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Background: This clinical trial explores the Sigstad score for late dumping syndrome in postoperative patients who have undergone sleeve gastrectomy (SG) or One Anastomosis Gastric Bypass (OAGB). The aims of this study are to investigate the correlations with late dumping syndrome, to evaluate the reliability and validity of the Sigstad score and to discuss a modified scoring system., Methods: The study was conducted at the Obesity Center of the Westküstenklinikum Heide and included 271 patients. Data collection involved conducting interviews, diet diaries and measuring blood glucose levels. Non-parametric tests, logistic regression and McDonald's Omega were the selected statistical approaches., Results: Body Mass Index (BMI) decreased over time (-9.67 kg/m 2 at 4 months, -15.58 kg/m 2 at 12 months). Preoperatively, the Sigstad score exhibited the highest value, and no occurrences of late dumping syndrome were observed. No significant differences were found in BMI concerning late dumping syndrome or Sigstad score among postoperative patients. Postoperative patients experienced an increase in gastrointestinal symptoms. The reliability test showed a McDonald's omega value of 0.509. The analysis conducted through binary logistic regression indicated dizziness as a significant predictor of late dumping syndrome; however, this finding did not hold up after performing Bonferroni correction., Conclusion: The Sigstad score is not a reliable or valid method for detecting late dumping syndrome after surgery for obesity and metabolic disorders. It is necessary to have alternatives that use objective measures and assess the quality of life, and that these alternatives be validated in large patient cohorts., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Post-prandial hypoglycemia is an uncommon but disabling late complication of Roux-en-Y gastric bypass (RYGB). Most patients can be treated with dietary interventions and medications; however, some patients develop refractory hypoglycemia that may lead to multiple daily episodes and seizures. While RYGB reversal surgery is an effective treatment, complication rates are high, and patients inevitably experience weight regain. Transoral gastric outlet reduction (TORe) is a minimally invasive treatment that is effective for early and late dumping syndrome. However, prior studies have not distinguished the effectiveness of TORe specifically for patients with post-prandial hypoglycemia. This study aims to describe a single institution's experience of TORe for treating post-prandial hypoglycemia., Methods: This is a case series of patients with prior RYGB complicated by post-prandial hypoglycemia who underwent TORe from February 2020 to September 2021. Pre-procedural characteristics and post-procedural outcomes were obtained. Outcomes assessed included post-prandial hypoglycemia episodes, dumping syndrome symptoms, and weight change., Results: A total of 11 patients underwent TORe from 2020 to 2021 for post-prandial hypoglycemia. Three (27%) patients had a history of seizures due to hypoglycemia. All had been advised on dietary changes, and ten patients (91%) were on medications for dumping. All patients reported a reduction in post-prandial hypoglycemic events as well as the majority of dumping syndrome symptoms during an average follow-up time of 409 ± 125 days. Ten patients (91%) had experienced weight regain from their post-RYGB nadir weight. For these patients, the average total body weight loss 12 months post-TORe was 12.4 ± 12%. There were no complications requiring hospitalization. One patient experienced post-TORe nausea and vomiting requiring dilation of the gastrojejunal anastomosis with resolution in symptoms., Conclusion: TORe is a safe and effective treatment for post-prandial hypoglycemia and weight regain after RYGB in patients with symptoms refractory to medications and dietary changes., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Both weight regain and dumping syndrome (DS) after Roux-en-Y gastric bypass (RYGB) have been related to the dilation of gastro-jejunal anastomosis. The aim of this study is to assess the safety and long-term efficacy of endoscopic transoral outlet reduction (TORe) for DS and/or weight regain after RYBG., Materials and Methods: A retrospective analysis was performed on a prospective database. Sigstad's score, early and late Arts Dumping Score (ADS) questionnaires, absolute weight loss (AWL), percentage of total body weight loss (%TBWL), and percentage of excess weight loss (%EWL) were assessed at baseline and at 6, 12, and 24 months after TORe., Results: Eighty-seven patients (median age 46 years, 79% female) underwent TORe. The median baseline BMI was 36.2 kg/m 2 . Out of 87 patients, 58 were classified as "dumpers" due to Sigstad's score ≥ 7. The resolution rate of DS (Sigstad's score < 7) was 68.9%, 66.7%, and 57.2% at 6, 12, and 24 months after TORe, respectively. A significant decrease in Sigstad's score as well as in early and late ADS questionnaires was observed (p < 0.001). The median Sigstad's score dropped from 15 (11-8.5) pre-operatively to 2 (0-12) at 24 months. The %TBWL was 10.5%, 9.9%, and 8.1% at 6, 12, and 24 months, respectively. Further, "dumpers" with resolution of DS showed better weight loss results compared with those with persistent DS (p < 0.001). The only adverse event observed was a perigastric fluid collection successfully managed conservatively., Conclusion: TORe is a minimally invasive treatment for DS and/or weight regain after RYGB, with evidence of long-term efficacy., (© 2023. The Author(s).)

Obesity is a chronic relapsing disease of global pandemic proportions. In this context, an increasing number of patients are undergoing bariatric surgery, which is considered the most effective weight loss treatment for long-term improvement in obesity-related comorbidities. One of the most popular bariatric surgeries is the Roux-en-Y gastric bypass (RYGB). Despite its proven short- and long-term efficacy, progressive weight regain and dumping symptoms remain a challenge. Revisional bariatric surgery is indicated when dietary and lifestyle modification, pharmaceutical agents and/or psychological therapy fail to arrest weight regain or control dumping. However, these re-interventions present greater technical difficulty and are accompanied by an increased risk of peri- and postoperative complications with substantial morbidity and mortality. The endoscopic approach to gastrojejunal anastomotic revision, transoral outlet reduction (TORe), is used as a minimally invasive treatment that aims to reduce the diameter of the gastrojejunal anastomosis, delaying gastric emptying and increasing satiety. With substantial published data supporting its use, TORe is an effective and safe bariatric endoscopic technique for addressing weight regain and dumping syndrome after RYGB.

Purpose: The present research was conducted to evaluate the effect of the severity of dumping syndrome (DS) on weight loss outcomes after Roux-en-Y gastric bypass (RYGB) in patients with class III obesity., Methods: The present retrospective cohort study used the dumping symptom rating scale (DSRS) to evaluate the severity of DS and its correlation with weight loss outcomes in 207 patients 1 year after their RYGB. The patients were assigned to group A with mild-to-moderate DS or group B with severe DS., Results: The mean age of the patients was 42.18 ± 10.46 years and their mean preoperative BMI 42.74 ± 5.59 kg/m 2 . The total weight loss percentage (%TWL) in group B was insignificantly higher than that in group A, but besides that was not significantly different in the two groups., Conclusion: The present findings suggested insignificant relationships between the presence and severity of DS after RYGB and adequate postoperative weight loss., (© 2023. The Author(s).)

Background and Aims: Gastrojejunostomy stomal dilation is a frequent cause of weight regain after Roux-en-Y gastric bypass and may be a contributing cause of dumping syndrome. This study aims to evaluate the long-term durability of endoscopic gastrojejunostomy revision (EGJR) to resolve dumping syndrome., Methods: A retrospective chart review was performed of patients undergoing EGJR at a single institution from January 1, 2013 to December 1, 2018. The primary endpoint, dumping symptom resolution, was measured at 1 month and at the most recent postoperative follow-up. Continuous data are reported as mean and standard deviations and categorical data as percentages. The Fisher exact test was used to assess associations between categorical variables., Results: Ninety-eight patients underwent EGJR for dumping syndrome. Mean patient age was 51 years (standard deviation [SD], 9.9), and mean body mass index (BMI) was 36.2 kg/m 2 (SD, 7.1), with most patients (53%) presenting with BMIs ≥35 kg/m 2 . Thirty-two patients (32%) reported severe dumping (≥3 symptoms). All patients were followed-up for 1 month, and 83% had a long-term follow-up at a mean of 3.45 years (SD, 1.7) after EGJR. In addition, 88% had initial symptom resolution at 1 month, and 85% reported symptom resolution 3 years postoperatively. Patients with GERD had a statistically significant improvement in dumping syndrome at 3 years compared with those without GERD (69% vs 62%, P = .03). Long-term weight loss averaged 2.1 pounds after EGJR., Conclusions: EGJR is associated with effective and durable resolution of dumping syndrome at 3 years postoperatively, with a minimal long-term impact on weight loss. The presence of GERD preoperatively correlates with a statistically significant resolution of dumping syndrome., (Copyright © 2022 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Dumping syndrome is a known complication of Roux-en-Y gastric bypass (RYGB). Recently, endoscopic gastrojejunal anastomosis (GJA) revision has been employed as a treatment option. The primary aim of this study was to perform a systematic review and meta-analysis for the role of endoscopic GJA revision in patients with RYGB for the treatment of dumping syndrome., Methods: Search strategies were developed for PubMed, EMBASE, Web of Science, and Cochrane Library databases from inception through December 2020 in accordance with PRISMA and MOOSE guidelines. Pooled proportions with rates estimated using random effects models were used. Outcomes included pooled technical success, clinical success, adverse events, and rate of reintervention. Heterogeneity was assessed with I 2 statistics and publication bias by funnel plot using Egger and Begg tests., Results: Six studies (n = 263 patients; 60.25% female) were included (1 prospective and 5 retrospective). Mean age was 46.27 ± 2.54 years. Average patient weight was 95.59 ± 4.78 kg, BMI of 41.43 ± 3.07 kg/m 2 , and pre-procedure GJA size of 32.23 ± 8.68 mm. Pooled technical and clinical success was 98.15% and 89.5%. Among studies reporting Sigstad scores, endoscopic GJA revision resulted in a significant improvement [mean Sigstad score difference of - 9.96 (95% CI, - 19.951 to - 0.975); P < 0.03]. Mean procedure time was 37.12 ± 10.40 min with an intra-procedural adverse event rate of 2.42%. Over a mean follow-up of 8.03 ± 6.87 months, post-procedure adverse events occurred in 2.96% of patients with a reintervention rate of 11.54%., Conclusion: This systematic review and meta-analysis suggests that endoscopic GJA revision appears an effective and safe treatment for dumping syndrome., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Dumping syndrome is a common post-operative complication following gastric surgery. Clinically, severe dumping can be a serious medical condition with a negative impact on the patient's life. In our case report, we present a case of refractory dumping syndrome which developed after laparoscopic subtotal gastrectomy with gastrojejunoanastomosis due to massive gastroptosis with stomach evacuation problems. Conservative gastroenterology treatment was not successful. Due to the progression of weight loss and life-threatening hypoglycaemia, the decision for surgical treatment was made. After the corrective gastro-duodenal and jejuno-jejunal anastomoses, all clinical symptoms resolved completely. With regard to the presented case, we discuss the common treatment options for dumping syndrome: the standard recommendations for dietary habits, pharmacological treatment and finally the surgery and its pitfalls. Due to the absence of randomized trials and guidelines, every patient should be treated in a personalized way.

Background: Dumping syndrome is a known long-term complication of Roux-en-Y gastric bypass (RYGB). Most cases can be avoided with dietary and lifestyle changes. Severe dumping is characterized by multiple daily episodes with significant impact on quality-of-life. As dumping correlates with rapid pouch emptying through a dilated gastro-jejunal anastomosis (GJA), the aim was to assess endoscopic gastro-jejunal revisions (EGR) regarding feasibility, safety, and outcome., Methods: From January 2016 to August 2018, we reviewed the electronic records of all patients with dumping syndrome undergoing EGR with the Apollo OverStitch suturing device (Apollo Endosurgery, Austin, Texas, USA). Demographics, procedure details, and outcome variables were recorded. Sigstad questionnaire was administered before and after surgery to assess symptomatic response., Results: There were 40 patients (M:F = 13:27) treated with EGR for dumping. Mean procedure time was 18.5 min (12-41) with a median number of 1 suture (range 1-3) used. Mean anastomotic diameter was 22.6 mm (R 18-35) at the beginning and 6.2 mm (R 4-13) at the end of the procedure, with 100% technical success in narrowing the GJA. There were no intra-operative or 30-day complications. Repeat EGR was required in 9 patients (22.5%) for persistent/recurrent dumping. Two patients (5%) required a laparoscopic pouch revision. For patients with minimum 1-month follow-up who were treated only endoscopically, 33/37 (89.2%) had improved or resolved symptoms during the follow-up period. Mean follow-up time was 12.5 months (R1-33.8). Survey responses were available for 25/34 (73.5%) patients. Mean Sigstad score decreased from 13.9 (R 0-28) pre-operatively to 8.6 (R 0-28) after EGR., Conclusion: EGR of the dilated GJA is a highly effective treatment option for dumping syndrome after RYGB. Due to its endoluminal approach, it is a feasible and safe procedure, and effective for immediate symptom resolution in most patients. In some patients, repeat narrowing of the anastomosis is necessary for the maintenance of symptom resolution.

Background and Aims: Roux-en-Y gastric bypass (RYGB) is refractory to lifestyle and pharmacotherapy measures, requiring reversal of the patient's bariatric surgery. Reversal can lead to weight regain and recrudescence of their comorbidities. Our aim was to report a multicenter experience on the endoscopic management of refractory dumping syndrome with endoscopic transoral outlet reduction (TORe)., Methods: A multicenter international series of consecutive patients who underwent TORe with a full-thickness endoscopic suturing device was analyzed for technical success, improvement in Sigstad scores, and weight trajectories after the procedure. Failure was defined as needing an enteral feeding tube, surgical reversal, or repeat TORe., Results: One hundred fifteen patients across 2 large academic centers in Germany and the United States underwent TORe for dumping syndrome. Patient age was mean 8.9 ± 1.1 years from their initial RYGB with an average percent total body weight loss of 31% ± 10.6% at the time of endoscopy. Three months postprocedure, the Sigstad score improved from a mean of 17 ± 6.1 to 2.6 ± 1.9 (paired t test P = .0001) with only 2% of patients (n = 2) experiencing weight gain. Mean weight loss and percentage of total body weight loss 3 months post-TORe were 9.47 ± 3.6 kg and 9.47% ± 2.5%, respectively. Six patients (5%) failed initial endoscopic therapy, with 50% (n = 3) successfully treated with a repeat TORe. Three patients underwent surgical reversal, indicating an overall 97% endoscopic success rate., Conclusions: TORe as an adjunct to lifestyle and pharmacologic therapy for refractory dumping syndrome is safe and effective at improving dumping syndrome and reducing rates of surgical revision., (Copyright © 2020 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: The patient presented with symptomatic postprandial biweekly hypoglycemic seizures. Her hypoglycemic episodes were aggravated by stress and also occurred during sleep. She managed these hypoglycemic episodes with an endocrinologist, trying both nutritional and medical management without successful control of her symptoms. An endoscopic gastrojejunal revision (EGJR) was recommended to provide more restriction and prolong transit time into the Roux limb to decrease the chance of postoperative dumping syndrome and subsequent hypoglycemia., Methods: This video is a case study of an EGJR done for persistent postoperative hypoglycemia. The gastroscope was introduced and using Argon Plasma Coagulation at a flow of 8 liters/min and 30 watts; the mucosa around the gastrojejunal stoma was ablated circumferentially. This was done to decrease bleeding from needle placement and to promote adherence of the mucosa after the sutures were placed. The purse-string technique was favored for this procedure due to an inherent reduction in suture tension. Several full-thickness bites were taken to narrow the stoma from 20 to 4 mm in diameter., Results: The patient was discharged home the same day following the procedure. She was placed on a two week liquid bariatric postoperative diet. At two week follow-up, the patient reported normal  blood sugars and no hypoglycemic episodes since surgery. At six month follow-up, the patient reported significant improvement in her hypoglycemia symptoms, and no further syncopal episodes or seizures., Conclusion: We believe this case demonstrates that endoscopic gastrojejunal revision (or EGJR) is an effective treatment option for postprandial hypoglycemia following Roux-en-Y gastric bypass.

Background: Data on the efficacy and safety of the long-acting somatostatin analogue lanreotide (LAN) for postoperative dumping syndrome are lacking., Objective: We performed a double-blind, randomised and placebo-controlled crossover study of LAN Autogel® 90 mg in postoperative dumping., Methods: Adults with a positive prolonged oral glucose tolerance test or spontaneous hypoglycaemia and total dumping score (DS) ≥ 10 despite dietary measures were treated with three monthly injections of LAN or placebo in a randomised crossover fashion with an eight-week wash-out period. Primary outcome was the effect of LAN on total DS versus placebo. Secondary outcomes were the effect on early and late DS, treatment assessment, quality of life and safety., Results: Of 24 included patients (66.7% female; age 49.1 ± 2.1 years), 12 were randomised to LAN first. Pooled DS after three injections were lower compared to baseline after LAN (median=14 (interquartile range (IQR) 11.5-23) vs. median = 22 (IQR 16-27); p  = 0.03) but not placebo (median = 20 (IQR 15-27) vs. median = 23 (IQR 13-29); p  = 0.15). Improvement of early (median = 7.5 (IQR 4.5-13) vs. median = 12 (IQR 9-16); p  = 0.03) but not late (median = 7 (IQR 6-10.3) vs. median = 9 (IQR 6-13); p  = 0.26) DS was seen. Overall treatment assessment correlated with change in DS ( r  = -0.69, p  = 0.004). Symptom improvement was not associated with changes in quality of life. Of the 81 reported adverse events, 44 occurred on LAN compared to 37 on placebo ( p  > 0.05), with seven serious adverse events on LAN., Conclusions: LAN is effective for treating early postoperative dumping symptoms, although side effects are common and quality of life is not significantly affected., (© Author(s) 2019.)

Background and Aims: Transoral outlet reduction (TORe) by devitalization and/or endoscopic suturing (ES) has been implemented in the management of weight regain post-RYGB. This study aims to assess the efficacy and safety of TORe following an insurance-based algorithm., Methods: A prospectively maintained database of patients who underwent TORe between September 2015 and January 2018 at a single academic center was reviewed. An algorithm was followed whereby management was based on insurance coverage. As part of the algorithm, all patients presented for a repeat endoscopy at 8 weeks. Patients did not receive any diet, lifestyle intervention, or pharmacotherapy., Results: In total, 55 patients were included (median age 48 years), out of which 50 were females (90.9%). Patients presented for evaluation at a mean of 8.7 years post-RYGB. The main presenting symptom was combined dumping syndrome (DS) and weight regain (49.1%), followed by weight regain alone (45.5%). Twenty-nine patients required treatment at their second procedure, and 11 required treatment at their third procedure. Average percent total body weight loss (%TBWL) after TORe observed at 3-, 6-, 9-, and 12-month follow-up was 8.2, 9.3, 8.4, and 5.5%, respectively. The mean DS Severity Score was significantly reduced from 23.3 ± 12.4 before TORe to 16.3 ± 6.51 after TORe (p < 0.01). The adverse event rate from TORe was 14.5%., Conclusion: TORe is effective in halting ongoing weight regain and achieving moderate short-term weight loss as well as improving DS in post-RYGB patients. Durability at 1 year remains questionable due to weight recidivism.

Background: Weight regain and dumping after Roux-en-Y gastric bypass (RYGB) are long-term challenges thought to be due to dilation of the gastrojejunal anastomosis. The aim of this study was to analyze the feasibility, safety, and outcomes of endoscopic gastrojejunal revisions (EGRs) after its introduction in a tertiary bariatric surgery center., Methods: From January 2016 to March 2018, we reviewed the electronic records of all patients undergoing EGR with the OverStitch suturing device. Demographics, procedure details, and outcomes were recorded., Results: There were 107 patients (M:F = 29:78) treated with 133 EGR procedures for weight regain (n = 81), dumping syndrome (n = 13), or both (n = 13) with mean age 47.3 years (R 22.0-72.9) and mean BMI 32.9 kg/m 2 (R 22.2-49.8) at time of procedure. Mean procedure time was 17.8 min (R 12-41), with median 1 suture used (R 1-2). No intra-operative or 30-day complications were recorded. Mean follow-up time was 9.2 months (R 1-26.8). Patients lost a mean of 4.1, 5.8, and 8.0 kg at 3, 6, and 12 months, respectively, after the procedure. Weight loss outcomes were significantly better when two compared to one suture was used (p = 0.036), and for patients with higher starting BMI (p = 0.047). For patients with dumping syndrome, 90-100% had treatment response after one or two EGRs., Conclusion: EGR is feasible and safe for weight regain and dumping syndrome after RYGB. It can stabilize weight regain and improve dumping symptoms. Around 20% of patients will need repeat EGR within 1 year to achieve sufficient narrowing of the anastomosis.

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.)

Dumping syndrome is a long-term postoperative complication of Roux-en-Y gastric bypass procedures. Morphologically, dumping syndrome usually correlates with a dilatation of the gastroenterostomy with accelerated pouch emptying. Conservative therapy includes diet changes, complementary pharmacotherapy and, if symptoms persist, surgical revision. Surgical options include endoscopic, endoluminal surgery to constrict the gastrojejunostomy using a novel endoscopic suturing device (OverStitch(TM), Apollo). In our study, we aimed to assess the viability, safety and efficacy of this procedure in patients with late dumping; 14 patients who had developed late dumping syndrome underwent surgery using an endoscopic suturing technique (OverStitch(TM), Apollo). Late dumping was confirmed by Sigstad score and an oral glucose tolerance test (OGTT). Prior to surgery, objective analysis of pouch emptying speed was assessed by gastric scintigraphy. Surgery was performed under general anaesthesia. None of the 14 patients suffered intra- or postoperative complications. No postsurgical increase in inflammation parameters was observed. The postinterventional pain scale (visual analogue scale) showed a mean score of 0.5 (range 0-10). In 13 of the 14 patients, no dumping was observed 1-month postsurgery. The postoperative Sigstad score (3.07 ± 2.06; range 1-9) showed an impressive reduction compared with the preoperative score (12.71 ± 4.18; range 7-24) (p < 0.001). Postoperative upper gastrointestinal gastrografin swallow revealed regular emptying in all the patients. The endoluminal endoscopic suturing technique-applied here for surgical revision of gastroenterostomy following Roux-en-Y gastric bypass-represents a promising, novel therapeutic option in late dumping syndrome involving minimal trauma and offering rapid reconvalescence.

Background: Complications after gastric bypass (RYGB) are well documented. Reversal of RYGB is indicated in select cases but can lead to weight gain. Conversion from RYGB to sleeve gastrectomy (SG) has been proposed for correction of complications of RYGB without associated weight gain. However, little is known about outcomes after this procedure., Objectives: To examine outcomes after conversion from RYGB to SG., Setting: University hospital., Methods: A retrospective study of patients who underwent RYGB to SG conversion was undertaken., Results: Twelve patients underwent RYGB to SG conversion for refractory marginal ulceration, stricture, dumping, gastrogastric fistula, hypoglycemia, and failed weight loss. No deaths occurred. Four patients experienced 7 major complications, including portal vein thrombosis, bleeding, pancreatic leak, pulmonary embolus, seroma, anastomotic leak, and stricture. Two required reoperation, and 6 were readmitted within 30 days. Four required nasoenteric feeding postoperatively because of prolonged nausea. The complication of RYGB resolved in 11 of 12 patients. At 14.7 months, change in body mass index for all patients was a decrease of 2.2 kg/m(2). In 5 patients with morbid obesity at conversion, the change in body mass index was a decrease of 6.4 kg/m(2) at 19 months., Conclusions: Laparoscopic conversion from RYGB to SG is successful in resolving certain complications of RYGB and does not result in short-term weight gain. However, conversion has a high rate of major complications as well as a high rate of readmission and need for supplemental nutrition. Although conversion to SG may be appropriate in carefully-selected patients, other options for patients with severe chronic complications after RYGB should be considered., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Dumping syndrome is not infrequent after laparoscopic Roux-en-Y gastric bypass (LRYGB) and could result in dreaded complications, such as neuroglycopenia. For those refractory to diet modification or/and medication, regarded as intractable dumping syndrome, revision procedures should be taken into consideration. Herein, we make a video presentation of laparoscopic revision surgery for intractable dumping syndrome with unsatisfactory weight loss., Methods: Two diabetic, morbidly obese women (initial body mass index 36.6 and 41.4 kg/m(2)) presented with intractable dumping syndrome 2 and 3 years after initial LRYGB, respectively. In addition, these patients had insufficient weight loss (body mass index 29 and 31 kg/m(2)). Laparoscopic revision procedure of loop duodenojejunal bypass with sleeve gastrectomy was conducted to relieve their intractable conditions., Results: The mean operation time was 174 min (160 and 188), and the average blood loss was 60 mL (50 and 70). There was no intraoperative complication. Both patients had uneventful postoperative courses, and the average postoperative hospital stay was 2 days. The uncomfortable symptoms relieved successfully after the revision surgery. The Sigstad's score decreased to 2 points 6 months later, and the body mass index reduced to 26 and 28 kg/m(2)., Conclusions: Though long-term follow-up is warranted to draw a definite conclusion, loop duodenojejunal bypass with sleeve gastrectomy for pyloric restoration and malabsorptive effect remains an acceptable revision procedure to relive intractable dumping syndrome and successfully maintain sustained weight loss in our patients.

Background: Dumping syndrome is not infrequent after laparoscopic Roux-en-Y gastric bypass and could result in dreaded complications, such as hypoglycemia or syncope. Those patients who failed medical therapy and diet modification, regarded as intractable dumping syndrome, may be considered as candidates for revisional surgery. Herein, we make a video presentation of laparoscopic revisional procedure for intractable dumping syndrome with unsatisfactory weight loss., Methods: A 32-year-old, morbidly obese woman (initial body mass index, 53.3 kg/m(2)) presented with dumping syndrome 17 months after initial laparoscopic Roux-en-Y gastric bypass. She underwent nutritional counseling, strict diet modification, and medication treatment but failed. In addition, the patient complained of worsening constipation and insufficient weight loss (body mass index, 36 kg/m(2)). Laparoscopic revisional procedure with modified duodenal switch was conducted to relieve her intractable condition., Results: The procedure took 260 min without any intraoperative complication. Blood loss was 100 mL The patient had an uneventful postoperative course and the postoperative hospital stay was 5 days. The uncomfortable symptoms relieved successfully after the revisional surgery., Conclusions: Though long-term follow-up is warranted to draw a definite conclusion, modified duodenal switch with pyloric restoration and shortening bowel length remains an acceptable revisional procedure to relive intractable dumping syndrome and constipation in our patient successfully.

The purpose of this study was to evaluate the merits of the sentinel node (SN)-navigated reduced gastrectomy (SNRG) procedure. The subjects (sT1N0) were divided into the SNRG group (n=34) and the GL group, that consisted of patients which underwent gastrectomy according to the Japanese Gastric Cancer Association guidelines (n=33). We compared the area of the resected stomach and evaluated their body weight changes, and the results of a questionnaire survey about postoperative symptoms, and nutritional effects by blood tests administered at postoperative months (POM) 3, 6 and 12. The median area of the resected stomach was 104 cm2 in the SNRG group vs. 192 cm2 in the GL group. The body weight loss ratio was -5.9±5.8 vs. -9.3±4.1% at POM 3, and the henoglobin (g/dl) change rate was -1.1±7.9 vs. -6.4±6.5% at POM 12 in the SNRG and GL groups, respectively. There were no significant differences regarding the passage of food, reflux, the incidence of dumping syndrome, digestive and excretory function, or general condition and the satisfaction levels of the patients. In conclusion, SNRG has some advantages over GL in terms of postoperative disorders for at least one year after surgery, and is the recommended choice of a surgical procedure for early gastric cancer.

Background: Dumping syndrome is a well-known complication after upper gastrointestinal (GI) surgery. There are scarce data in the literature about the incidence of dumping after bariatric operations but, certainly no relation between this syndrome and laparoscopic sleeve gastrectomy (LSG) has been attempted., Methods: We conducted a prospective clinical study in order to evaluate the potential presence, incidence and severity of Dumping syndrome after LSG. Thirty one non-diabetic morbidly obese patients (eight male, 23 female) eligible for LSG were evaluated. Median age was 38 (22-58 years) and mean body mass index (BMI) was 45.55 (± 5.37). The diagnosis of dumping syndrome was based on clinical provocation of signs and symptoms using an oral glucose challenge before and 6 weeks after the operation. The Sigstad's dumping score was estimated in order to separate dumpers from non-dumpers, and the Arts questionnaire was completed to distinguish between early and late dumping. Moreover, blood glucose levels during the oral glucose challenge were measured., Results: No patient had symptoms of dumping after provocation preoperatively, whereas after LSG 9 patients (29%) experienced definite dumping and other 5 patients (16%) symptoms suggestive of dumping syndrome. Arts' questionnaire demonstrated that dumping occurrence after LSG was associated with early symptoms. Late hypoglycaemia occurred in one patient., Conclusion: A significant proportion of patients after LSG experienced dumping syndrome upon provocation. It seems that LSG should no longer be considered as a pure restrictive procedure, and it might be an option for heavy sweeters by changing their food tolerance patterns.

Background: Nissen Fundoplication is a common surgical procedure performed in treating gastroesophageal reflux disease (GERD). Complications include dysphagia, gastric hypersensitivity, abnormal gastric motility, gas bloat syndrome and GERD relapse. Dumping syndrome may occur when a large volume of gastric content is delivered to the duodenum or jejunum, resulting in both gastrointestinal and vasomotor symptoms. Occasionally, dumping syndrome may be a complication in patients that have undergone nissen Fundoplication, especially in adults. The BreathID® continuous online 13C-Octanoicoctanoic acid breath test detects variations of less than 1/100,000 in the 13CO2/12CO2 ratio in exhaled air., Case Presentation: We report a case of a 38 year old male who was admitted and diagnosed with dumping syndrome following nissen Fundoplication, who was diagnosed using the BreathID® continuous online 13C-Octanoic acid breath test., Conclusions: Early performance of a gastric emptying rate breath test in symptomatic patients, following upper GI tract surgery may help in the prediction or diagnosis of nissen Fundoplication complications such as dumping syndrome.

Background: Laparoscopic Roux-en-Y gastric bypass (RYGB) is one of the most common bariatric procedures performed. Dumping syndrome, intolerance to RYGB-induced restriction, and weight loss issues are possible problems bariatric surgeons are confronted with. This study reports the feasibility, safety, and outcomes of laparoscopic reconversion of RYGB to original anatomy (OA) as treatment of these complications., Methods: Between January 2005 and April 2008, eight patients benefited from laparoscopic reconversion of RYGB to OA. Reason was dumping syndrome without postprandial hypoglycemia (three), intolerance to RYGB-induced restriction (three), too much (one) and too little weight loss (one). Mean weight and body mass index (BMI) at RYGB were 104.7±19.3 kg and 38.7±6 kg/m(2), respectively. Four patients suffered of obesity co-morbidities. Mean time between RYGB and reconversion was 21±18.8 months. Mean weight, BMI, and % excess weight loss at reconversion was 66.8±21.7 kg, 20.1±7 kg/m(2), and 23.7±55%, respectively. The procedure involved dismantling both gastrojejunostomy and jejunojejunostomy, reanastomosing gastric pouch to gastric remnant, and proximal alimentary limb end to distal biliary limb end., Results: Mean operative time was 132.2±29.5 min. There were no conversions to open surgery and no early complications. Gastrogastrostomy was performed manually (four) and by linear stapler (four), and jejunojejunostomy by linear stapler (eight). Mean hospital stay was 7.7±3.5 days. After a mean follow-up of 18.3±9.2 months, two patients continued to further lose weight, two patients maintained the same weight, and four patients presented weight regain. Gastroesophageal reflux disease appeared in three patients., Conclusions: Laparoscopic reconversion of RYGB to OA is feasible and safe. Dumping syndrome and intolerance to RYGB-induced restriction are resolved. The anatomy remains one of the aspects besides nutritional and psychological factors in cases of reconversion for weight issues.

Objective: A new technique for endoscopic plication and revision of the gastric pouch (EPRGP) for patients who underwent gastric bypass (RGB) surgery was evaluated in patients with severe GERD, dumping syndrome, failure of weight loss, or all of these., Patients and Methods: Patients underwent EPRGP over a 12-month period. The StomaphyX device (Endogastric Solutions, Redmond, WA) was utilized over a standard flexible gastroscope. Patients were kept on a liquid diet for 1 week., Results: The study included 64 patients with a mean age of 48 years who underwent 67 procedures. EPRGP was performed an average of 5 years after RGB. The mean preoperative BMI was 39.5 kg/m². The primary indications for the procedure were inadequate weight loss, dumping syndrome (42), and GERD (15). The mean follow-up period was 5.8 months (range, 3 to 12). The average operative time was 50 minutes, with a significant reduction with increased operator experience. There were only 2 (3%) intraoperative complications during the early period (equipment failure), which did not result in any morbidity. All symptoms from dumping syndrome or reflux improved, with no further operative-related complications. The mean weight loss was 7.3 kg., Conclusions: This study demonstrates the technical feasibility, safety, and efficacy of EPRGP.

Background: Dumping syndrome is a well-described consequence of Roux-en-Y gastric bypass. Although the condition can benefit some patients with morbid obesity, a subset will develop intractable dumping syndrome characterized by symptomatic episodes with most meals. We describe the first series of patients successfully treated endoscopically for intractable dumping syndrome., Methods: Endoscopic gastrojejunal anastomotic reduction was performed in patients with intractable dumping syndrome after Roux-en-Y gastric bypass using a combination of argon plasma coagulation, endoscopic suturing, and fibrin glue. The technical feasibility of endoscopic anastomotic reduction and the clinical improvement in dumping symptoms were assessed by clinical follow-up., Results: Endoscopic anastomotic reduction was technically successful in 6 consecutive patients with a dilated gastrojejunal anastomosis and intractable dumping syndrome. One patient reported hematemesis 2 days after the procedure that was treated endoscopically. No other significant complications occurred. Complete and persistent resolution of the dumping symptoms was achieved in all patients, with a median follow-up of 636 days., Conclusion: Endoscopic anastomotic reduction appears technically feasible and safe and might be a minimally invasive treatment option for patients who experience intractable dumping symptoms after Roux-en-Y gastric bypass. Additional studies are needed to determine the long-term efficacy of this procedure., (2010 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Bariatric surgery is, at present, the most effective method to achieve major, long-term weight loss in severely obese patients. Recently, severe recurrent symptomatic hyperinsulinemic hypoglycemia was described as a consequence of gastric bypass surgery (GBS) in a small series of patients with severe obesity. Pancreatic nesidioblastosis, a hyperplasia of islet cells, was postulated to be the cause, and subtotal or total pancreatectomy was the suggested treatment., Methods: We observed that severe, disabling hypoglycemia after GBS occurred only in patients with loss of restriction. Whether restoration of gastric restriction might treat severe, recurrent hypoglycemia after GBS is unknown., Results: Therefore, gastric restriction was restored by surgical placement of a silastic ring (n = 8, first two patients with additional distal pancreatectomy) or an adjustable gastric band (n = 4) around the pouch in 12 consecutive patients presenting with severe hypoglycemia (blood glucose below 2.2 mM). At follow-up after restoration of gastric restriction (median follow-up 7 months, range 5 to 19 months), 11 patients demonstrated no hypoglycemic episodes, while one had recurrence of hypoglycemia and underwent distal pancreatectomy. Procedural mortality was 0% and morbidity 8.3%., Conclusion: Patients suffering from severe recurrent hypoglycemia after GBS can be treated, in most cases, just by restoration of gastric restriction. Distal pancreatectomy should be considered a second-line treatment.

Background: Laparoscopic Roux-en-Y gastric bypass (RYGBP) is considered as a non-reversible procedure. We report the laparoscopic conversion of RYGBP into a normal anatomy., Methods: In June 2004, a laparoscopic RYGBP was performed in a 46-year-old female sweet-eater with BMI 46 kg/m(2). After 7 months, the patient reported a significant and incapacitating dumping syndrome without postprandial hypoglycemia. She requested conversion to a normal anatomy; hence, a laparoscopic RYGBP reversal was performed. The BMI at the time was 27 kg/m(2)., Results: Operative time was 95 minutes and intra-operative blood loss was 150 ml. The patient had an uneventful recovery and was discharged home on the 5th postoperative day. At 6 months follow-up, her BMI was 27 kg/m(2), and barium swallow showed good passage with good gastric motility. After 1 year, the BMI is still unchanged and she is doing well., Conclusion: Restoration of normal anatomy after RYGBP is feasible.

The aim of the study was the evaluation of efficacy of the resection with pyloric retention proposed by the authors as a method for prevention of post gastroresectional damping syndrome in patients with ulcers. Resection with pyloric retention is performed in six modifications of three basic methods of resections. We have the experience of using this approach in 712 clinical cases. Among them 237 were women and 475 were men 19-75 years of age. It was shown that resection with pyloric retention provides rhythmic evacuation and prevents development of damping syndrome and duodenal reflux. It was found that the main reasons of the development of postgastroresectional syndromes include wide-area mobilization of the stomach and resection of the small curvature, which induce insufficiency of cardia, atony, chronic disturbances of the duodenal passing. Due to the retention of pyloric function damping syndrome have been developed only in 3 patients. In all these cases the syndrome was mild. It may be concluded that gastric resection with pyloric retention represents the most "physiological" intervention and has many advantages in comparison with other methods.

Aiming to minimize the surgical trauma and interventional risks of treatment, as well as to reach the most precise visualization and safe separation of the n. vagus, in order to increase the efficacy of truncal vagotomy during correction of severe post-gastric-resection dumping syndrome we have developed the new method of thoracoscopic supradiafragmal vagotomy. The suggested method of bilateral thoracoscopic supradiafragmal truncal vagotomy allows to decrease the surgical intervention trauma, and the risk of post operative complications, as well as to better the immediate and remote results of treatment of the dumping syndrome.

A new method of treatment of reflux-esophagitis developed for patients after gastrectomy has a distinctive moment: the formation of a restraining mechanism in the field of esophago-gastric anastomosis, without opening the intestinal tube lumen. The carried on trials of clinical application of the method have shown its high effectiveness for prophylactics ofjejuno-esophageal reflux both in the early and distant terms after operation. The method of operating was given a patent of the Russian Federation.

Aim of the study is to evaluate the causes of dumping syndromes following partial gastrectomies, and to report an unusual feature of dumping. A case of early dumping due to diverticular-like dilation of gastro-jejunal anastomosis is described with preoperative imaging and intraoperative picture. The surgical correction led to complete clinical remission; the common causes and physiopathological bases of dumping are reviewed and the role of en-Y gastro-jejunal reconstruction is underlined in order to reduce the risk of developing the syndrome.

During the last twenty years a significant reduction of the number of gastric resections on account of peptic ulceration occurred due to better therapeutic possibilities in gastrodudodenal ulcers and due to changes in the epidemiology of gastric tumours. However, resections are made, frequently on account of complicated cases of unsuccessful treatment of ulcers in "treatment at any cost". This problem was frequently the subject of professional discussions. Therefore we consider it important to remind young colleagues of the omitted chapter of possible pathological conditions which develop after gastric resections. The latter include a group of vasomotor, gastrointestinal and humoral symptoms which develop as a result of the loss of reservoir function and the function of the closing mechanism of the pyloroantral part of the stomach after gastric resections in derivation surgery. In addition to data in the literature reporting that dumping syndrome is encountered only in 2-3% of any gastric operation the authors describe two of their own observations and the results of their surgical treatment.

Between 5-50% of patients undergoing gastric resection still develop postgastrectomy syndrome in spite of the development of surgical techniques and an improved knowledge of gastrointestinal physiopathology: unfortunately, 2-5% of these patients require surgery. The technique to be used depends on a careful clinical and instrumental evaluation aimed at identifying the dominant type of postresection syndrome and any associated lesions, on the previous operation and obviously on the intraoperative situation. Soupault-Bucaille's gastroduodenojejunoplasty aims to correct the postresection syndrome by reinserting the duodenum in the digestive circuit, interposing between it and the gastric stump a jejunal loop made from the efferent (or afferent in the case of Billroth II with efferent on the lesser gastric curvature). This reconstitutes a paraphysiological condition of the digestive circuit, reduces biliary reflux and resolves acute gastritis. It is indicated in patients affected by early or late dumping syndrome, or multi-deficiency syndromes that do not respond to pharmacological therapy. The presence of concomitant biliary reflux is not a contraindication for this procedure, but confirms the need. Roux-en-Y is able to produce better results in postgastrectomy syndromes with alkaline gastritis and/or esophagitis sustained by biliary reflux, gastric atonia and afferent loop syndromes.

A method of reduodenization providing the formation of the invagination-valvular jejunoduodenal and sphinctero-valvular esophagojejunoanastomoses has been developed for treatment of patients with postgastroresectional disorders. The method allows the duodenum to be included in the process of digestion by means of creation of the small intestine transplant from the efferent intestinal loop. For prevention of regurgitation at the remote postoperative period the invagination-valvular jejunoduodenal anastomosis was formed by the authors method. Observation of the patients during 5 years following the operation showed good functional results of the operation proposed.

An experience with treatment of 545 patients with organic, functional and combined postgastroresectional syndromes (PGRS) is analyzed. The patients are divided into groups depending on the character of the syndromes and their combinations. The most frequent causes of the development of PGRS are formulated. Special methods of preoperative examination and preparing are described which allow individual approach to choice of the method of reconstructive-restorative operations. Some technical details of the reconstructive interventions are described. In 95% of the patients operated upon long-term results of treatment were good and satisfactory.

The experience of treatment of 303 patients with the operated stomach diseases (OSD) is summarized. It was established that to reduce the frequency of their occurrence it is necessary: to perform vagotomy especially selective proximal (SPV) thoroughly for complete acid producing zone denervation achievement; to examine gastric cardia and pyloroduodenal zone before and intraoperatively thoroughly to select an optimal method of its drainage; to conduct conservative therapy of ulcer disease after vagotomy conduction up to the ulcer defect healing according to endoscopic control data.

Surgical treatment of 293 patients with diseases of an operated on stomach is analysed. Relapse of peptic ulcer after closure of a perforation was encountered in 170 patients, the dumping syndrome in 54, peptic ulcer of the anastomosis in 60, the afferent loop syndrome in 6, and a rare type of diseases of an operated on stomach in 3 patients. Classification of diseases of an operated on stomach according to the syndromes and differential diagnosis of functional syndromes are presented. Indications for surgical correction depending on the type and severity of the pathological condition were developed. The late-term results were studied in 266 patients. The results were good in 72%, satisfactory in 21%, and poor in 7% of cases. The late-term results in surgical correction of functional syndromes were good in 29%, satisfactory in 51.6%, and poor in 13.5% of patients. Mortality after all repeated operation was 1.3%.

Dumping is a common adverse effect of gastrectomy and severe dumping is one of the most intractable conditions in gastroenterology. When medical treatment and diet are insufficient, different operative techniques have been tried, all with an unsatisfactory rate of success. The Lygidakis technique for operative treatment of postgastrectomy-dumping is presented, and results from operations on four patients presented. The results obtained are promising, and Lygidakis operation may be considered as an important alternative to wellknown operative techniques when medical treatment or diet is without effect on severe dumping.

We report herein the case of a 76-year-old man with intractable dumping syndrome which had manifested itself 3 years after he underwent a gastric resection and Billroth I reconstruction for a gastric ulcer. Despite aggressive medical therapy by the time of admission, he had suffered from disabling dumping symptoms for 9 years. In an attempt to relieve these symptoms, a 15-cm segment of the jejunum was placed isoperistaltically between the lesser curvature of the remnant stomach and the duodenum, and a selective vagotomy was performed. The dumping symptoms that he had experienced preoperatively completely disappeared after the revisory surgery. Postoperatively, an upper gastrointestinal series demonstrated a larger gastric pouch and slower gastric passage into the small intestine than what was seen preoperatively, while gastric emptying studies using the acetaminophen method also showed normal patterns in both the early and late postoperative phases. Thus, we consider that this surgical procedure is a simple and effective way to inhibit rapid gastric emptying and to slow intestinal transit in the treatment of dumping syndrome.

Clinical follow-up results of 876 patients with operated stomach malady, 342 of whom were operated on, were analyzed. In 58% of patients after the perforation closure the ulcer recurrence occurred, in 26% after gastric resection--peptic ulcer, in 26%--functional pathological syndrome. Surgical tactics depended on character of previously conducted procedure, general condition and age of the patient, secretory function of stomach and operative situation. Complications occurred in 6.1% of patients. Mortality was 1.2%.

During the last 100 years, since Cesar Roux (1857-1934) began utilizing his "Loop-en-Y" procedure for gastric outlet obstruction, this technique fell into disfavour but later, with the vagotomy, it was adapted for multiple applications. The greatest factor in its revival has been the treatment of postgastrectomy sequels, including alkaline reflux gastritis, reflux esophagitis, dumping and other syndromes. Additionally Roux-en-Y anastomosis has been used to drain diverse organs as the biliary tract, pancreas and esophagus. The main complication of loop-en-Y is the Roux syndrome, secondary to gastric or efferent jejunal stasis, or both. As the centennial of Roux's first use of his eponymic procedure approaches its seems appropriated to remind its memory as a part of our surgical inheritance.

The results of surgical treatment of 158 patients with gastric cancer, using the original techniques for the esophago-gastric and esophago-intestinal anastomoses formation, have been summarized. Gastrectomy was performed in 65.2%, subtotal proximal reaction of the stomach--in 8.9%, subtotal distal resection--in 25.9% of the patients. The postoperative lethality was 3.2%. At late complex examination, I stage reflux esophagitis after gastrectomy was observed in 3 (3.4%) patients, after proximal gastric resection--in 1 (8.3%). After the operation, 32 (20.3%) patients are alive for 5 and more years.

An examination of 9 patients with primary and postoperative reflux gastritis has found severe forms subject to surgical correction. When choosing the operative method, not only the intensity of reflux of the duodenal content and the character of alterations of gastric mucosa were taken into consideration but also the cause of chronic disorders of the duodenal patency. In all the patients complete disappearance of preoperative symptoms was noted.

The aim of this paper is to describe the technique, indications, and results of the Roux operation as used in the treatment of postgastrectomy syndromes. A Roux gastrojejunostomy with a 40-cm Roux limb is the procedure of choice for alkaline reflux gastritis, because it virtually eliminates reflux of bile and pancreatic juice into the stomach. The slow transit through a Roux limb can also be used to good advantage to slow gastric emptying in patients with dumping. Patients with delayed gastric emptying respond to the combination of near-total gastric resection, which removes the atonic gastric remnant and speeds emptying, and Roux-Y gastrojejunostomy, which prevents reflux esophagitis and provides a reservoir for ingesta in the upper gut. After all Roux operations, however, the Roux limb may slow emptying so much that pain, fullness, nausea, and food vomiting result, the so-called Roux stasis syndrome. Prevention of the Roux stasis syndrome with an "uncut" Roux limb and the treatment of the syndrome by using electrical pacing to suppress the ectopic pacemakers that emerge in the limb offer possible new solutions to this vexing problem.