess weight loss (EWL) < 50% or body mass index (BMI) > 35 kg/m2, were assessed. Proximal RYGB or very very long limb RYGB (VVLL RYGB) was modified by shortening of the total alimentary limb length (TALL) to create a long BPL.

Results

A total of 28 patients received revisional surgery from either PRYGB (n = 22) or VVLL RYGB (n = 6). Mean age at operation was 45.3 ± 10.4 years, with 78% females. Mean prerevisional BMI was 41.7 ± 4.4 kg/m2. Mean time to revision was 76.5 ± 38.5 months. Limb lengths were 150 cm (95% CI 133–156 cm) for RL and 100 cm (95% CI 97–113 cm) for CC, thus providing a total median alimentary limb length of 250 (95% CI 238–260 cm). Additional %EWL and TWL improved significantly in long-term. Five years postoperatively, all patients (n = 9) had an EWL% > 50%. Six patients (21.4%) required reoperation due to severe malnutrition during the postoperative course.

Conclusion

Conversion from RYGB to BPL RYGB leads to significant additional weight loss in the long term. However, the morbidity is relevant, especially severe protein malnutrition and the frequency of revisional surgery. Therefore, this type of surgery should not be done routinely.

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References

  1. Colquitt JL, Pickett K, Loveman E, Frampton GK. Surgery for weight loss in adults. Cochrane database Syst Rev. 2014 Aug 8;(8):CD003641.

  2. Schauer P, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes - 5-year outcomes. N Engl J Med. 2017;376(7):641–51.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Kizy S, Jahansouz C, Downey MC, Hevelone N, Ikramuddin S, Leslie D, et al. National trends in bariatric surgery 2012 – 2015: demographics , Procedure Selection, Readmissions , and Cost. 2017;

  4. Spaniolas K, Kasten KR, Brinkley J, Sippey ME, Mozer A, Chapman WH, et al. The changing bariatric surgery landscape in the USA 2015;1544–6.

  5. Bauknecht F. Bariatrische Operationen in der Schweiz 2001-2015. 2016.

  6. Mehaffey JH, Lapar DJ, Clement KC, Turrentine FE, Miller MS, Hallowell PT, et al. 10-year outcomes after Roux-en-Y gastric bypass. 2016;264(1):121–6.

  7. Obeid NR, Malick W, Concors SJ, Fielding GA, Kurian MS, Ren-Fielding CJ. Long-term outcomes after Roux-en-Y gastric bypass: 10- to 13-year data. Surg Obes Relat Dis. 2016 Jan;12(1):11–20.

  8. Sjöström L. Review of the key results from the Swedish Obese Subjects (SOS) trial - a prospective controlled intervention study of bariatric surgery. J Intern Med. 2013;273(3):219–34.

    Article  PubMed  Google Scholar 

  9. Adams T, Gress R, Simper Smith S, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357(8):753–61.

    Article  CAS  PubMed  Google Scholar 

  10. Flum D, Belle S, King W, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361(5):445–54.

    Article  PubMed  Google Scholar 

  11. Magro D, Geloneze B, Delfini R, et al. Long-term weight regain after gastric bypass: a 5-year prospective study. Obes Surg. 2008;247(1):648–51.

    Article  Google Scholar 

  12. Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg. 2004;240(3):416–24.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Rawlins ML, Teel D, Hedgcorth K, et al. Revision of Roux-en- Y gastric bypass to distal bypass for failed weight loss. Surg Obes Relat Dis. 2011;7(1):45–9.

    Article  PubMed  Google Scholar 

  14. Karmali S, Brar B, Shi X, Sharma AM, Gara C De, Birch DW. Weight recidivism post-bariatric surgery : a systematic review 2013;1922–33.

  15. Maleckas A, Gudaityt R, Petereit R, Venclauskas L, Veli D. Weight regain after gastric bypass : etiology and treatment options 2016;5(10):617–24.

  16. Mahawar KK, Kumar P, Parmar C, et al. Small bowel limb lengths and Roux-en-Y gastric bypass: a systematic review. Obes Surg. 2016;26(3):660–71.

    Article  PubMed  Google Scholar 

  17. Kaska Ł, Kobiela J, Proczko M, et al. Does the length of the biliary limb influence medium-term laboratory remission of type 2 diabetes mellitus after Roux-en-Y gastric bypass in morbidly obese patients? Wideochirurgia I Inne Tech Maloinwazyjne. 2014;9(1):31–9.

    Google Scholar 

  18. Tran DD, Nwokeabia ID, Purnell S, et al. Revision of Roux-en-Y gastric bypass for weight regain: a systematic review of techniques and outcomes. Obes Surg. 2016;26(7):1627–34.

    Article  PubMed  Google Scholar 

  19. Nelson W, Fatima J, Houghton S, et al. The malabsorptive very, very long limb Roux-en-Y gastric bypass for super obesity: results in 257 patients. Surgery. 2006;140(4):517–22.

    Article  PubMed  Google Scholar 

  20. Angrisani L, Santonicola A, Iovino P, et al. Bariatric surgery worldwide 2013. Obes Surg. 2015;25(10):1822–32.

    Article  CAS  PubMed  Google Scholar 

  21. Ionut V, Bergman RN. Mechanisms responsible for excess weight loss after bariatric surgery. J Diabetes Sci Technol. 2011 Sep 1;5(5):1263–82.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Parikh M, Pomp A, Gagner M. Laparoscopic conversion of failed gastric bypass to duodenal switch: technical considerations and preliminary outcomes. Surg Obes Relat Dis. 2007;3(6):611–8.

    Article  PubMed  Google Scholar 

  23. Keshishian A, Zahriya K, Hartoonian T, et al. Duodenal switch is a safe operation for patients who have failed other bariatric operations. Obes Surg. 2004;14(9):1187–92.

    Article  PubMed  Google Scholar 

  24. Brolin RE, Cody RP. Adding malabsorption for weight loss failure after gastric bypass. Surg Endosc. 2007;21(11):1924–6.

    Article  PubMed  Google Scholar 

  25. Dapri G, Cadière GB, Himpens J. Laparoscopic conversion of Roux-en-Y gastric bypass to distal gastric bypass for weight regain. J Laparoendosc Adv Surg Tech. 2011;21(1):19–23.

    Article  Google Scholar 

  26. Caruana JA, Monte S V, Pharm D, Jacobs DM, Pharm D, et al. Distal small bowel bypass for weight regain after gastric bypass : safety and efficacy threshold occurs at o 70% bypass. 2015;11:1248–55.

  27. Himpens J, Coromina L, Verbrugghe A, et al. Outcomes of revisional procedures for insufficient weight loss or weight regain after Roux-en-Y gastric bypass. Obes Surg. 2012;22(11):1746–54.

    Article  PubMed  Google Scholar 

  28. Ghiassi S, Higa K, Chang S, et al. Conversion of standard Roux-en-Y gastric bypass to distal bypass for weight loss failure and metabolic syndrome: 3-year follow-up and evolution of technique to reduce nutritional complications. Surg Obes Relat Dis. 2018;14(5):554–61.

    Article  PubMed  Google Scholar 

  29. Shah K, Nergård BJ, Fagerland MW, Gislason H. Limb Length in Gastric Bypass in Super-Obese Patients-Importance of Length of Total Alimentary Small Bowel Tract. Obes Surg. 2019 Jul;29(7):2012–21.

  30. Homan J, Boerboom A, Aarts E, et al. A longer biliopancreatic limb in Roux-en-Y gastric bypass improves weight loss in the first years after surgery: results of a randomized controlled trial. Obes Surg. 2018;28(12):3744–55.

    Article  PubMed  Google Scholar 

  31. Boerboom A, Homan J, Aarts E, et al. A long biliopancreatic and short alimentary limb results in more weight loss in revisional RYGB surgery. Outcomes of the randomized controlled ELEGANCE REDO trial. Obes Surg. 2019;15(1):274.

    Google Scholar 

  32. Varban OA, Cassidy RB, Bonham A, et al. Factors associated with achieving a body mass index of less than 30 after bariatric surgery. JAMA Surg. 2017;152(11):1058–64.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Pinheiro JS, Schiavon CA, Pereira PB, Correa JL, Noujaim P, Cohen R. Long-long limb Roux-en- Y gastric bypass is more efficacious in treatment of type 2 diabetes and lipid disorders in super-obese patients. 2008;4:521–5.

  34. Murad AJ, Cohen RV, de Godoy EP, et al. A prospective single-arm trial of modified long biliopancreatic and short alimentary limbs Roux-en-Y gastric bypass in type 2 diabetes patients with mild obesity. Obes Surg. 2018;28(3):599–605.

    Article  PubMed  Google Scholar 

  35. Nora M, Morais T, Almeida R, Guimarães M, Monteiro MP. Should Roux-en-Y gastric bypass biliopancreatic limb length be tailored to achieve improved diabetes outcomes? Medicine (Baltimore). 2017 Dec;96(48):e8859.

  36. Leifsson BG, Gislason HG. Laparoscopic Roux-en-Y gastric bypass with 2-metre long biliopancreatic limb for morbid obesity: technique and experience with the first 150 patients. Obes Surg. 2005;15(1):35–42.

    Article  PubMed  Google Scholar 

  37. Sugerman H, Kellum J, DeMaria E. Conversion of proximal to distal gastric bypass for failed gastric bypass for superobesity. J Gastrointest Surg. 1997;1(6):517–24.

    Article  CAS  PubMed  Google Scholar 

  38. Shin RD, Goldberg MB, Shafran AS, Shikora SA, Majumdar MC, Shikora SA. Revision of Roux-en-Y Gastric Bypass with Limb Distalization for Inadequate Weight Loss or Weight Regain. Obes Surg. 2019 Mar;29(3):811–8.

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Author notes

  1. Urs Zingg and Tarik Delko contributed equally to this work.

Authors and Affiliations

  1. Department of General Surgery, Limmattal Hospital, 8952, Zurich-Schlieren, Switzerland

    Marko Kraljević, Thomas Köstler, Julian Süsstrunk & Urs Zingg

  2. Clarunis, University Center for Gastrointestinal and Liver Diseases, 4002, Basel, Switzerland

    Ioannis I. Lazaridis & Tarik Delko

  3. Institute of Clinical Chemistry, University Hospital Zurich, 8952, Zurich-Schlieren, Switzerland

    Amy Taheri

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  1. Marko Kraljević
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Correspondence to Tarik Delko.

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Kraljević, M., Köstler, T., Süsstrunk, J. et al. Revisional Surgery for Insufficient Loss or Regain of Weight After Roux-en-Y Gastric Bypass: Biliopancreatic Limb Length Matters. OBES SURG 30, 804–811 (2020). https://doi.org/10.1007/s11695-019-04348-8

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