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One Anastomosis Gastric Bypass for Revisional Bariatric Surgery: Assessment of Short-Term Safety

Pivo, Sarah; Jenkins, Megan; Fielding, Christine Ren; Kim, Mirhee; Schwack, Bradley
PURPOSE/OBJECTIVE:With the continued increase in bariatric procedures being performed in the USA, a growing percentage are revisions for weight regain after sleeve gastrectomy (SG) and gastric banding (LAGB). Standard practice in the USA involves conversion to Roux-en-Y gastric bypass (RYGB). Internationally, one anastomosis gastric bypass (OAGB) has become a popular and effective alternative. Without the jejuno-jejunal anastomosis, OAGB has reduced potential related long-term complications. The purpose of this study is to compare the short-term safety of revision to OAGB versus RYGB. MATERIALS AND METHODS/METHODS:Patients who underwent conversion to OAGB from LAGB or SG for weight regain from January 2019 to October 2021 were compared to BMI, sex, and age-matched patients who underwent conversion to RYGB. RESULTS:In our study, 82 patients were included, 41 in each cohort (41 OAGB vs. 41 RYGB). The majority in both groups underwent conversion from SG (71% vs. 78%). Operative time, estimated blood loss, and length of stay were comparable. There was no difference in 30-day complications (9.8% vs. 12.2%, p = .99) or reoperation (4.9% vs. 4.9%, p = .99). Mean weight loss at 1 month was also comparable (7.91 lbs vs 6.36 lbs). CONCLUSIONS:Patients undergoing conversion to OAGB for weight regain had similar operative times, post-operative complication rates, and 1-month weight loss compared to those who underwent RYGB. While more research is needed, this early data suggests that OAGB and RYGB provide comparable outcomes when used as conversion procedures for to failed weight loss. Therefore, OAGB may present a safe alternative to RYGB.
PMID: 37191735
ISSN: 1708-0428
CID: 5503522

Body Weight and Prandial Variation of Plasma Metabolites in Subjects Undergoing Gastric Band-Induced Weight Loss

Bruno, Joanne; Verano, Michael; Vanegas, Sally M; Weinshel, Elizabeth; Ren-Fielding, Christine; Lofton, Holly; Fielding, George; Schwack, Bradley; Chua, Deborah L; Wang, Chan; Li, Huilin; Alemán, José O
BACKGROUND:Bariatric procedures are safe and effective treatments for obesity, inducing rapid and sustained loss of excess body weight. Laparoscopic adjustable gastric banding (LAGB) is unique among bariatric interventions in that it is a reversible procedure in which normal gastrointestinal anatomy is maintained. Knowledge regarding how LAGB effects change at the metabolite level is limited. OBJECTIVES/OBJECTIVE:To delineate the impact of LAGB on fasting and postprandial metabolite responses using targeted metabolomics. SETTING/METHODS:Individuals undergoing LAGB at NYU Langone Medical Center were recruited for a prospective cohort study. METHODS:We prospectively analyzed serum samples from 18 subjects at baseline and 2 months after LAGB under fasting conditions and after a 1-hour mixed meal challenge. Plasma samples were analyzed on a reverse-phase liquid chromatography time-of-flight mass spectrometry metabolomics platform. The main outcome measure was their serum metabolite profile. RESULTS:We quantitatively detected over 4,000 metabolites and lipids. Metabolite levels were altered in response to surgical and prandial stimuli, and metabolites within the same biochemical class tended to behave similarly in response to either stimulus. Plasma levels of lipid species and ketone bodies were statistically decreased after surgery whereas amino acid levels were affected more by prandial status than surgical condition. CONCLUSIONS:Changes in lipid species and ketone bodies postoperatively suggest improvements in the rate and efficiency of fatty acid oxidation and glucose handling after LAGB. Further investigation is necessary to understand how these findings relate to surgical response, including long term weight maintenance, and obesity-related comorbidities such as dysglycemia and cardiovascular disease.
PMCID:10195098
PMID: 37216066
ISSN: 2451-8476
CID: 5543652

The Effect of Laparoscopic Sleeve Gastrectomy on Gastroesophageal Reflux Disease

Silveira, Flavia Carvalho; Poa-Li, Christina; Pergamo, Matthew; Gujral, Akash; Kolli, Sindhura; Fielding, George A; Ren-Fielding, Christine J; Schwack, Bradley F
BACKGROUND:The laparoscopic sleeve gastrectomy (LSG) has become one of the most popular surgical weight loss options. Since its inception as a procedure intended to promote durable weight loss, the association between LSG and gastroesophageal reflux disease (GERD) has been a point of debate. First and foremost, it is known that GERD occurs more frequently in the obese population. With the sleeve gastrectomy growing to be the predominant primary bariatric operation in the United States, it is imperative that we understand the impact of LSG on GERD. OBJECTIVE:To examine the effects of LSG on GERD symptoms. METHODS:One hundred and ninety-one bariatric surgery candidates completed a Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire before and after undergoing elective LSG (mean follow-up time of 20.4 ± 2.7 months). Values were stratified by the presence or absence of preoperative GERD, GERD medications, age, gender, crural repair, patient satisfaction with present condition, and percent total weight loss (%TWL). RESULTS:respectively. Within the overall cohort, there was no significant change in GERD symptoms from before to after surgery (mean GERD-HRQL scores were 6.1 before and after surgery, p = 0.981). However, in a subgroup analysis, patients without GERD preoperatively demonstrated a worsening in mean GERD-HRQL scores after surgery (from 2.4 to 4.5, p = 0.0020). The percentage of change in the usage of medications to treat GERD was not statistically significant (from 37 to 32%, p = 0.233). The percent of patients satisfied with their condition postoperatively was significantly increased in those with preoperative GERD, older age, crural repair intraoperatively, and in those with the highest %TWL. CONCLUSION/CONCLUSIONS:These results suggest that while overall LSG does not significantly affect GERD symptoms, patients without GERD preoperatively may be at risk for developing new or worsening GERD symptoms after surgery. It is important to remark that this is a review of the patient's clinical symptoms of GERD, not related to any endoscopic, pathological, or manometry studies. Such studies are necessary to fully establish the effect of LSG on esophageal health.
PMID: 33244654
ISSN: 1708-0428
CID: 4681062

Gastrojejunostomy stricture after Roux-en-Y gastric bypass, a 17 year experience [Meeting Abstract]

Nowak, B; Fielding, G; Kurian, M; Schwack, B; Bedrosian, A; Ren-Fielding, C
Introduction: The gastrojejunostomy (GJ) during Roux-en-Y gastric bypass (RYGB) can be performed by stapled or hand-sewn techniques, and is at risk for anastomotic stricture, reported in the literature at rates from 0 to 33%. This study reviews a single center's experience with anastomotic stricture and intervention required. Methods and Procedures: A retrospective chart review was performed of 904 patients who underwent RYGB as primary or revisional surgery at a single institution from October 2000 through September 2017. There were 182 patients excluded for follow up duration of less than 1 year, 5 for an esophagojejunostomy rather than GJ, and 1 for gastroparesis as the surgical indication rather than morbid obesity. This left 716 patients to be included in the study. Demographic and operative data were collected including technique for GJ, postoperative follow up, and complications, with a focus on GJ stricture and subsequent interventions.
Result(s): Gastrojejunostomy (GJ) was performed with a 25 CEEA stapler in 674 (94.1%) patients, with a linear stapler in 25 (3.5%), was hand-sewn in 7 (1.3%), and the technique was unknown in the remaining 8 (1.1%). Roux-en-Y gastric bypass was performed as a primary surgery in 522 (72.9%) patients and as a revisional surgery in 194 (27.1%). Stricture of the GJ was diagnosed in 29 (4.1%) patients. The average time to diagnosis of early strictures occurring prior to 3 months was 40.3 days, and for late strictures was 871 days. By technique, stricture was diagnosed in 26 (3.9%) patients in the 25CEEAgroup, 1 (4%) in the linear stapler group, and 2 (22.2%) in the hand-sewn anastomosis group. In primaryRYGBpatients stricture was diagnosed in 20 (3.8%) patients, and in revisionalRYGB in 9 (4.6%) patients (p = 0.626). Esophagogastroduodenoscopy (EGD) with dilation was performed at least once (1-9 times) in 26 patients, 2 with concomitant stenting, 2 required operative intervention, and 1 patient awaits operative intervention. Both patients who required surgery also had marginal ulcers, and possible gastro-gastric fistula at time of surgery.
Conclusion(s): The results of this study show that the 25 CEEA circular stapler is a reasonable technique for performance of the GJ anastomosis in RYGB, with a stricture rate of 3.9%. There is also a slightly increased stricture rate in revisional surgical patients, though not statistically significant
EMBASE:627144201
ISSN: 1432-2218
CID: 3811422

Effects of a single subanaesthetic dose of ketamine on pain and mood after laparoscopic bariatric surgery: A randomised double-blind placebo controlled study

Wang, Jing; Echevarria, Ghislaine; Doan, Lisa; Ekasumara, Nydia; Calvino, Steven; Chae, Floria; Martinez, Erik; Robinson, Eric; Cuff, Germaine; Franco, Lola; Muntyan, Igor; Kurian, Marina; Schwack, Bradley F; Bedrosian, Andrea S; Fielding, George A; Ren-Fielding, Christine J
BACKGROUND:When administered as a continuous infusion, ketamine is known to be a potent analgesic and general anaesthetic. Recent studies suggest that a single low-dose administration of ketamine can provide a long-lasting effect on mood, but its effects when given in the postoperative period have not been studied. OBJECTIVE:We hypothesised that a single low-dose administration of ketamine after bariatric surgery can improve pain and mood scores in the immediate postoperative period. DESIGN/METHODS:We performed a randomised, double-blind, placebo-controlled study to compare a single subanaesthetic dose of ketamine (0.4 mg kg) with a normal saline placebo in the postanaesthesia care unit after laparoscopic gastric bypass and gastrectomy. SETTING/METHODS:Single-centre, tertiary care hospital, October 2014 to January 2018. PATIENTS/METHODS:A total of 100 patients were randomised into the ketamine and saline groups. INTERVENTION/METHODS:Patients in the ketamine group received a single dose of ketamine infusion (0.4 mg kg) in the postanaesthesia care unit. Patients in the placebo groups received 0.9% saline. OUTCOME MEASURES/METHODS:The primary outcome was the visual analogue pain score. A secondary outcome was performance on the short-form McGill's Pain Questionnaire (SF-MPQ). RESULTS:There were no significant differences in visual analogue pain scores between groups (group-by-time interaction P = 0.966; marginal group effect P = 0.137). However, scores on the affective scale of SF-MPQ (secondary outcome) significantly decreased in the ketamine group as early as postoperative day (POD) 2 [mean difference = -2.2 (95% bootstrap CI -2.9 to 1.6), Bonferroni adjusted P < 0.001], compared with placebo group in which the scores decreased only by POD 7. Scores on the total scale of SF-MPQ for the ketamine group were smaller compared with the placebo group (P = 0.034). CONCLUSION/CONCLUSIONS:Although there was no significant difference between ketamine and placebo for the primary outcome measure, patients who received ketamine experienced statistically and clinically significant improvement in their comprehensive evaluation of pain, particularly the affective component of pain, on POD 2. However, future studies are needed to confirm the enduring effects of ketamine on the affective response to postoperative pain. CLINICAL TRIAL REGISTRATION/BACKGROUND:NCT02452060.
PMID: 30095550
ISSN: 1365-2346
CID: 3226762

ONE VERSUS TWO STAGE GASTRIC BAND CONVERSION TO SLEEVE GASTRECTOMY: A COMPARISON OF WEIGHT LOSS OVER FIVE YEARS Revisional surgery [Meeting Abstract]

Nowak, B.; Ren-Fielding, C.; Fielding, G.; Kurian, M.; Schwack, B.
ISI:000480523003105
ISSN: 0960-8923
CID: 4071502

Long-term results for gastric banding as salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass

Liu, Shinban; Ren-Fielding, Christine J; Schwack, Bradley; Kurian, Marina; Fielding, George A
BACKGROUND:Studies reporting revisionary options for weight loss failure after Roux-en-Y gastric bypass (RYGB) have been underpowered and lacking long-term data. We have previously shown that short-term (12 mo) and midterm (24 mo) weight loss is achievable with laparoscopic adjustable gastric banding (LAGB) for failed RYGB. The present study represents the largest published series with longest postoperative follow-up of patients receiving salvage LAGB after RYGB failure. OBJECTIVE:To investigate long-term results of salvage gastric banding. SETTING/METHODS:University Hospital, New York, United States. METHODS:Data were prospectively collected with retrospective review. Baseline characteristics were evaluated and weights at multiple time intervals (before RYGB, before LAGB, each year of follow-up). Additional data included approach (open or laparoscopic), operative time, hospital length of stay, and postoperative complications. RESULTS:with 22.5% total weight loss and 65.9% excess weight loss. The long-term reoperation rate for complications related to LAGB was 24%, and 8% of patients ultimately had their gastric bands removed. CONCLUSION/CONCLUSIONS:The results of our study have shown that LAGB had good long-term data as a revisionary procedure for weight loss failure after RYGB.
PMID: 30154032
ISSN: 1878-7533
CID: 3480472

Gastric band conversion to Roux-en-Y gastric bypass shows greater weight loss than conversion to sleeve gastrectomy: 5-year outcomes

Creange, Collin; Jenkins, Megan; Pergamo, Matthew; Fielding, George; Ren-Fielding, Christine; Schwack, Bradley
BACKGROUND:Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are often used as revisional surgeries for a failed laparoscopic adjustable gastric band (LAGB). There is debate over which procedure provides better long-term weight loss. OBJECTIVE:To compare the weight loss results of these 2 surgeries. SETTING/METHODS:University hospital, United States. METHODS:A retrospective review was conducted of all LAGB to RYGB and LAGB to LSG surgeries performed at a single institution. Primary outcomes were change in body mass index (BMI), percent excess BMI lost, and percent weight loss. Secondary outcomes included 30-day complications and reoperations. RESULTS:The cohort included 192 conversions from LAGB to RYGB and 283 LAGB to LSG. The baseline age and BMI were similar in the 2 groups. Statistical comparisons made between the 2 groups at 24 months postconversion were significant for BMI (RYGB = 32.93, LSG = 38.34, P = .0004), percent excess BMI lost (RYGB = 57.8%, LSG = 29.3%, P < .0001), and percent weight loss (RYGB = 23.4%, LSG = 12.6%, P < .0001). However, the conversion to RYGB group had a higher rate of reoperation (7.3% versus 1.4%, P = .0022), longer operating room time (RYGB = 120.1 min versus LSG = 115.5 min, P < .0001), and longer length of stay (RYGB = 3.33 d versus LSG = 2.11 d, P < .0001) than the LAGB to LSG group. Although not significant, the conversion to RYGB group had a higher rate of readmission (7.3% versus 3.5%, P = .087). CONCLUSION/CONCLUSIONS:Weight loss is significantly greater for patients undergoing LAGB conversion to RYGB than LAGB to LSG. However, those undergoing LAGB conversion to RYGB had higher rates of reoperation and readmission. Patients looking for the most effective weight loss surgery after failed LAGB should be advised to have RYGB performed, while also understanding the increased risks of the procedure.
PMID: 30449510
ISSN: 1878-7533
CID: 3480532

Predicting morbidity in Roux-en-y gastric bypass patients: A verified scoring tool [Meeting Abstract]

Defnet, A M; Fielding, C R; Fielding, G; Schwack, B; Youn, A; Craig, Wood G; Bedrosian, A
Introduction: We aimed to create a morbidity prediction score for patients undergoing RYGB using MBSA-QIP data. Methods and Procedures: We retrospectively analyzed all RYGB cases in MBSA-QIP during 2015, and identified factors associated with 30-day complications using chi-squared analysis. Multiple logistic regression identified pre-operative factors independently associated with 30-day complication to develop a prediction score, verified using a Cochran Armitage trend test. Results: For 42,849 procedures, there were 3034 (7.1%) with any 30-day complication. Preoperative patient characteristics independently associated with increased risk of morbidity are shown in Table 1. A scoring algorithm was formulated by assigning points based on strength of the odds ratio (Table 1), with the final score a summation of points accrued. The rate of any 30-day complication was evaluated across the range of scores (Table 2). Higher scores were associated with a higher rate of morbidity (p<0.0001 for each). [Figure Presented] Conclusion: We created and verified a morbidity prediction score for patients undergoing RYGB based on MBSA-QIP data
EMBASE:622359803
ISSN: 1432-2218
CID: 3153972

Long term results for gastric banding as salvage procedure for patients with weight loss failure after Roux-en-y gastric bypass [Meeting Abstract]

Liu, S; Ren-Fielding, C J; Schwack, B; Kurian, M; Fielding, G A
Introduction: Laparoscopic Roux-en-Y gastric bypass (RYGB) is a common and effective form of bariatric weight loss surgery. However, a subset of patients will fail to achieve the expected total body weight loss (TBWL) greater than 20% after 12 months or experience significant weight regain despite dietary, psychiatric, and behavioral counseling. Although alternative procedural interventions exist for operative revision after suboptimal RYGB weight loss, laparoscopic adjustable gastric banding (LAGB) provides an option with short operative time, low morbidity, and effective results. We have previously demonstrated that short-term (12-month), and mid-term (24-month) weight loss is achievable with LAGB for failed RYGB. The objective of this study is to report the long term 5 year outcomes of LAGB after RYGB failure. Methods and Procedures: A retrospective review of prospectively collected data before and after RYGB when available, and before and after revision with LAGB was performed. The data included weight, height, body mass index, gender, race, age, operative time, length of stay, postoperative complications, and percentage of total body weight loss. Results: A total of 182 patients (81.3% female, 18.7% male) were included in this study. The mean age of patients undergoing LAGB after RYGB was 47+/-9.98 years old. The majority of patients (98.4%) underwent gastric band placement laparoscopically, with 2 patients requiring conversion to an open procedure, and 1 planned open approach. The mean preoperative weight was 319+/-64 lbs and BMI of 53+/-10 kg/m2 before RYGB. After RYGB, patients experienced a mean %TBWL of 16+/-11%, had a weight of 264+/-50 lbs, and a BMI of 43+/-7 kg/m2 before undergoing LAGB an average of 9 years after their first bariatric procedure. At the time of 5 year follow up after LAGB the patients had a %TBWL of 35+/-13%, weight of 201.9+/-46 lbs, and had a BMI of 33+/-7 kg/m2. The mean operative time was 73+/-34 minutes and 85% of patients had a hospital length of stay less than 24 hours. Conclusion: The results of our study have shown that LABG had good long term data as a revi-sionary procedure for weight loss failure after RYGB. Patients experienced a satisfactory amount of total body weight loss with reduction in BMI and had a short operative time and length of stay
EMBASE:622360922
ISSN: 1432-2218
CID: 3153902