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Background: Single anastomosis sleeve ileal (SASI) bypass is a modification of sleeve gastrectomy with transit bipartition (SG + TB). This study aims to assess the safety and efficacy of SASI as a primary metabolic and bariatric surgery (MBS)., Methods: This is a retrospective case series of 30 patients who underwent SASI bypass from January to December 2021. All patients completed at least 12 months of follow-up., Results: Among the 30 patients, 93.3% were women, the mean age was 37.4 years, and the mean body mass index (BMI) was 45.6 kg/m 2 . The percentage of total body weight loss (TWL%) was 42.7%, the percent excess body weight loss (EWL%) was 92.7%, and the mean BMI at 12 months went from 45.6(35.2-58.4) to 25.8 kg/m 2 (19.2-33.4). The obesity-associated complications remission rate was 87.5% for type 2 diabetes (T2D), 71.4% for hypertension (HTN) and 100% for obstructive sleep apnea (OSA). Thirteen patients (43.3%) had diarrhea, 7 (23.3%) had hypoalbuminemia, defined as serum albumin < 3 g/dl, and 6 (20%) underwent reversal of their index SASI. As for other nutritional issues, iron deficiency anemia was present in 21 patients (70%), while 19 patients (63.3%) had vitamin D, and 2(6.6%) had vitamin B12 deficiency., Conclusion: Despite good short-term weight loss and improvement of obesity-associated complications, SASI is accompanied by high alarming malnutrition, even in short-term follow-up. Novel MBS should be judged for their long-term effects and compared to well-tested standard operations before they are used in routine clinical practice., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Malnutrition and liver impairment after duodenal switch (DS) are possible and undesired complications, often conservatively treated. However, in specific cases, surgical revision may be necessary. This study aims to describe outcomes achieved by two bariatric surgery centers and address effectiveness and safety of revisional surgical procedures to resolve these complications., Methods: A retrospective chart review was performed in two bariatric surgery centers from 2008 to 2022. Patients who required revisional surgery to treat malnutrition and/or liver impairment refractory to nutritional and total parenteral nutrition intervention (TPN) after duodenal switch were included. No comparisons were performed due to the descriptive nature of this study., Results: Thirteen patients underwent revisional surgery, the mean age was 44.7, the 53.8% were females, and the mean preoperative BMI was 54.7 kg/m2; the mean time between DS and revisional procedure was 26.5 months, and 69.1% of patients were placed on TPN. One patient developed hepatic encephalopathy; one patient presented with ascites, pleural effusion, and renal insufficiency, undergoing reoperation after revisional procedure due to a perforated ileal loop. Mortality rate was 0%; all patients regained weight after the revisional procedure, and the mean total protein and albumin blood levels 12 months after surgery were 6.3 and 3.6 g/dl, respectively., Conclusions: While refractory malnutrition and/or liver failure are rare among patients post-DS, if underdiagnosed and untreated, this can lead to irreversible outcomes and death. All revisional procedures included in this study resulted in improvement of the nutritional status and reversal of liver impairment, with low complication rates., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Severe malnutrition following one-anastomosis gastric bypass (OAGB) remains a concern. Fifty studies involving 49,991 patients were included in this review. In-hospital treatment for severe malnutrition was needed for 0.9% (n = 446) of patients. Biliopancreatic limb (BPL) length was 150 cm in five (1.1%) patients, > 150 cm in 151 (33.9%), and not reported in 290 (65%) patients. OAGB was revised to normal anatomy in 126 (28.2%), sleeve gastrectomy in 46 (10.3%), Roux-en-Y gastric bypass in 41 (9.2%), and shortening of BPL length in 17 (3.8%) patients. One hundred fifty-one (33.8%) patients responded to treatment; ten (2.2%) did not respond and was not reported in 285 (63.9%) patients. Eight (0.02%) deaths were reported. Standardisation of the OAGB technique along with robust prospective data collection is required to understand this serious problem., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Bariatric surgery (BS) can lead to postoperative nutritional deficiencies (NDs) due to restrictive and malabsorptive mechanisms, but there is limited literature quantifying NDs' prevalence over time and their predictors among patients undergoing BS., Objective: To characterize time trends and predictors of postoperative NDs., Setting: This retrospective cohort study used the U.S. IBM MarketScan commercial claims database (2005-2019) to include adults who underwent BS with continuous enrollment., Methods: BS included Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), adjustable gastric band (AGB), and biliopancreatic diversion with duodenal switch. NDs included protein malnutrition, deficiencies in vitamins D and B12, and anemia that may be related to NDs. Logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of NDs across BS types after adjusting for other patient factors., Results: Within 83,635 patients (mean age [SD], 44.5 [9.5] yr; 78% female patients), 38.7%, 32.9%, and 28% underwent RYGB, SG, and AGB, respectively. Age-adjusted prevalence of any NDs within 1, 2, and 3 years after BS ranged from 23%, 34%, and 42%, respectively (in 2006) to 44%, 54%, and 61%, respectively (in 2016). Relative to the AGB group, the adjusted OR of any 3-year postoperative NDs was 3.00 (95% CI, 2.89-3.11) for the RYGB group and 2.42 (95% CI, 2.33-2.51) for the SG group., Conclusions: RYGB and SG were associated with 2.4- to 3.0-fold odds of developing 3-year postoperative NDs compared with AGB, independent of baseline ND status. Pre- and postoperative nutritional assessments are recommended for all patients undergoing BS to optimize postoperative outcomes., (Copyright © 2023 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Single anastomosis sleeve ileal bypass (SASI) is a combined bariatric metabolic technique, in which few studies have shown its outcomes efficacy. However, this technique has a high risk of malnutrition due to long biliopancreatic limb. Single anastomosis sleeve jejunal bypass (SASJ) has a shorter limb. Therefore, it seems to have a lower risk of nutrient deficiency. Furthermore, this technique is relatively new, and little is known about the efficacy and safety of SASJ. We aim to report our mid-term follow-up of SASJ from a high-volume center for bariatric metabolic surgery in the Middle East region., Methods: For the current study, the 18-month follow-up data of 43 patients with severe obesity who underwent SASJ was collected. The primary outcome measures were demographic data, weight change variables according to ideal body mass index (BMI) of 25 kg/m 2 at 6, 12, and 18 months, laboratory assessments, remission of obesity-associated medical problems, and other potential bariatric metabolic complications after the surgery., Results: No patient was lost due to follow-up. After 18 months, patients lost 43.4 ± 11 kg of their weight and 68 ± 14% of their excess weight, and their BMI decreased from 44.9 ± 4.7 to 28.6 ± 3.8 kg/m 2 (p < 0.001). The percentage of total weight loss till 18 months was 36.3%. The T2D remission rate at 18 months was 100%. Patients neither faced deficiency in significant markers for nutrition state nor represented major bariatric metabolic surgery complications., Conclusion: SASJ bypass achieved satisfactory weight loss and remissions in obesity-associated medical problems within 18 months after surgery without major complications and malnutrition., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Malnutrition after bariatric operation is a rare but potentially life-threatening complication. The safety and efficacy of revisional bariatric operation in malnourished patients are not well elucidated., Study Design: We performed a retrospective chart review of patients who underwent revisional bariatric operation for severe malnutrition at our institution between 2008 and 2020. Associations of demographic and clinical characteristics with dichotomous outcomes of interest were examined using Fisher's exact tests, Cochran-Armitage tests for trend, and two-sample t -tests when appropriate., Results: Fifty-three patients underwent revisional bariatric operation for malnutrition from 2008 and 2020. The median follow-up was 24 months. The anatomy before revision was Roux-en-Y gastric bypass (n = 40, 75%), biliopancreatic diversion with duodenal switch (n = 6, 11%), sleeve gastrectomy (n = 4, 8%), and mini gastric bypass (n = 3, 6%). The percentage of patients requiring supplemental or total nutritional support decreased from 89% preoperatively (47% on enteral feedings and 42% on total parenteral nutrition (TPN) with or without tube feeding) to 13.2% at the last encounter after revision (7.5% still requiring enteral feedings and 5.7% on TPN). There was an association between the number of prior abdominal operations and postoperative pneumonia (p 0.03) and need for blood transfusion (p 0.01). There were no associations between major complications or last encounter nutrition and any preoperative variables other than age at the time of operation. There were 2 mortalities during a median follow-up of 24 months, and both occurred more than 1 year postoperatively., Conclusion: Revisional operation for severely malnourished bariatric operation patients is effective in the discontinuation of supportive nutrition. Postoperative complications are increased but not prohibitive., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Weight loss failure or weight regain may occur after Roux-en-Y gastric bypass (RYGB). Revisional surgery includes distalization. However, few studies have looked at the associations between the total alimentary limb length (TALL) and weight loss outcomes, none with long-term results., Objectives: Peri- and postoperative outcomes were assessed after employing TALL of either 250 cm or 300 cm in the failed RYGB., Methods: This study is a retrospective cohort analysis of 90 patients that underwent laparoscopic distalization between January 2006 and January 2016 due to failed RYBG. The index RYGB was modified to TALL of 250 cm (n = 48) or of 300 cm (n = 42) which entailed elongating the bilio-pancreatic limb (BPL) and transposing the Roux limb (RL) to a common limb (CL) of 100 cm and 150 cm, respectively. Long-term weight loss outcomes along with nutritional and vitamin status were analyzed., Results: Preoperative BMI at distalization was 38.6 kg/m 2 . After 8 years, excess weight loss (EWL) was 61.8%. No differences between the two groups were seen in weight loss outcomes or early surgical complication rates (6.7%). However, more vitamin and nutritional deficiencies were present in the TALL 250-cm group (50.0% and 35.4%, respectively) versus the TALL 300-cm group (33.3% and 14.3% respectively), which led to laparoscopic revision in 27 patients by lengthening the TALL with 100 cm. Patients with weight regain after index RYGB had in average 59.9% higher EWL than patients with EWL failure., Conclusion: Distalization of the failed RYGBP is safe and effective, but TALL should not be shorter than 300 cm (and CL 150 cm) due to high rates of malnutrition. Adequate supplementation and long-term follow-up are mandatory to prevent serious malnutrition., (© 2022. The Author(s).)

Background: Santoro's operation is a sleeve gastrectomy with transit bipartition. The operation aims to maintain passage to the duodenum to minimize nutritional deficiency. This procedure is rapidly changed to single anastomosis sleeve ileal (SASI) bypass. SAS-J bypass is a modification of SASI with a short biliary limb., Material and Methods: This study is a retrospective study of prospectively collected data. The study includes a comprehensive review of 1986 patients who underwent SAS-J bypass over 6 years. The total number is used to evaluate the perioperative data. One- and two-year follow-up was used to evaluate weight loss and comorbidities; follow-up of more than 5 years was used to obtain long-term results., Results: In this study, 70.4% of patients were female and 29.6% were male. The mean body mass index (BMI) was 44.7. The mean age was 42 years. Regarding comorbidities, 25.8% of the patients had type 2 diabetes, 31% were hypertensive, 14.2% had sleep apnea syndrome, 6.6% had gastroesophageal reflux disease (GERD), and 39.6% had hyperlipidemia. Of the 1294 patients who complete one-year follow up, %EWL reached 87%. Blood glucose levels were normalized in 98.5% of patients, hypertension remitted in 93%, hyperlipidemia improved in 97%, SAS is improved in all cases, and GERD improved in 89% of patients. After 5 years, 94 patients' BMI decreased from 44.3 to 28.3 without significant nutritional deficiency., Conclusions: Laparoscopic SAS-J bypass is an effective and simple alternative bariatric procedure at short- and long-term follow-up., (Copyright © 2022 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Gastroparesis (GP) is a rare condition for which several symptomatic treatments are available, but they may fail, leading to a discussion of gastrectomy. Few studies have described gastric-preserving surgery, particularly in malnourished patients., Objective: To describe the treatment of severe refractory GP with Roux-en-Y gastric bypass (RYGB)., Setting: A university center., Methods: A retrospective review was conducted of adult patients who underwent laparoscopic RYGB. Severity and frequency of GP symptoms were compared before and 1 year after surgery using the Gastroparesis Cardinal Symptom Index (GCSI) score (0-5), the vomiting (VM) score (0-4), and the visual analog scale (VAS) for abdominal pain., Results: Of the 9 patients with refractory GP, 7 were malnourished and 2 had obesity. There were no postoperative deaths. One patient was operated on for internal hernia without bowel necrosis. The mean GCSI score decreased significantly from 3.6 (range: 1-5) preoperatively to 2.1 (range: .3-4.4) postoperatively (P = .0019). The mean VM score improved significantly after surgery, from .22 (range: 0-1 units) preoperatively to 2.55 (range: 1-4) postoperatively (P = .007). The mean VAS score also decreased significantly from 7.0 (range: 5-9) preoperatively to 2.44 (range: 0-7) postoperatively (P = .0015). A nonsignificant weight and albumin change was observed at 1 year postoperatively, with a tendency for weight regain in malnourished patients., Conclusion: In malnourished patients with severe and refractory GP, this study suggests the feasibility, safety, and efficacy of RYGB for the treatment of vomiting and abdominal pain., (Copyright © 2022 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Single anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S) is a powerful form of bariatric surgery; however, it has a high risk of malnutrition. Single anastomosis sleeve ileal (SASI) bypass with sleeve gastrectomy may be used as an alternative procedure to avoid malnutrition associated with SADI-S; however, no comparison between the two procedures has been performed., Methods: Sprague-Dawley rats with diabetes (n = 32) were divided into four groups: SADI-S (n = 8), SASI (n = 8), SG (n = 8), and SHAM (n = 8). Body weight, food intake, and fasting blood glucose were measured, and the oral glucose tolerance test (OGTT) and insulin tolerance test (ITT) were performed before and after surgery. Blood samples were collected before and after the surgery to assess the levels of glucagon-like peptide-1 (GLP-1), hemoglobin, albumin, vitamin B12, calcium, and iron., Results: The SADI-S and SASI groups showed significantly greater weight loss and better glucose control than the SG group postoperatively. The SADI-S and SASI groups showed similar improvements in glucose control throughout the study. The SADI-S and SASI groups had significantly higher GLP-1 levels than the SG group at 6 months. The SADI-S and SASI groups presented with various degrees of deficiencies, with the SADI-S group showing a higher risk for hypoalbuminemia and iron deficiency than the SASI group., Conclusions: The SASI procedure may be a better alternative as it has excellent bariatric and metabolic results with lower risk for hypoalbuminemia and can be easily converted into either SADI-S or SG procedures. Nevertheless, further clinical results are needed., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Roux-en-Y gastric bypass (RYGB) is recently the second most frequent operation worldwide and is only preceded by sleeve gastrectomy. We present an alternative technique of reversal of RYGB. There is no need to dissect or resect the gastrojejunal anastomosis. This dissection might be difficult as the gastrojejunal anastomosis might be adherent to the residual stomach. The 2 anastomoses performed are technically easy and done on healthy non-inflammatory tissue.

Introduction: Since it was first described in 2001, the one anastomosis gastric bypass (OAGB) has been gaining popularity in the Middle East region and worldwide. We designed a survey to evaluate the trends, techniques, and outcomes of OAGB in our region., Methods: A questionnaire to study OAGB was sent to the members of the IFSO MENA chapter., Results: One-hundred and forty-eight surgeons (74%) responded. Forty-six percent of all respondents (64 surgeons) performed OAGB routinely. The most commonly performed procedures were the laparoscopic sleeve gastrostomy (LSG), followed by OAGB, and then Roux-en-Y (RYGB). Of the surgeons who responded, 65% did not perform routine pre-operative endoscopy. Seventy-two percent believed that OAGB produces better weight loss than the LSG while 58% did not believe it produced better results to RYGB. The most common length of biliopancreatic limb utilized was 200 cm, and 72% of surgeons did not measure the total length of the small bowel. Fifty percent of the surgeons offered OAGB as a treatment for acid reflux and 33% offered it to active smokers. Early complications included leak (< 1%), venous thromboembolism (< 1%), and mortality (< 0.5%) in most centers. Leaks were managed conservatively (23%), by conversion to RYGB (20%), reinforcing the anastomosis (19%), reversal to normal anatomy (6%), and others (32%). Of the total surgeons, 41% reported revising at least one patient for malnutrition and steatorrhea, and 32% reported revising at least one patient for sever bile reflux., Conclusion: OAGB is a commonly performed and safe procedure in the MENA region. Malnutrition and bile reflux requiring surgical intervention are serious long-term concerns.

Background: Severe post-operative malnutrition (SM) is a dreaded complication after gastric bypass often related to the short bowel syndrome consecutive limb length mismeasurement or intestinal resections. Patients with rapid weight loss or malnutrition can experience liver failure with cirrhosis and require liver transplantation (LT). Malnutrition can constitute a contraindication to LT since it negatively impacts on postoperative morbidity. RYGB reversal is an effective option to consider when nutritional support has failed. We describe the performance of a RYGB reversal in a pre-LT setting., Material and Methods: A 36-year-old patient with morbid obesity (weight, 140 kg; BMI, 50.1 kg/m 2 ) underwent a RYGB 9 years ago. She presented with 85 kg weight loss (i.e., 60.7% total body weight loss) associated with SM and hepatocellular insufficiency. LT was considered but contraindicated because of SM. An intensive nutritional support was attempted but failed and the RYGB reversal was recommended., Results: Laparoscopic exploration revealed ascites, cirrhosis, and splenomegaly. The whole small bowel measurement revealed a short gut. Alimentary, biliary, and common channel limb lengths were 250 cm, 150 cm, and 30 cm long. The alimentary limb was stapled off the gastric pouch and the gastrojejunostomy was resected. After resection of the gastrojejunostomy, linear stappled gastro-gastrostomy and jéjuno-jejunostomy were performed to restore the normal anatomy. At 1 year, malnutrition was resolved and the cirrhosis was stabilized., Conclusion: Reversal to normal anatomy appeared effective and safe in this setting but must be considered only after failure of intensive medical management. Careful bowel measurement is mandatory to prevent patients from this complication.

The technique of "small bowel limb transposition" consists in leaving the gastro-jejunal anastomosis (GJA) intact. It involves stapling (sectioning) of the alimentary limb (AL) at the level of the gastric antrum and creating a new anastomosis between the AL and the antrum. The "small bowel limb transposition" is an easy, simple, and interesting technique to be performed for the correction and treatment of severe malnutrition after laparoscopic Roux-en-Y gastric bypass, but this single case is not sufficient to prove that this is a standard option.

Purpose: Malnutrition after mini-gastric bypass (MGB) is a rare and dreaded complication with few data available regarding its surgical management. We aim to report the feasibility, safety, and results of laparoscopic reversal of MGB to normal anatomy (RMGB) in case of severe and refractory malnutrition syndrome after intensive nutritional support (SRMS)., Methods: A 10-year retrospective chart review was performed on patients who underwent RMGB (video included) for SRMS following MGB., Results: Twenty-six of 2934 patients underwent a RMGB at a mean delay of 20.9 ± 13.4 months post-MGB. At presentation, mean body mass index (BMI), excess weight loss (%EWL), and albumin serum level were 22 ± 4.4 kg/m 2 , 103.6 ± 22.5%, and 25.5 ± 3.6 gr/L, respectively. Seventeen (63.5%) patients had at least one severe malnutrition related complication including severe edema in 13 (50%), venous ulcers in 2 (7.7%), infectious complications in 7 (27%), deep venous thrombosis in 5 (19.2%), and motor deficit in 5 (19.2%) patients. At surgical exploration, 8 of 12 (66.5%) patients had a biliary limb longer than 200 cm and 9 (34.6%) had bile reflux symptoms. Overall morbidity was 30.8% but lower when resecting the entire previous gastrojejunostomy with creation of a new jejunojejunostomy (8.3 vs 50%, p = 0.03). After a mean follow-up of 8 ± 9.7 months, all patients experienced a complete clinical and biological regression of the SRMS after the RMGB despite a mean 13.9 kg weight regain in 16 (61.5%) patients., Conclusions: Post-MGB SRMS and its related comorbidities are rare but dreaded conditions. Although burdened by a significant postoperative morbidity and weight regain, RMGB remains an effective option to consider, when intensive nutritional support fails.

Data is limited regarding the success and safety of percutaneous endoscopic gastrostomy (PEG) placements by single balloon enteroscopy (SBE) in patients with Roux-en-Y gastric bypass (RNY-GB) anatomy. We report on 23 cases of PEG placements by SBE with overall technical success of reaching the excluded stomach 70% and with PEG placement success rate of 69%. No intra-procedural adverse events occurred. This technique seems safe when feasible for PEG placement in patients with RNY-GB anatomy.

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: After gastric bypass, some patients develop conditions that ultimately require reversal of the bypass. There are currently few publications on the topic to guide clinicians., Objectives: To describe the indications, techniques, and outcomes for gastric bypass reversal., Setting: Two academic medical centers., Methods: We conducted a retrospective chart review of all patients who underwent gastric bypass reversal at our institutions between 2008 and 2015. Information regarding the original operation, the indications for reversal, procedures performed, and the postoperative outcomes were collected and analyzed., Results: Nineteen patients underwent gastric bypass reversal. All but 4 reversal operations were performed laparoscopically. The indications for reversal were malnutrition or excessive weight loss (6 patients); chronic nausea, vomiting, and abdominal pain (5); neuroglycopenia (4); massive small bowel loss due to internal hernia (3); and need for surveillance gastric endoscopy (1). In the perioperative period, 4 patients had a complication that required intervention. Five patients required additional delayed procedures. One patient was lost to follow-up. The remaining patients' mean follow-up was 22±18 months. Symptoms that prompted reversal of the gastric bypass resolved in the majority of patients. However, 1 patient's hypoglycemia did not resolve and 2 continued to have diarrhea. Six patients were weaned off of total parenteral nutrition., Conclusions: Laparoscopic gastric bypass reversal is feasible and well tolerated. The procedure can be employed to treat a variety of conditions that may occur after gastric bypass and the majority of patients benefit, with resolution of symptoms. In a carefully selected patient population, gastric bypass reversal should be considered if conservative approaches to adverse conditions fail., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Due to the large number of Roux-en-Y gastric bypass surgeries performed over the last decade, reversal of the bypass to normal anatomy has been increasingly reported., Setting: University affiliated Teaching Hospital, United States., Objectives: The aim of this systematic review was to summarize the literature data regarding the indications, technical considerations, and outcomes of gastric bypass reversal., Methods: PubMed/MEDLINE search was conducted for articles reporting reversal of gastric bypass to normal anatomy. Patients' demographic characteristics, primary reason for reversal, reversal technique, and postreversal events were retrieved and categorized from each eligible paper., Results: Thirty-five articles encompassing a total of 100 patients were eligible. Malnutrition was the most common indication for reversal (12.3%), followed by severe dumping syndrome (9.4%), postprandial hypoglycemia (8.5%), and excessive weight loss (8.5%). Techniques for gastrogastrostomy were available in 42 patients, with the hand-sewn technique as the most common (67.4%) followed by the linear stapler (23.2%) and the end-to-end anastomosis stapler used in 3 patients (6.9%). The reversal technique was performed endoscopically and described in 3 studies (3 patients). Techniques for handling the Roux limb were described in 56 patients (56%); the limb was reconnected in 32 patients (57.2%) and resected in 24 patients (42.8%). Weight regain was the most prevalent postreversal event (28.8%), followed by severe gastroesophageal reflux diseases (10.2%) and persistent abdominal pain (6.8%). There was no reported mortality., Conclusion: Gastric bypass reversal is indicated for excessive weight loss, dumping syndrome, and postprandial hypoglycemia. The procedure is well tolerated and feasible when performed laparoscopically and has no reported mortality., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Gastric bypass procedures can potentially lead to middle and long-term complications (Podnos et al. Arch Surg 138(9):957-61, 2003). For several years, Roux-en-Y gastric bypass reversal procedures performed by laparotomy or laparoscopic way have been described in literature (Moon et al. Surg Obes Relat Dis 11(4):821-6, 2015). Major complications are anastomotic ulcers, anastomotic complications or functional disorder such as dumping syndrome, hypocalcemia, severe hypoglycemia, and malnutrition (Moon et al. Surg Obes Relat Dis 11(4):821-6, 2015; Campos et al. Surg Obes Relat Dis 10(1):36-43, 2014). One-anastomosis gastric bypass (OAGB) also called omega-loop gastric bypass (OLGB) or mini-gastric bypass (MGB) is a technique that has demonstrated similar results to traditional Roux-en-Y procedures in terms of weight loss and postoperative quality of life (Lee et al. Ann Surg 242(1):20-8, 2005). However, in a recent description of 1000 patients, the percentage of malnutrition was 0.2 % (two patients) with an indication to revert omega-loop gastric bypass back into normal anatomy (Chevallier et al. Obes Surg 25(6):951-8, 2015), but technical details have not been exposed yet. The first robotic gastric bypass was published by Horgan and Vanuno in 2001 (Horgan and Vanuno J Laparoendosc Adv Surg Tech A 11(6):415-9, 2001). The present work describes for the first time a robotic procedure to reverse OLGB into normal anatomy., Methods: We present the video report of a 69-year-old woman suffering of severe malnutrition (weight of 42 kg, body mass index of 15.8 kg/m(2), albumin 21 g/l) who had undergone laparoscopic omega-loop gastric bypass 2 years ago (initial weight of 104 kg and initial body mass index of 39.6 kg/m(2)). She was referred to our Bariatric Surgery Unit, and after a period of parenteral nutrition support to improve nutritional status (albumin 32 g/l), we decided in a multidisciplinary staff to perform a reversal omega-loop gastric bypass back into normal anatomy using the DaVinci Si™ system by Intuitive Surgical Inc ®, Sunnyvale, CA., Results: In this high definition video, we present step-by-step robotic reversal of the omega-loop gastric bypass. The procedure began with a careful adhesiolysis of the left lobe of the liver, small gastric pouch, and omega-loop. Then, the gastro-jejunostomy was transected with a 45-mm Endo GIA endocutter with purple staples. The key-point was the creation of a gastro-gastric anastomosis between the small gastric pouch and the excluded stomach. Omega-loop jejunum was resected and the anastomosis was performed in order to avoid intestinal stenosis. The operative time was 232 min. Postoperative course was uneventful and the patient was discharged in postoperative day 8. One month after the procedure, she has gained 10 kg (albumin 34 g/l) and stabilized her nutritional status without further nutritional support., Conclusions: This is the first case described in the literature of a reversal omega-loop gastric bypass into normal anatomy and the first description of the use of a robotic approach. This intervention is challenging, but a feasible procedure. This technology may increase the number of surgeons who are able to provide the benefits of minimal invasive surgery to their patients without the increased risks of complications associated with initial learning curves. The three-dimensional robotic vision, a stable camera, and the multiples degrees of freedom of the robotic instruments are the features that seem to provide greater surgical precision for these complex laparoscopic operations.

Nutritional and metabolic complications can develop after Roux-en-Y gastric bypass (RYGB) when there is an exaggerated response to the anatomical and functional changes or when there is inadequate nutritional supplementation. Severe malnutrition is rare, but deficiencies of vitamin B12, iron, calcium and thiamin, metabolic bone disease and gallstones are common after RYGB. Shortage of vitamin B12, iron, calcium and also cholelithiasis are caused at least partially by excluding the duodenum and proximal jejunum from food transit. We designed a new procedure, with the maintenance of the duodenum and proximal jejunum in the gastrointestinal transit through interposition of jejunal loop, as a primary operation to prevent such deficiencies or as corrective surgery for severe malnutrition after RYGB with failure in responding to conservative treatment. Complicações nutricionais e metabólicas podem se desenvolver após a derivação gástrica em Y de Roux (DGYR) quando há uma resposta exagerada às mudanças anatômicas e funcionais ou quando há suplementação nutricional inadequada. A desnutrição grave é rara, mas deficiências de vitamina B12, ferro, cálcio e tiamina, doença óssea metabólica e cálculos biliares são comuns após a DGYR. Dessas deficiências mencionadas, a de vitamina B12, de ferro, de cálcio e também a colelitíase, são causadas, ao menos parcialmente, pela exclusão do duodeno e jejuno proximal. Um novo procedimento com a manutenção do duodeno e do jejuno proximal no trânsito gastrointestinal, mediante interposição de alça jejunal, foi idealizado como operação primária para prevenir essas deficiências ou como cirurgia corretiva de desnutrição grave após DGYR com falha na resposta a exaustivas tentativas de tratamento conservador.