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Resumen: Introducción y objetivos: La cirugía bariátrica es el tratamiento más efectivo para la pérdida de peso, con control de comorbilidades. Con bajas tasas de complicaciones, las razones para una reintervención pueden ser complicaciones mayores o falla/reganancia de peso. También se presentan problemas no quirúrgicos como anemia, deshidratación, dolor crónico y desnutrición, entre otros. El objetivo fue analizar las principales causas de cirugía revisional, reoperación y readmisión en un centro bariátrico de referencia. Métodos: Estudio retrospectivo de pacientes sometidos a cirugía bariátrica entre 2012 y 2019. Se realizó un análisis basal incluyendo datos demográficos, antropométricos y perioperatorios y un subanálisis con las principales indicaciones de readmisión y complicaciones. Resultados: Se realizaron 776 cirugías primarias (649 BPGYR, 127 MG y 10 cirugías de revisión), incluyendo 99 pacientes para el estudio: 10 de cirugía revisional, 44 reoperaciones y 45 readmisiones. La incidencia de cirugía revisional fue 1,2%, reoperación y readmisión 5,6% y 5,8% respectivamente. El 50% de las cirugías revisionales fue por pérdida insuficiente o reganancia de peso. Las causas más frecuentes de reoperación fueron: colecistitis (38.6%) y hernias internas (9.1%); las causas de readmisión más comunes fueron dolor abdominal inespecífico (35.5%) y deshidratación (24.4%). Conclusión: Las causas más frecuentes de readmisión poscirugía fueron enfermedades no quirúrgicas, seguido de reoperaciones no bariátricas y, finalmente, cirugías de revisión. Las reoperaciones tempranas por complicaciones tienen una incidencia baja. Es importante conocer lo previo para identificar a los pacientes con mayor riesgo y así prevenir complicaciones mayores. Abstract: Introduction and objectives: Bariatric surgery is the most effective treatment for weight loss, with comorbidity control. With low complication rates, the reasons for reoperation are major complications or weight loss failure/weight regain. Nonsurgical problems can also present, such as anemia, dehydration, chronic pain, and malnutrition, among others. Our aim was to analyze the main causes of revisional surgery, reoperation, and hospital readmission, at a specialized bariatric center. Methods: A retrospective study was conducted on patients that underwent bariatric surgery within the time frame of 2012 and 2019. The baseline analysis included demographic, anthropometric, and perioperative data, as well as a sub-analysis of the main readmission causes and complications. Results: A total of 776 primary surgeries were performed (649 RYGBP, 127 SG, and 10 revisional surgeries), and 99 patients were identified for the study: 10 revisional surgeries, 44 reoperations, and 45 readmissions. The incidence of revisional surgery was 1.2%, reoperation was 5.6%, and readmission 5.8%. Fifty percent of the revisional surgeries were performed due to insufficient weight loss or weight regain; the most frequent causes of reoperation were cholecystitis (38.6%) and internal hernias (9.1%); and the most common causes of readmission were nonspecific abdominal pain (35.5%) and dehydration (24.4%). Conclusion: The most frequent causes of postoperative readmission were nonsurgical events, followed by non-bariatric reoperations, and finally revisional surgeries. There was a low incidence of early reoperations. Knowledge of the abovementioned data is important for identifying higher-risk patients, to prevent major complications.

Background: Symptoms of reflux after sleeve gastrectomy (SG) are common and may be refractory to medical treatment., Objectives: To assess outcomes of conversion of SG to Roux-en-Y gastric bypass (RYGB) with concomitant repair of hiatal hernias on symptoms of reflux., Setting: Tertiary community hospital., Methods: We reviewed data from all consecutive patients (2018-2021) who underwent conversion from SG to RYGB for refractory reflux symptoms. Concomitant hiatal hernias were diagnosed endoscopically or radiographically. Improvement in reflux symptoms, nausea, vomiting, dysphagia, or abdominal pain and postoperative proton pump inhibitor (PPI) use were compared with McNemar statistical test. Data are reported as mean ± standard deviation., Results: In total, 64 patients (92% female; 48 ± 10 years) underwent conversion from SG to RYGB and repair of concomitant hiatal hernias 4 ± 3 years after the index SG. A hiatal hernia was detected preoperatively in 57 of 64 patients (89%) by either upper gastrointestinal contrast studies, computed tomography scan, or esophagogastroduodenoscopy. At 29 ± 14 months postconversion to RYGB, percent total body weight loss was 14 ± 9% and percent excess weight loss was 37 ± 29%, and body mass index decreased from 37 ± 7 to 32 ± 6 kg/m 2 . Symptoms of reflux and use of PPI improved during the early follow-up period (median: 14 months; P < .001) and was sustained at late follow-up (median: 32 months; P < .01). Improvement of nausea and dysphagia reached statistical significance at late follow-up (median: 32 months; P < .01). Vomiting and abdominal pain decreased with time but did not reach statistical significance. Postoperative complications were deep surgical-site infection (n = 3), pulmonary embolism (n = 1), bleeding (n = 5), reoperation (n = 3), and 30-day readmission (n = 6)., Conclusions: Conversion of SG to RYGB and repair of concomitant hiatal hernia improves reflux symptoms, nausea, and dysphagia, reduces PPI use, and confers additional weight loss., Competing Interests: Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Roux-en-Y gastric bypass (RYGB) effectively treats severe obesity, but some patients may require revisional surgery like limb lengthening (LL) for postoperative weight gain., Objectives: This study aims to compare 30-day serious complications and mortality rates between LL and primary RYGB, given limited safety data on LL., Methods: Patients who underwent LL and RYGB were identified from the 2020 and 2021 MBSAQIP databases, the only years in which LL data were available. Baseline characteristics and 30-day rates of serious complications and mortality were analyzed., Results: A total of 86,990 patients underwent RYGB and 455 underwent LL. Patients undergoing RYGB were younger (44.4 versus 49.8 yr, P < .001), had a higher body mass index (BMI) (45.5 versus 41.8 kg/m 2 , P < .001) and higher rates of comorbidities including diabetes (30.0 versus 13.6%, P < .001). RYGB and LL had similar operative duration (125.3 versus 123.2 min, P = .5). There were no statistical differences between cohorts for length of stay (LOS) (1.6 RYGB versus 1.6 LL d, P = .6). After LL, there were higher 30-day rates of reoperation (3.3 versus 1.9%, P = .03) and deep surgical site infections (1.3 versus .5%, P = .03) compared to RYGB. There were no differences in overall serious complications (5.1 LL versus 5.0% RYGB, P = 1.0) and mortality (.2 LL versus .1% RYGB, P = .5). Multivariable logistic regression adjustment found that previous venous thromboembolism was associated with serious complications after LL., Conclusions: When compared to primary RYGB, LL has a favorable safety profile with similar 30-day rates of serious complications and mortality., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Patients are increasingly referred for conversion of laparoscopic adjustable gastric band (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (SG). The safety of a 1- versus 2-stage approach to this revision is debated., Objectives: We examined the safety and efficacy of 1-stage conversion of LAGB to SG at our institution., Setting: University hospital., Methods: An institutional database was used to retrospectively identify patients who underwent single-stage LAGB-to-SG conversion between 2010 and 2018. Patients were matched 1:1 for age, sex, and body mass index with primary SG patients during this same period. Primary endpoints were operative time, complication rate, length of hospital say, and weight loss 12 months from surgery., Results: Two-hundred and twenty-nine patients undergoing conversion of LAGB to SG were identified. Median postoperative length of hospital stay was 2 days. Two patients (.8%) developed surgical site infection. One patient (.4%) developed a postoperative myocardial infarction. There were 4 total readmissions (1.7%) and 1 reoperation within 30 days (.4%). There were no statistically significant differences in 30-day complication rates between groups. Weight loss at 12 months was significantly different: Median body mass index loss for conversion patients was 5.1 kg/m 2 compared with 8.85 kg/m 2 for patients in the primary SG group (P < .0001)., Conclusion: Single-stage conversion of LAGB to SG is safe and effective. Patients may not experience the same extent of weight loss as those with primary SG. Our findings represent the largest single-institutional experience to date and support a 1-stage approach whenever feasible., (Copyright © 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The process of reintroducing bariatric surgery to our communities in a COVID-19 environment was particular to each country. Furthermore, no clear recommendation was made for patients with a previous COVID-19 infection and a favorable outcome who were seeking bariatric surgery., Objectives: To analyze the risks of specific complications for patients with previous COVID-19 infection who were admitted for bariatric surgery., Setting: Eight high-volume private centers from 5 countries., Methods: All patients with morbid obesity and previous COVID-19 infection admitted for bariatric surgery were included in the current study. Patients were enrolled from 8 centers and 5 countries, and their electronic health data were reviewed retrospectively. The primary outcome was to identify early (<30 d) specific complications related to COVID-19 infection following bariatric surgery, and the secondary outcome was to analyze additional factors from work-ups that could prevent complications., Results: Thirty-five patients with a mean age of 40 years (range, 21-68 yr) and a mean body mass index of 44.3 kg/m 2 (±7.4 kg/m 2 ) with previous COVID-19 infection underwent different bariatric procedures: 23 cases of sleeve (65.7 %), 7 cases of bypass, and 5 other cases. The symptomatology of the previous COVID-19 infection varied: 15 patients had no symptoms, 12 had fever and respiratory signs, 5 had only fever, 2 had digestive symptoms, and 1 had isolated respiratory signs. Only 5 patients (14.2 %) were hospitalized for COVID-19 infection, for a mean period of 8.8 days (range, 6-15 d). One patient was admitted to an intensive care unit and needed invasive mechanical ventilation. The mean interval time from COVID-19 infection to bariatric surgery was 11.3 weeks (3-34 wk). The mean hospital stay was 1.7 days (±1 d), and all patients were clinically evaluated 1 month following the bariatric procedure. There were 2 readmissions and 1 case of complication: that case was of a gastric leak treated with laparoscopic drainage and a repeated pigtail drain, with a favorable outcome. No cases of other specific complications or mortality were recorded., Conclusion: Minor and moderate COVID-19 infections, especially the forms not complicated with invasive mechanical ventilation, should not preclude the indication for bariatric surgery. In our experience, a prior COVID-19 infection does not induce additional specific complications following bariatric surgery., (Copyright © 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Vertical banded gastroplasty (VBG) presents a significant rate of long-term complications, and revisions are often necessary. Conversion to Roux-en-Y gastric bypass (RYGB) seems to be preferred, but literature data remain limited., Objectives: To analyze the indications, safety, results of conversions from VBG to RYGB, and to identify predictive factors of success or failure., Setting: Two specialized centers of bariatric surgery., Methods: This bicentric retrospective study included all the patients who benefited from a conversion from VBG to RYGB between 2008 and January 2020. Demographic characteristics, indications, preoperative workups, intraoperative data, complications, and weight loss results were analyzed., Results: During the study period, 85 patients underwent a conversion to RYGB. The mean body mass index (BMI&#95; before conversion was 40.6 kg/m 2 . 82.3% of the patients were converted because of weight loss failure and 17.6% because of a complication of their VBG. The global rate of complications was 25%. After an average follow-up of 35 months and a rate of loss to follow-up of 33%, the mean BMI was 33.5 kg/m. The weight loss success rate according to Reinhold's criteria was 64.7%, and resolution of complications was obtained in 89.1%. The association of a fundectomy was a predictive factor of weight loss (odds ratio, .27; P = .04), whereas primary failure of the VBG was a predictive factor of failure., Conclusion: Conversion from VBG to RYGB remains the procedure of choice to achieve satisfying weight loss and resolution of functional complications. The addition of a fundectomy appeared to have a significant positive impact on weight loss outcomes., (Copyright © 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Revisional procedures in bariatric surgery are increasing with several debated failure risk factors, such as super obesity and old age. No study has yet evaluated the outcomes and risks of a third bariatric procedure indicated for weight loss failure or weight regain., Objectives: To assess failure risks of a third bariatric procedure according to Reinhold's criteria (percentage excess weight loss [%EWL] ≤50% and/or body mass index [BMI] ≥35 kg/m 2 )., Setting: A university-affiliated tertiary care center, France., Methods: From 2009 to 2019, clinical data and weight loss results of patients who benefited from 3 bariatric procedures for weight loss failure or weight regain were collected prospectively and analyzed using a binary logistic regression. Weight loss failure was defined according to Reinhold's criteria., Results: Among 1401 bariatric procedures performed, 336 patients benefited from 2 or more procedures, and 45 had a third surgery. Eleven patients that were reoperated on because of malnutrition or gastroesophageal reflux disease were excluded from the final analysis. Among 34 patients with 3 procedures because of weight loss failure or regain, mean BMI was 48.3 ± 8.3 kg/m 2 , and mean age was 30 ± 10.7 years. Three out of 34 patients (9%) presented a severe complication (Dindo-Clavien IIIb) and 2 (6%) had a minor one. Achieving Reinhold's weight loss criteria after the second bariatric procedure was a significant predictor of success of the third procedure (β = 2.9 ± 1.3 S.E.)., Conclusion: Not reaching Reinhold's criteria after a second bariatric procedure was identified as a significant risk factor of failure of a third procedure. A third surgery should be carefully discussed especially in case of primary failure of previous procedures., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Sleeve gastrectomy is the most common bariatric procedure worldwide. Several studies report good short- and midterm results. However, recent studies report alarming long-term outcomes, in particular about the revision rate., Objectives: The aim of this study is the assessment of the revisional rate after sleeve gastrectomy and the analysis of most common reasons for surgical conversion and early complications., Setting: This study is based on a national claims database comprehensive of all bariatric procedures performed in a 10-year period., Methods: The French Programme De Médicalisation des Systèmes d'Information database was used to identify all patients who underwent sleeve gastrectomy between 2008 and 2018. Codes for diagnoses and procedures were used to describe the reason for and the morbidity of revision surgeries. Multivariate Cox proportional hazard regression analysis was performed to compare the risk of having a revision procedure., Results: During the analyzed period, a total of 224,718 sleeve gastrectomies were performed. The rate of revision surgery after sleeve gastrectomy was 4.7%, 7.5%, and 12.2%, at 5, 7, and 10 years post procedure, respectively. A history of gastric banding was associated with a higher risk of revision (hazard ratio, 2.81; 95% CI, 2.66-2.95; P < .001). The most common revision procedure was gastric bypass (75.2%), followed by resleeve (18.7%). The main reasons for revision surgery were persistence of obesity (87.0%) and gastroesophageal reflux disease (5.2%). After revision surgery, we observed the following complications: 5.1% gastric leak, 18% bleeding, and reoperation rate of 6.4%., Conclusions: This study suggests that a large number of patients who initially underwent a sleeve gastrectomy will undergo a revisional surgery. This information should be considered in the initial choice of the bariatric procedure, and patients should be informed of the mid- and long-term risks., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: One-loop duodenal switch leads to weight loss and improvement or resolution of co-morbidities similar to standard duodenal switch, and it is technically less demanding., Objectives: To analyze the weight loss and metabolic improvement after conversion of sleeve gastrectomy to single-anastomosis duodenoileal bypass., Setting: University Hospital, Madrid, Spain., Methods: This was a retrospective cohort study. Patients submitted to sleeve gastrectomy with insufficient weight loss or programmed for a 2-step surgical approach were included. Single-anastomosis duodenoileostomy was completed if there was no stricture in the stomach and no severe symptoms of gastroesophageal reflux., Results: Fifty-one patients with a mean initial body mass index of 52 kg/m2 were included. Maximum excess weight loss after the sleeve procedure was 63%. Mean time to the second operation was 36 months. The common channel was 250 cm in 41 patients and 300 cm in 10 patients. The follow-up rate was 77% at 5 years. Excess weight loss and total weight loss were 79% and 39%, respectively, at 1 year from the second surgery and 79% and 41%, respectively, at 5 years. Furthermore, 47% of the patients with diabetes achieved complete remission after sleeve gastrectomy, and 94% achieved remission after conversion to single-anastomosis duodenoileal bypass. Final weight loss was significantly higher in those patients who achieved better weight loss after the sleeve gastrectomy than those who did not., Conclusions: Single-anastomosis duodenoileal bypass is a beneficial procedure after sleeve gastrectomy for those who fail to lose weight or those with co-morbidities or as a planned second step., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Laparoscopic sleeve gastrectomy (LSG) has become increasingly popular in bariatric surgery. However, in the long-term follow-up, weight loss failure and intractable severe acid reflux after primary LSG can necessitate further interventions., Objectives: The aim of our study was to evaluate long-term results 5 years after resleeve gastrectomy (ReSG)., Setting: Private hospital, France., Methods: The study included all patients with failure after LSG who underwent ReSG between October 2008 and January 2014. The patients underwent radiologic evaluation, and an algorithm of treatment was proposed. We analyzed the 5-year outcomes concerning weight loss and long-term complications after ReSG., Results: A total of 52 patients (46 women; mean age 40.2 yr) with a mean body mass index (BMI) of 39.4 kg/m 2 underwent ReSG. The mean interval time from the primary LSG to ReSG was of 27.8 months (11-72 mo). The indication for ReSG was inadequate weight loss (28 patients; 53.8%), weight regain (22 patients; 42.3%), and gastroesophageal reflux disease (2 patients; 3.8%). In 35 cases the contrast agent (diatrizoate meglumine/diatrizoate sodium solution [Gastrografin]) swallow results were interpreted as primary dilation and in the remaining 17 cases as secondary dilation. One patient died from gynecologic cancer. Of the remainder, 3 patients underwent single-anastomosis duodenoileal bypass, 5 patients underwent Roux-en-Y gastric bypass, and 1 patient underwent a second ReSG for reflux. A total of 39 of 42 patients with ReSG as definitive procedure had available data at 5-year follow-up. The mean percentage of excess BMI loss was 63.7%. Of the 39 patients, 28 (71.8%) had >50% excess BMI loss at 5 years. Eight of the 11 patients with weight loss failure (<50% excess BMI loss) after ReSG were diagnosed with secondary or diffuse dilation on preoperative imaging; the remaining 3 patients had been operated in our early initial experience with the resleeve procedure. All cases were completed by laparoscopy with no intraoperative incidents. In terms of complications, we recorded 1 leak, 2 stenoses, and 2 cases of bleeding with no mortality., Conclusions: At 5 years postoperative, the ReSG as a definitive bariatric procedure remained effective for 53.8%. The results appear to be more favorable especially for the non-super-obese patients and for those with primary dilation. ReSG is a well-tolerated bariatric procedure with a low long-term complication rate. Further prospective clinical trials are required to compare the outcomes of ReSG with those of Roux-en-Y gastric bypass or single-anastomosis duodenoileal bypass for weight loss failure after LSG., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Laparoscopic sleeve gastrectomy (LSG) is currently the most commonly performed bariatric procedure worldwide. However, the incidence of gastroesophageal reflux disease (GERD) after LSG is high., Objectives: The aim of this systematic review was to identify the optimal surgical strategy for treating GERD after LSG., Setting: West China Hospital, Sichuan University, Chengdu, China., Methods: A systematic literature search was performed to identify studies on surgical treatments for GERD after LSG. The effectiveness and safety profile of surgical management on GERD after LSG were analyzed., Results: A total of 40 articles enrolling 2049 patients were included in this review. Surgical strategies to prevent GERD after LSG were mainly of 2 types: concomitant LSG + antireflux procedures (hiatal hernia repair or fundoplication) and secondary procedures (conversion to Roux-en-Y gastric bypass [RYGB] or repeat sleeve gastrectomy). The short-term remission or improvement rate of GERD was 34.6%-100% after concomitant LSG + antireflux procedures. The postoperative complication rate was the same (3.0%) for both LSG + antireflux procedures and LSG alone. The remission or improvement rate of GERD was 57.1%-100% after conversion to RYGB and 100% after repeat sleeve gastrectomy., Conclusions: The effectiveness and safety profile of concomitant LSG + antireflux procedures is uncertain. However, secondary operations after LSG, such as conversion to RYGB, appear to provide good results. The data overall are heterogeneous, with imprecise methods of documenting and defining GERD complicating LSG. More cohort studies or RCT studies of high quality with long-term follow-up are needed in the future., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Single-anastomosis duodeno-ileal bypass (SADI) and the one-anastomosis gastric bypass (OAGB) are 2 revisional procedures to address the problem of weight recidivism after laparoscopic sleeve gastrectomy (LSG)., Objectives: To evaluate the efficacy and safety of SADI and OAGB as revisional bariatric surgery (RBS) in initially super-obese patients (body mass index [BMI] >50 kg/m 2 )., Setting: Academic hospital, bariatric center of excellence, Germany., Methods: Observational study of outcomes in 84 initially super-obese patients who had undergone RBS after LSG (SADI n = 42, OAGB n = 42) between July 2013 and April 2018. Follow-up examinations were performed at 1, 6, 12, 24, and 36 months after RBS. The variables analyzed included time between LSG and RBS, BMI, excess weight loss, total weight loss, operation time, and complications., Results: The time interval between LSG and RBS was 45.5 ± 22.8 and 43.5 ± 24.2 months for SADI and OAGB, respectively. At the time of RBS, the mean BMI was 42.8 ± 7.9 kg/m 2 for SADI and 43.4 ± 9.2 kg/m 2 for OAGB. The follow-up examinations rates (%) after SADI were 97.6, 92.8, 90.5, 78.6, 57.1, and 100, 97.6, 95.2, 85.7, and 59.5 after OAGB. The BMI at the follow-up examinations were 39.1 ± 7.2, 34.2 ± 6.9, 31.2 ± 5.8, 30.2 ± 5.3, 29.3 ± 5.1 for SADI, and 39.5 ± 8.1, 36.6 ± 7.4, 34.7 ± 7.9, 32.9 ± 6.3, and 31.6 ± 5.9 for OAGB. The mean operating times for SADI and OAGB were 138 ± 40 and 123 ± 39 minutes, respectively. Three patients in the SADI group and 1 patient in the OAGB group developed a major complication within the first 30 postoperative days., Conclusion: SADI and OAGB were effective second-step procedures for further weight reduction after LSG in initially super-obese patients after short to medium follow-up. There was a trend toward higher weight loss for SADI though this did not reach statistical significance. Substantial differences concerning surgery time and complications between the 2 procedures were not observed., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

The isolated stricture after the sleeve gastrectomy is one of the possible surgical complications. Previous algorithms have been proposed to address the workup and treatment of sleeve gastrectomy stricture. However, current literature lacks standardization and systematic reviews on this topic. This study aimed to review all currently available publications and to create evidence-based recommendations. We searched Medline (PubMed), EMBASE, and Central Cochrane from inception to June 10, 2019. Inclusion criteria were studies reporting treatment of sleeve gastrectomy stricture with no associated leaks. The primary outcome was the reported clinical resolution rate. The final analysis included 32 articles. The pooled reported clinical resolution rate for the primary treatment was 68% (11/16), 82% (296/361), and 75% (34/45) for noninvasive medical therapy, endoscopic, and surgical treatments, respectively (not significant). Among the endoscopic modalities, the pneumatic dilation has the highest clinical success rate. Most rescue surgeries described in the literature were successful. Conclusively, the initial treatment should entail noninvasive medical management followed by the endoscopic approach, if needed. Pneumatic balloon dilation should be the preferred approach, if technically feasible. Revisional surgery should be reserved for endoscopic failure., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Bariatric surgery is the strongest evidence-based treatment available for obesity, but the long-term morbidity and durability of these procedures is being increasingly scrutinized., Objective: To report the incidence, timing, indications, and risk factors for bariatric reoperations., Setting: A state-wide, multicenter, retrospective study., Methods: Using the Western Australian Department of Health Data Linkage Unit, all patients undergoing an index bariatric procedure where identified across a 10-year period (2007-2016)., Results: Of 24,766 patients who underwent bariatric surgery, 5001 patients (20.2%) required at least 1 bariatric reoperation. The 5-yearly rates were 19.6% (95% confidence interval [CI], 19.0%-20.2%) for a first revision, 58.2% (95%CI, 56.6%-59.8%) for a subsequent second revision, 38.3% (95%CI, 35.4%-41.2%) for a subsequent third revision, and 45.2% (95%CI, 39.9%-50.5%) for a subsequent fourth revision. Surgical complications (67.4%) were the main indication for any bariatric reoperation ahead of weight-related causes (32.6%). In a Cox regression analysis, being younger, female, without private health insurance, and having a gastric band as the initial bariatric procedure were all significant risk factors for bariatric reoperations. Compared with bariatric patients needing only an index procedure, patients requiring bariatric reoperations also had higher postoperative incidence rate ratios of endoscopic (incidence rate ratio 2.4; 95%CI, 2.3-2.5) and body contouring (incidence rate ratio 3.8; 95%CI, 3.5-4.1) procedures., Conclusions: Patients undergoing bariatric surgery had a high incidence of bariatric reoperations, predominantly for surgical complications. Of those patients who required bariatric reoperations, there were additional high rates of recurrent bariatric surgery, postoperative endoscopy, and body contouring procedures., (Copyright © 2020 American Society for Bariatric Surgery. All rights reserved.)

Background: The rates of primary laparoscopic adjustable gastric banding (LAGB) have declined in the last 5 years due to band removal secondary to complications and the subsequent weight regain that requires revisional procedures., Objectives: This study aimed to present medium-term weight loss results and the safety profile of converting LAGB to Roux-en-Y gastric bypass in patients with body mass index (BMI) <35.0 kg/m 2 who presented with LAGB intolerance or complications. Many health services do not permit such procedures on low BMI patients., Settings: Single-surgeon series, including public and private practice, Brisbane, Australia., Method: A prospectively maintained database was reviewed and retrospectively analyzed for LAGB patients with a BMI <35.0 kg/m 2 who underwent conversion to Roux-en-Y gastric bypass by a single surgeon. Indications for conversion, weight loss data, and early (30 d postoperative) and late complications were recorded with follow-up out to 5 years., Results: One hundred thirty-two adult patients with a BMI <35.0 kg/m 2 underwent conversion from 2009 to 2016. The main indications for conversion were reflux and band complications. Median BMI at bypass was 32.8 kg/m 2 (23.1-35.0). Median percentage excess weight loss was 77%, 90%, 73%, 47%, 49%, and 44% at 1, 2, 3, 4, and 5 years, respectively among patients who were eligible and present at follow-up. Median BMI was <30.0 kg/m 2 (29.1-40.9) at 5 years with only 1 subject exceeding >35.0 kg/m 2 . Mortality was 0%. Early morbidity occurred in 31.8% of patients. The most common late complication was gastrojejunostomy stricture requiring endoscopic dilation., Conclusions: In combination with our 2014 study showing morbidity data in the short-term period being comparable to patients with BMI >35.0 kg/m 2 , our study demonstrates that converting LABG to Roux-en-Y gastric bypass in low BMI patients is a feasible and safe option that avoids weight regain and maintains adequate weight loss at 5 years, with acceptable morbidity and no mortality., (Copyright © 2020 American Society for Bariatric Surgery. All rights reserved.)

Background: Laparoscopic adjustable gastric banding has been a popular bariatric surgery in the United States since the early 2000s. Over the years, various long-term complications have prompted removal of these devices. To avoid subsequent weight gain, explanation of the gastric band is often followed by concomitant or staged conversion to another bariatric procedure., Objective: It is our goal to evaluate the relative leak rate in 1- versus 2-stage adjustable gastric band conversion surgery., Setting: Private teaching hospital, United States., Methods: A search was performed in the PubMed/MEDLINE and Cochrane Library databases to evaluate literature regarding adjustable gastric band conversion procedures. After identification of publications that directly compared 1- and 2-stage laparoscopic adjustable gastric banding conversions, the Newcastle-Ottawa Quality Assessment Scale was used to determine if they would be used in our meta-analysis. The risk ratio for leak in 1- versus 2-stage conversions was then calculated., Results: Our search yielded 483 publications. Twenty-five publications qualified for inclusion. The overall calculated risk ratio for leak in 1- versus 2-stage conversions was .90 (confidence interval [CI] .51-1.61, P = .73). Eight publications were found that discussed conversion from laparoscopic adjustable gastric banding to Roux-en-Y gastric bypass. The risk ratio for 1- versus 2-stage conversions for this subgroup was .82 (CI .35-1.93, P = .65). Eight publications were found that evaluated conversion to sleeve gastrectomy. The risk ratio of leak for 1- versus 2-stage conversions for these patients was 1.61 (CI .55-4.72, P = .39)., Conclusions: Based on the results of this meta-analysis, there does not appear to be a significant difference in the overall leak rate between 1- and 2-stage adjustable gastric band conversions. The findings of our subgroup analysis suggest that there may be a safety advantage for 1-stage procedures when converting to Roux-en-Y gastric bypass and 2-stage procedures when converting to sleeve gastrectomy., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure, while laparoscopic adjustable gastric banding (LAGB) has been for a decade one of the most popular interventions for weight loss. After LSG and LAGB, some patients may require a second surgery due to weight regain or late complications. One anastomosis gastric bypass (OAGB) is a promising bariatric procedure, which provides effective long-term weight loss and has a favorable effect on type 2 diabetes., Objectives: To retrospectively analyze data from 10 Italian centers on conversion from LAGB and LSG to OAGB., Setting: High-volume centers for bariatric surgery., Methods: Prospectively collected data from 10 high-volume centers were retrospectively reviewed. Body mass index (BMI), percentage of excess BMI loss, reasons for redo, remission from co-morbidities (hypertension, diabetes, gastroesophageal reflux, and dyslipidemia), and major complications were recorded., Results: Three hundred patients were included in the study; 196 patients underwent conversion from LAGB to OAGB and 104 were converted from LSG. BMI was 45.1 ± 7 kg/m 2 at the time of first intervention, 41.8 ± 6.3 kg/m 2 at redo time, and 30.5 ± 5.5 kg/m 2 at last follow-up appointment. Mean percentage of excess BMI loss was 13.2 ± 28.2 at conversion and 73.4 ± 27.5 after OAGB. Remission rates from hypertension, diabetes, gastroesophageal reflux, and dyslipidemia were 40%, 62.5%, 58.7% and 52%, respectively. Mean follow-up was 20.8 (range, 6-156) months and overall complications rate was 8.6%., Conclusion: Our data show that OAGB is a safe and effective revisional procedure after failed restrictive bariatric surgery., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The aim of the study is to present surgical techniques and treatment outcomes for re-banding and sleeve gastrectomy as a revisional surgery after removing eroded adjustable gastric bands., Methods: A retrospective analysis was performed to study laparoscopic re-banding or sleeve gastrectomy as revisional surgery for band erosion. Main outcome measures were success of therapeutic strategies, morbidity, body mass index, and percentage total excess weight loss before and after revision., Results: From March 2013 to June 2017, a total of 11 patients underwent the revisional surgery. Six patients underwent sleeve gastrectomy at median 15.7 months (13.2-73.3 months) after band removal, and 5 patients gastric re-banding at median 5.4 months (3.1-43.8 months). One of the six patients that underwent sleeve gastrectomy was diagnosed to have a minor leak. No other critical postoperative complication was observed in each group. Median BMI at revision in the sleeve gastrectomy group was 32.7 kg/m 2 (31.2-40.8 kg/m 2 ). Median follow-up after revision was 33.8 months (15.5-63.7 months), and at last follow-up, median BMI was 26.4 kg/m 2 (23.6-34.6 kg/m 2 ), and median %TWL was 17.6% (9.5-31.5%). In the rebanding group, median BMI at revision was 30.7 kg/m 2 (27.0-41.4 kg/m 2 ). Median follow-up after revision was 25.5 months (13.5-45.4 months), and at last follow-up, median BMI was 23.5 kg/m 2 (22.0-30.1 kg/m 2 ) and median %TWL was 23.9% (9.1-29.0%)., Conclusion: Given the surgical techniques adopted, both re-banding and sleeve gastrectomy were found to be safe and effective revisional surgery after removal of eroded gastric band., (Copyright © 2018. Published by Elsevier Taiwan LLC.)

Background: To date, laparoscopic adjustable gastric banding remains the third most commonly performed surgical procedure for weight loss. Some patients fail to get acceptable outcomes and undergo revisional surgery at rates ranging from 7% to 60%. Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB), and sleeve gastrectomy (SG) are among the most common salvage options for failed laparoscopic adjustable gastric banding., Objective: To compare the outcomes of converting failed laparoscopic adjustable gastric banding to RYGB, OAGB, or SG., Methods: Data collected from 7 experienced bariatric centers around the world were retrospectively collected, reviewed, and analyzed. Final body mass index (BMI), change in BMI, percentage excess BMI loss, and major complications with particular attention to leaks, hemorrhage, and mortality were reported., Results: Of 1219 patients analyzed, 74% underwent RYGB, 16% underwent OAGB, and 10% underwent SG after banding failure. The mean age was 38 years (±10 yr), and 82% of patients were women. The mean follow-up was 33 months. The follow-up rate was 100%, 87%, and 52% at 1, 3, and 5 years, respectively. At the latest follow-up, percentage excess BMI loss >50% was achieved by 75% of RYGB, 85% of OAGB, and 67% of SG patients. Postoperative complications occurred in 13% of patients after RYGB, 5% after OAGB, and 15% after SG., Conclusion: Our data show that it is possible to achieve or maintain significant weight loss with an acceptable complication rate with all 3 surgical options., (Copyright © 2018. Published by Elsevier Inc.)

Background: Sleeve gastrectomy (SG) has become the predominant bariatric surgery worldwide. However, the surgical management in case of failure is still debated., Objectives: To evaluate the risks and benefits of converting SG to biliopancreatic diversion with duodenal switch (BPD-DS) for suboptimal outcome after SG., Setting: University-affiliated tertiary care center., Methods: We included all patients who underwent a laparoscopic second-stage duodenal switch (DS) for weight loss failure after SG and had a minimal follow-up of 2 years. Patients were matched 1:1 for age, sex, body mass index, and year of surgery with a group of patients who underwent a single-stage laparoscopic BPD-DS. Data were obtained from our prospective electronic database and are reported as the mean ± standard deviation, comparing 2- versus 1-stage BPD-DS., Results: A total of 118 patients were included (59 in each group). There was no significant difference in initial body mass index (53.8 ± 9.7 versus 52.7 ± 7.8 kg/m 2 , P = .4), age (44.0 ± 10.2 versus 43.4 ± 9.6 yr, P = .5), and sex ratio (37 female/22 male, P > .9) between the 2 groups. Mean follow-up was 59.9 ± 27 months, with an 85% (n = 100) follow-up rate. Patients were converted to BPD-DS after a mean 24.4 ± 10.2 months. There was no short- or long-term mortality. Major 90-days complications occurred in 2%, 5%, and 5% after SG, second-stage DS and single-stage BPD-DS, respectively (P > .05). At the time of conversion, the excess weight loss for SG was 39 ± 17% and total weight loss was 20 ± 9%. After DS or single-stage BPD-DS, the excess weight loss was 74.8 ± 18% versus 87.9 ± 18% at 1 year (n = 107, P = .00021), 80.2 ± 17% versus 92.3 ± 14% at 2 years (n = 100, P = .002), and 80.2 ± 18% versus 87.2 ± 16% at 3 years (n = 70, P = .6). Total weight loss was 38.7 ± 9% versus 44.5 ± 8% at 1 year (P = .0004), 41.2 ± 9% versus 46.8 ± 7% at 2 years (P = .001), and 42.3 ± 9% versus 45.1 ± 9% at 3 years (P = .2). The incidence of type 2 diabetes and hypertension before surgery were 61% versus 54% and 58% versus 47%. Remission rate for type 2 diabetes increased from 59% to 94% after second-stage DS (P = .001), which is identical to first-stage BPD-DS (94%). Remission of hypertension increased from 42% to 77% after second-stage DS (P = .03) and was 71% after first-stage BPD-DS (P = .8)., Conclusion: Second-stage DS is an effective option for the management of suboptimal outcomes of SG, with an additional 41% excess weight loss and 35% remission rate for type 2 diabetes. At 3 years, the global outcomes of staged approach did not significantly differ from single-stage BPD-DS; however, longer-term outcomes are still needed., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Data regarding management of former bariatric operations after onset of a malignancy are still lacking and there is no consensus whether bariatric surgery negatively influences the oncologic management of patients., Objectives: To investigate the strategy by which patients previously submitted to bariatric surgery were managed after diagnosis of malignancy of the digestive apparatus, whether a revision was performed or not, to assess the incidence of nutritional complications, and the effect of revision versus no revision of bariatric surgery on the outcome of cancer treatment., Setting: University Hospital, Italy., Methods: Occurrence of a malignancy of the digestive apparatus in patients submitted to biliopancreatic diversion was investigated retrospectively. Patients' data were collected preoperatively, at 2 and 3 years after the operation, at oncologic diagnosis, and at the longest available postoncologic follow-up., Results: From May 1976 to January 2017, 3341 morbidly obese patients were submitted to biliopancreatic diversion. Sixteen patients were diagnosed with a malignancy involving the digestive apparatus 5 to 28 years after bariatric surgery. Of 10 patients diagnosed with colorectal cancer, 6 were revised. At 2 years after biliopancreatic diversion, body mass index, hemoglobin, and iron levels were significantly lower than preoperatively. Serum transferrin and total protein were unchanged. There was no difference between body mass index, hemoglobin, transferrin, and total protein levels at 2 years and at oncologic diagnosis, or between revised and unrevised patients., Conclusion: Revision of a preexisting bariatric operation after digestive cancer surgery is common, although selected, unrevised cases do not seem to be associated with worse outcome., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Laparoscopic sleeve gastrectomy (LSG) became the most frequent bariatric procedure performed in France (2011) and in the United States (2013), but studies reporting long-term results are still rare., Setting: Private hospital, France., Methods: This is a retrospective analysis of a prospective cohort of 168 patients who underwent LSG between 2005 and 2008. The objective of this study was to present the 8-year outcome concerning weight loss, modification of co-morbidities, and to report the revisional surgery after sleeve., Results: The preoperative mean body mass index was 42.8 kg/m2 (31.1-77.9), 35 patients were super obese, and 64 patients had a previous gastric band. For LSG as a definitive bariatric procedure, 8 years of follow-up data were available for 116 patients (follow-up: 69%). Of the remainder, 23 patients underwent revisional surgery and 29 were lost to follow-up. For the entire cohort, the mean excess weight loss (EWL) was 76% (0-149) at 5 years and 67% (4-135) at 8 years, respectively. Of the 116 patients with 8 years of follow-up, 82 patients had>50% EWL at 8 years (70.7%). Percentages of co-morbidities resolved were hypertension, 59.4%; type 2 diabetes, 43.4%; and obstructive sleep apnea, 72.4%. Twenty-three patients had revisional surgery for weight regain (n = 14) or for severe reflux (n = 9) at a mean period of 50 months (9-96). Twelve patients underwent resleeve gastrectomy, 6 patients underwent conversion to a bypass, and 5 patients to duodenal switch (1 single anastomosis duodeno-ileostomy). A total of 31% of patients reported gastroesophageal reflux symptoms at 8 years., Conclusions: At 8 years postoperatively, the LSG as a definitive bariatric procedure remained effective for 59% of cases. The results appear to be more favorable especially for the non-super-obese patients and primary procedures. LSG is a well-tolerated bariatric procedure with low long-term complication rates., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Omega-loop gastric bypass (OLGB) may be associated with severe complications, including anastomotic leak, refractory ulcer or stenosis, undernutrition, and disabling digestive disorders (chronic diarrhea, steatorrhea, bile reflux, and vomiting). OLGB conversion to Roux-en-Y gastric bypass (RYGB) was suggested to treat these complications., Objectives: To evaluate the efficacy and risk of severe complications after OLGB conversion to RYGB., Setting: University hospital., Methods: Retrospective analysis between October 2011 and June 2016., Results: Seventeen patients underwent OLGB conversion to RYGB. Fourteen patients (82%) presented at least 1 disabling digestive disorder. Before conversion, 10 patients (58.8%) received nutritional support for undernutrition. There was no postoperative mortality. Seven patients (41.1%) developed major adverse events (<90 d). At conversion, the average weight, body mass index, and percent of excess weight loss for the population without undernutrition (n = 7) were 103.7±24 kg, 38.7±6.8 kg/m², and 37%±33%, respectively. These values were 85±18.3 kg, 30.6±4.7 kg/m², and 73.3%±21.5%, respectively, at 2 years. In patients with undernutrition (n = 10), the average weight, body mass index, and percent of excess weight loss were 52.2±16.5 kg, 18.7±5.9 kg/m², and 149.3%±46.5%, respectively, before nutritional support and 58.9±14.7 kg, 21.1±5.2 kg/m², and 132.7%±39.1%, respectively, at revisional surgery. At 2 years the values were 71±5.6 kg, 24.3±2.2 kg/m², and 104.6%±15.2%, respectively. The patients experienced significant improvements in hypoalbuminemia, anemia, and vitamin/trace element deficiencies. The disabling digestive disorders resolved in 85% of patients., Conclusion: The conversion of OLGB to RYGB for severe complications allows for weight correction in patients with undernutrition, reduces disabling digestive disorders, and improves the nutritional status of patients. However, the conversion is associated with high morbidity., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Marginal ulcer (MU) is not infrequent after laparoscopic Roux-en-Y gastric bypass (LRYGB). Medication plus lifestyle modification remains the mainstay solution. Patients with refractory MU may be candidates for revisional surgery., Objective: To summarize our experience of revisional surgery for treating refractory MU after LRYGB., Setting: University hospital, Taiwan., Methods: A retrospective analysis was performed for 11 patients with refractory MU undergoing totally hand-sewn gastrojejunostomy and truncal vagotomy at our institution between August 2005 and May 2015. The mean follow-up after surgery was 28.0±16.2 months (range, 10-48 mo); 9 patients (81.8%) were followed up more than 1 year after., Results: The mean age of the cohort (7 males; 4 females) was 39.5±16.0 years (range, 19-66 yr), with a mean initial body mass index of 37.5±9.3 kg/m 2 (range, 32.1-57 kg/m 2 ). Intractability was the dominant manifestation (100%); 8 patients (72%) had stricture at the gastrojejunostomy. The mean interval from initial LRYGB to refractory MU and revisional surgery was 10.2±7.7 months (range, 4-28 mo) and 38.7±21.6 months (range, 10-67 mo), respectively. The average operation time was 150.4±59.8 minutes (range, 80-300 min), and the average length of hospital stay was 4.2±1.4 days (range, 2-7 d). The 9 patients with more than 1 year follow-up all achieved endoscopic resolution of the refractory MU., Conclusions: Although longer follow-up is warranted, revisional surgery with totally hand-sewn gastrojejunostomy and truncal vagotomy can be an effective solution for refractory MU., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Gastrogastric fistula (GGF) is a known complication after Roux-en-Y gastric bypass that can lead to marginal ulceration (MU) and failure of weight loss., Objectives: To describe our experience with GGF management and propose a classification of GGF based on its anatomic location., Setting: University hospital, France., Methods: After internal review board approval, data from all patients with a GGF were reviewed. GGF was classified as type 1 when located in the proximal part of the gastric pouch and type 2 when located near the gastrojejunostomy., Results: Nine patients developed a GGF (.5%). GGF symptoms included epigastric pain (78%), vomiting (11%), gastrointestinal bleeding (11%), and weight regain (44%). Upper contrast study identified GGF in all patients. Upper endoscopy confirmed GGF in 6 patients, all with type 2. Eight patients required revisional surgery. Patients with type 1 GGF (n = 3) had excision of the fistulous tract. Patients with type 2 GGF (n = 5) had associated revision of the gastrojejunostomy. Mean operative time was significantly longer for type 2 GGF. The mean follow-up was 43 months, with no patient lost. One patient developed a recurrent MU requiring iterative revision. After that, all revisional patients were symptom free and the mean body mass index was 35.3±9.5 kg/m²., Conclusion: Weight regain and epigastric pain with or without associated MU are the most common signs of GGF. Combining upper gastrointestinal endoscopy and contrast study is the best method to confirm the diagnosis. Surgical treatment should be tailored to both GGF location and status of the gastrojejunostomy. Based on its anatomic location, GGF classification could serve as a working basis to compare different surgical approaches., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Weight loss failure and proton pomp inhibitor (PPI)-resistant gastroesophageal reflux diseases (GERD) after sleeve gastrectomy (SG) are frequently encountered., Objectives: The aim of this study was to evaluate the efficacy and risks of SG conversion to Roux-en-Y gastric bypass (RYGB) in the case of weight loss failure or severe GERD., Setting: University hospitals., Methods: Between March 2007 and December 2014, 34 patients with history of SG underwent RYGP. A retrospective analysis of a prospectively collected database was undertaken., Results: Among 34 patients, 31 underwent revisional surgery for weight loss failure and 3 for PPI-resistant GERD. Six patients in the weight loss failure group had symptomatic GERD that was effectively treated with PPIs. The average body mass index (BMI) was 53±11 kg/m2 before SG. A laparoscopic approach was performed in 94% of patients. There was no postoperative mortality. Major adverse events (<90 days) occurred in 4 patients (11.7%). The mean length of stay was 6.7±2.8 days. At the time of revisional surgery, the mean BMI, percentage excess weight loss, and percentage weight loss were 44.7±9.8 kg/m2, 33.6±27.1%, and 16±9.7%, respectively, compared with 40.9±8.5 kg/m2, 63.1±36.2%, and 23.8±14% at 3 years. The GERD was resolved in all patients, allowing the cessation of PPI medication., Conclusion: Laparoscopic conversion of SG to RYGB is feasible and it allows improvement in secondary weight loss and GERD, but at the cost of high morbidity., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Laparoscopic sleeve gastrectomy (SG) has gained popularity as a standalone procedure. However, long-term complications are reported, mainly weight loss failure and gastroesophageal reflux disease (GERD). Therefore, demand for revisional surgery is rising., Objectives: The aim of this study was to report preliminary results within the 2 main indications for laparoscopic conversion of SG to Roux-en-Y gastric bypass (RYGB)., Setting: University Hospital, France., Methods: Data from all patients who underwent laparoscopic conversion from SG to RYGB were retrospectively analyzed as to indications for revisional surgery, weight loss, and complications., Results: Forty patients underwent conversion, 29 cases (72.5%) for weight loss failure and 11 cases for refractory GERD (27.5%). The mean interval from SG to RYGB was 32.6 months (range 8-113). Revisional surgery was attempted by laparoscopy in all cases, and conversion to laparotomy was necessary in 3 patients (7.5%). Mean length of follow-up was 18.6 months (range 9-60) after conversion. Follow-up rate was 100%. Mean percent total weight loss and percent excess weight loss were 34.7% and 64%, respectively, when calculated from weight before SG. Remission rate for GERD was 100%. Improvement was observed for all co-morbidities after conversion. There was no immediate postoperative mortality. The postoperative complication rate was 16.7%. According to the Clavien-Dindo classification, there were 5 grade II and 2 grade IIIa complications., Conclusion: Laparoscopic conversion of SG to RYGB is safe and feasible. In the short term, it appears to be effective in treating GERD and inducing significant additional weight loss and improvement of co-morbidities., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Sleeve gastrectomy (SG) is currently one of the most frequently performed bariatric interventions worldwide due to its simplicity and good weight loss results. Nevertheless, SG failure and complications are increasingly being observed as the number of procedures increases., Objectives: To report our results in converting SG to revisional laparoscopic Roux-en-Y gastric bypass (R-LRYGB)., Setting: University Hospital, Chile., Methods: Retrospective analysis of our bariatric surgery database. Patients who underwent R-LRYGB after SG between June 2005 and April 2015 were identified. Demographic characteristics, anthropometrics, preoperative workup, and perioperative data were retrieved. Total weight loss (TWL), excess weight loss (EWL), and clinical progression over 3 years were registered., Results: Fifty patients were identified, mean age 39±8.4 years, 42 (84%) women; median body mass index previous to R-LRYGB was 33.8 (31-36) kg/m 2 . Indications for revision were weight regain (n = 28, 56%), gastroesophageal reflux disease (n = 16, 32%), and gastric stenosis (n = 6, 12%). In weight-regain patients, mean follow-up at 3 years was 72.2% and median percentage of total weight loss at 12 and 36 months was 18.5 (12-24) and 19.3 (8-23), respectively; percentage of excess weight loss at 12 and 36 months was 60.7 (37-82) and 66.9 (26-90), respectively. Over 90% of gastroesophageal reflux disease patients resolved or improved symptoms. All patients with gastric stenosis resolved symptoms after conversion. There were no major complications., Conclusion: R-LRYGB is a feasible, effective, and well-tolerated alternative in selected patients with failed SG in which other therapies have been insufficient to either maintain weight loss or resolve complications. However, long-term follow-up is still needed., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Conversion of adjustable gastric band to laparoscopic sleeve gastrectomy (LSG) is feasible, but multiple reports have indicated higher morbidity and staple line leak rates when this is performed as a single-stage procedure. The objective of this study is to compare the safety profile and outcomes of LSG with concomitant gastric band removal (LSG/GBR) versus LSG using the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP)., Methods: Using the ACS-NSQIP database (2010-2012), LSG cases were identified using Current Procedural Terminology (CPT) code 43775 and concomitant LSG/LGBR using CPT code 43775+(43772 or 43774). Baseline patient characteristics and perioperative variables including postoperative mortality and morbidity rates were retrieved. The primary endpoint was sepsis within 30 days. Bivariate and multivariate analyses were carried out., Results: During the study period, 11,189 (96.9%) patients had LSG and 357 (3.1%) had LSG/GBR for a total of 11,546 patients. On bivariate analyses, the rate of sepsis was higher after LSG/GBR (1.68% versus .58%; P = .022), and the mean operative time was longer (124.6±52.3 versus 98.6±49.0 min; P<.001). There was no statistically significant difference in the rate of postoperative mortality (.28% versus .08 %; P = .27) or that of other outcomes such as return to the operating room, wound infection, or venous thromboembolism. After multivariate analysis, the odds of developing postoperative sepsis remained significantly higher for patients undergoing LSG/GBR compared with LSG alone (odds ratio [OR] 3.32; confidence interval [CI] 1.41-7.84; P = .006)., Conclusion: LSG/GBR can be performed with low morbidity and mortality. However, this procedure carries a higher rate of postoperative sepsis., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Laparoscopic adjustable gastric banding (LAGB) is a well-tolerated procedure but has high long-term complication and failure rates. Laparoscopic conversion to Roux-en-Y gastric bypass (LRYGB) is one of the rescue strategies., Objectives: To analyze short- and long-term results of reoperative LRYGB after failed LAGB., Setting: Three European expert bariatric center (2 university hospitals and 1 regional hospital)., Methods: A retrospective review of prospectively collected data, including all consecutive patients submitted to revisional LRYGB for failed LAGB between 1999 and 2013, was performed. Complications were classified according to the Dindo-Clavien system. Long-term results in terms of weight loss were analyzed in a subgroup of patients., Results: A total of 642 patients (569 women and 73 men) were included. Mean±standard deviation operating time was 188±43 minutes. There was no mortality and an overall complication rate of 9.7%, including 3.6% major complications, with no difference between the 1- or 2-step approaches. Follow-up rate was 88% at 10 years for the Swiss patient cohort. The mean excess body mass index loss was between 65% and 70% throughout the study period, and the mean total weight loss was between 28% and 30% based on the maximum weight. The mean body mass index decreased from 44.7 kg/m(2) before LAGB to 31.6, 32.2, and 32.5 kg/m(2) at 1, 5, and 10 years after revision., Conclusions: Revisional LRYGB is well tolerated and feasible after failed LAGB. A 1-step approach, in cases without erosion, does not increase operative morbidity. Results up to 10 years after revision are comparable to those reported after primary LRYGB., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Roux-en-Y gastric bypass (RYGB) may result in nutritional deficiencies, mainly involving micronutrients, and occasionally protein-calorie malnutrition (PCM) because of the resulting anatomic and functional changes. Failure of conservative PCM treatment may be an indication for corrective surgery, where the technique may vary according to the surgical cause of the malnutrition. In this study, we present the results of the reconnection of the duodenum and the proximal jejunum to the alimentary tract for the treatment of severe PCM caused by malabsorption after RYGB., (Copyright © 2016 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Revisional bariatric surgery (RBS) is increasing. The various primary operations with their distinctive complications make this group of patients quite heterogeneous, and treatment has to be individualized. There are concerns regarding the safety profile and efficacy of these procedures. The objective of the present study was to analyze the indications, safety, and efficacy of RBS at a high-volume Asian center and provide insight into the different treatment options., Methods: Of a total of 1578 bariatric surgeries from July 2006 to June 2012, 52 patients underwent revisional bariatric procedures. The primary operations included 6 different procedures. The indications for surgery were grouped into weight loss failure (n = 21) or complications related to the primary operation (n = 31). The revisional operations performed were conversion to another procedure (n = 22), revision of existing anatomy (n = 29), or reversal to normal anatomy (n = 1)., Results: 96% of revisional surgeries were performed laparoscopically. The median operating time was 72 minutes (25-240 min), and the median duration of hospital stay was 4 days (3-25 d). The mean body mass index for weight loss failure decreased significantly from 36.3 to 29.6 kg/m(2) after 1 year of revisional surgery (P<.01). However, revision of RYGB was only associated with a body mass index loss of 3.2 kg/m(2) and percentage of excess weight loss of 31.8%. More than 90% of the patients with complications had complete resolution of their preoperative symptoms. There were 3 major complications with an overall morbidity rate of 5.8%. There was no mortality., Conclusions: RBS is well-tolerated, with satisfactory early outcomes, in high-volume centers. However, larger studies with longer follow-up periods are needed to determine the long-term efficacy of these procedures., (Copyright © 2015. Published by Elsevier Inc.)

Background: The most performed restrictive bariatric procedure is the laparoscopic adjustable gastric band (LAGB). With many patients still receiving a LAGB in Europe and the United States, inevitably, the number of complications also increases. For many complications revisional bariatric surgery is necessary. In this study, the outcomes of one-stage LAGB conversion to a Roux-en-Y gastric bypass (RYGB) at our institution are presented. The objective of this study was to investigate the safety and efficiency of RYGB performed as a one-stage procedure after failed LAGB., Methods: Patients were retrospectively selected using a prospectively collected database. The gastric band had to be in situ for at least 1 year and minimum postoperative follow-up was 12 months. The revisional RYGB had to be performed as a 1-step procedure., Results: A total of 195 patients were included while 3 were lost to follow up. Overall, 178 (91%) procedures were performed without perioperative complications, and only 8 (4%) patients required reoperation within 30 days. The mean follow-up was 40 months (±24) after RYGB. Mean excess weight loss (EWL) increased from 25% (±26/-50- 120%) to 60% (±21.2/0- 130), 65% (±23.5/0- 131), 63% (±24.2/2- 132), 60% (±24.1/0- 111) and 53% (±28.7/-39- 109) in the first 5 postoperative years., Conclusion: Converting a gastric band to a RYGB in a one-stage procedure is safe and feasible, with acceptable complication rates when performed in a specialized institution. The RYGB conversion results in a good EWL of 65% after 2 years. However, proper patient selection is of the utmost importance., (Copyright © 2014 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The laparoscopic adjustable gastric band (LAGB) is widely used for the treatment of morbid obesity. Many patients benefit from this procedure initially, but experience complications after a few years. The treatment for many complications is revisional bariatric surgery. A number of patients, however, request only band removal without secondary bariatric surgery. The aim of this study was to assess the perioperative and medium term outcomes of patients who had their LAGB removed without secondary bariatric surgery., Methods: Patients were retrospectively selected using a prospectively collected database. The LAGB had to be in situ for at least 1 year, and minimum postoperative follow-up had to be 12 months., Results: Thirty-eight patients who had their LAGB laparoscopically removed between 2000 and 2010 were included. Median follow-up after LAGB removal was 3.0 (1.4 to 8.9) years. Only 2 complications (5%) and no mortality occurred perioperatively. In the 21 patients who did not undergo additional bariatric surgery, the median excess weight loss (EWL) decreased from 41% (-12% to -100%) at band removal to 9% (-10% to 90%), 0% (-20% to 78%), and -11% (-12% to 56%) after 1, 2, and 5 years, respectively. Percentage weight loss (%WL) was 17% (-54% to -5%), 4% (-47% to -9%), 0% (-41% to 11%), and -5% (-29% to 9%) after these same time intervals, respectively. After a median 2.1 (.5 to 9.9) years, 17 patients underwent either a Roux-en-Y gastric bypass (14 patients) or a Scopinaro (3 patients) all because of weight regain. The current EWL and %WL in these patients is 67% (24% to 113%) and 30% (12% to 53%), respectively compared with -11% (-33% to 57%) and -4% (-14% to 34%) in patients without a secondary bariatric procedure (P< .001)., Conclusion: Patients who have their LAGB removed are guaranteed to suffer from weight regain. It is inadvisable to only remove the LAGB without performing an additional bariatric procedure when deemed technically feasible and safe. In this study, no patient was able to maintain the weight loss achieved with the LAGB after its removal., (© 2013 American Society for Bariatric Surgery Published by American Society for Metabolic and Bariatric Surgery All rights reserved.)

Background: Laparoscopic sleeve gastrectomy (LSG) has been proposed as an alternative revisional procedure for failed/complicated gastric banding. This is a retrospective cohort study of a prospectively maintained database of revisional LSG after band removal for insufficient weight loss and/or band-related complications, using a 2-step approach. The outcomes were compared with a control group of primary LSG. The study was conducted at a university hospital (Sapienza University of Rome-Polo Pontino, Icot, Latina, Italy) and 2 community general hospitals (Hospital Andosilla Civita Castellana, Viterbo, Italy and Hospital Villa D'Agri, Potenza, Italy)., Methods: A total of 76 revisional LSG procedures was recorded; a control group of 279 LSG patients was selected. The primary endpoint was to compare the perioperative complication rate between the revisional versus the control group. Secondary endpoints were operative time, conversion rate, postoperative length of stay and percentage excess weight loss (%EWL) at 6, 12, and 24 months., Results: The indications for band removal were inadequate weight loss (47 patients), slippage (10 patients), erosion (7 patients), and pouch dilation (12 patients). All procedures were completed laparoscopically. The median operative time was 78 minutes for the revision LSG and 65 minutes for the control LSG (P<.05). In the revision group, the overall complication rate was 17.1%, and the median postoperative length of stay was 4 days; in the control group, the overall complication rate was 10.7%, and the median postoperative length of stay was 3. No complications requiring reoperation or readmission occurred in the revision group. In the control group, there were 5 cases of major complications. All the patients completed the follow-up. A total of 56 patients in the revision group and 184 patients in the control group were followed-up for at least 24 months. The %EWL at 6, 12, and 24 months was 46.5%, 66.4%, and 78.5%, respectively, in the revision group, and 49.8%, 78.2%, and 78%, respectively, in the control group., Conclusion: Results confirmed that LSG, performed in 2 steps, is an effective revision procedure for failed or complicated laparoscopic adjustable gastric banding with good perioperative outcomes and 2-year weight loss., (© 2013 American Society for Bariatric Surgery Published by American Society for Metabolic and Bariatric Surgery All rights reserved.)

Background: There remains controversy as to whether immediate autologous breast reconstruction with postoperative radiotherapy is associated with acceptable complications and aesthetic outcomes. This systematic review analyses the literature regarding outcomes of immediate autologous breast reconstruction with postoperative radiotherapy compared with no radiotherapy, as well as with delayed autologous breast reconstruction following post-mastectomy irradiation., Methods: Pubmed (1966 to October 2012), Ovid MEDLINE (1966 to October 2012), EMBASE (1980 to October 2012), and the Cochrane Database of Systematic Reviews (Issue 10, 2012) were searched. Overall complications (including fat necrosis), fat necrosis, revisional surgery, loss of volume, and aesthetic outcome, were analysed individually. Comparable data from observational studies were combined for meta-analysis where possible and quality assessment of the studies was performed., Results: The majority of studies of immediate autologous breast reconstruction and postoperative radiotherapy reported satisfactory outcomes (19 of 25 studies; n=1,247 patients). Meta-analysis of observational studies demonstrated no significant differences in total prevalence of complications (p=0.59) or revisional surgery (p=0.38) and a summary measure for fat necrosis favouring the group without radiotherapy (OR 2.82, 95% CI 1.35-5.92, p=0.006). The majority of studies comparing immediate reconstruction and postoperative radiotherapy with delayed reconstruction following post-mastectomy radiotherapy (10 of 12 observational studies; n=1,633 patients) reported satisfactory outcomes following immediate reconstruction. Meta-analysis of observational studies demonstrated no significant difference in overall incidence of complications (p=0.53) and fat necrosis (OR 0.63, 95% CI 0.29-1.38, p=0.25), and a summary measure for revisional surgery (OR 0.15, 95% CI 0.05-0.48, p=0.001) favouring the delayed surgery group. No randomised-controlled trials met the inclusion criteria, and all of the observational studies included were missing more than one important component for reporting of observational studies., Discussion: The majority of studies reported satisfactory outcomes and a similar incidence of complications for immediate autologous breast reconstruction and adjuvant radiotherapy when compared with no radiotherapy or delayed reconstruction following radiotherapy; the proportion that required revisional surgery was higher though for immediate than delayed breast reconstruction. The findings are limited by the paucity of high quality data in the published literature, and until better data is available the findings of this review suggest that immediate autologous breast reconstruction should at least be considered when adjuvant chest wall radiotherapy is anticipated., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)