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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.)

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: Traditional methods for securing a laparoscopic gastrostomy (LG) involve the placement of two monofilament transabdominal (TA) sutures to be removed after a short interval of 5 days. A modified technique employing an absorbable suture tunneled subcutaneously has been adopted by many surgeons. The aim of this study was to compare wound complications between these techniques., Methods: A retrospective review of patients who underwent LG placement between 2010 and 2016 was conducted, dividing patients into two cohorts by securing stitch type, TA and subcutaneous (SC), and evaluating for complications., Results: A total of 740 children underwent laparoscopic gastrostomy tube (GT) placement, of whom 554 (75%) patients had a TA stitch and the remaining 186 (25%) had a SC stitch. Demographic data were comparable in both groups. The most common wound complication was granulation tissue (22%), dislodgement (19%), external drainage (16%), cellulitis (10%), erosion (3%), and abscess formation (2%). Seven patients required operative revision for dislodgement; TA patients comprised the majority of these patients. Operative times were significantly longer in the SC group (22 minutes versus 28 minutes, P < .05). Rates of granulation, erosion, external and internal leakage, and dislodgement were equivalent between cohorts. There were higher rates of cellulitis (7.3% versus 19%, P < .05) and abscess (0.8% versus 7.6%, P < .05) noted in the SC group. Time to external leakage was significantly earlier in the SC group (P < .05); however, all other complications occurred at comparable times following initial operation. Persistent gastrocutaneous fistula requiring surgical closure occurred at equal rates with no difference in times to closure from GT discontinuation in both groups., Conclusion: While both techniques are feasible, there was a significant increase in infectious complications and operative times observed in the SC stitch patients, suggesting this may not be the optimal securing method.

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.

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: Feeding difficulties and gastroesophageal reflux (GER) are major problems in severely neurologically impaired children. Many patients are managed with a simple gastrostomy, with or without fundoplication. Unfortunately, fundoplication and gastrostomy are not devoid of complications, indicating the need for other options in the management of these patients., Methods: Between January 2002 and June 2010, ten patients (age range, 18 months-14 years) have been treated by creating a jejunostomy with the laparoscopic-assisted procedure. The procedure was performed using 2-3 trocars. The technique consists of identifying the first jeujnal loop, grasping it 20-30 cm away from the Treitz ligament, and exteriorizing it to the trocar orifice under visual guide. The jejunostomy was created outside the abdominal cavity during open surgery. At the end of the jejunostomy, the correct position of the intestinal loops was evaluated via laparoscopy., Results: Surgery lasted 40 min on average, the laparoscopic portion about 10 min. Hospital stay was 3 or 7 days for all patients. At the longest follow-up (8 years), all patients had experienced a significant weight gain. One patient died 1 year after the procedure of unknown causes. As for the other complications: 4/10 patients experienced peristomal heritema, 2/10 device's dislocation and 1 patient a peristomal granuloma., Conclusions: Laparoscopic-assisted jejunostomy is a safe and effective procedure to adopt in neurologically impaired children with feeding problems and GER. We advocate the use of this procedure in neurologically impaired patients with feeding problems and reflux due to its overall practicability and because there is minimal surgical trauma. The improvement in the quality of life of these children after the jejunostomy seems to be the major advantage of this procedure. However the management of jejunostomy can be difficult for parents above all in the first postoperative months.