The first study to demonstrate the safety and effectiveness of a conversion from sleeve gastrectomy (SG) to a Ring-augmented Roux-en-Y Gastric Bypass (RaRYGB), has been published by researchers from the Netherlands. They reported that significant cumulative weight loss was achieved at one-year follow-up, which is comparable to primary RYGB, while resolution of medical-associated problems was comparable to conversion from SG to standard RYGB. The study, ‘Short-term safety and effectiveness of conversion from sleeve gastrectomy to Ring augmented Roux-en-Y gastric bypass’, was published in BMC Surgery.
The authors noted that despite the popularity of SG, an estimated 20 to 30% of patients eventually require revisional or conversional surgery due to non-response, weight recurrence and gastrointestinal complaints (such as stenosis and/or severe gastro-oesophagal reflux disease (GERD). Conversion option include a most performed surgical procedures after a SG a re-sleeve or conversion to either RYGB or single-anastomosis duodeno-ileal bypass (SADI).
Although conversion to RYGB has been shown to be especially effective regarding GERD, it can result in a lower percentage total weight loss (%TWL) compared to primary RYGB. To improve weight loss and minimize weight recurrence after RYGB, a silicone ring (MiniMizer Ring, Bariatric Solutions International) can be added on the pouch above the gastrojejunal anastomosis and multiple studies have shown the benefits of adding this silicone ring resulting in increased weight loss and less weight recurrence up until five years after RaRYGB vs regular RYGB. However, the silicone ring can also cause complications as slippage, erosion and dysphagia.
Therefore, the researchers sought to evaluate the short-term safety and effectiveness of conversion from SG to RaRYGB regarding weight loss, medical-associated problems, and complications.
All procedures were performed laparoscopically. Five trocars were placed and if necessary adhesiolysis was performed, especially between the gastric sleeve and the liver to ensure the placement of the liver retractor. First an 8–10 cm long pouch was created by transection of the sleeve and was resized over a 40 French orogastric tube. If a hiatal hernia was present, cruroplasty was performed. The jejunum was identified at the ligament of Treitz and the biliopancreatic limb was measured at a length of 60 cm in all patients. The limb was brought antecolically and antegastrically to the gastric pouch and a linear stapled end-to-side gastrojejunal anastomosis was created. The biliopancreatic limb was transected and a side-to-side jejunojejunal anastomosis was created with an alimentary limb of 120 cm. Both mesenteric defects were closed using endoclips.
The MiniMizer silicone ring was placed around the pouch. The MiniMizer was placed at least 2cm above the gastrojejunal anastomosis and at least 2cm below the gastroesophageal junction. The closing position was standardised at 7.5 cm for males and 7.0cm for females. The MiniMizer was fixated on the vertical staple line with a non-absorbable suture. Post-operatively patients follow an obligated five-year postoperative trajectory at the Dutch Obesity Clinic.
Outcomes
A total of 50 patients were include in the study, 44 were female (88%) and 6 male (12%). The patients had a mean age of 44 years (± 10.3), the median preoperative BMI was 37.6 kg/m2 (33.4–40.8) and the medical-associated problems consisted of hypertension (18%), T2DM (2%), obstructive sleep apoena (8%), GERD (36%) and dyslipidaemia (6%). The indications for conversion were weight recurrence (40%) or gastrointestinal complaints (60%). Of the patients with gastrointestinal complaints the majority also experienced recurrent weight gain (60%).
In 22 (44%) of the patients a hiatal hernia (HH) repair was performed simultaneously with the RaRYGB conversion. In the conversion group with gastro-intestinal problems 50% had simultaneous HH repair while 35% of the weight recurrence group also underwent a simultaneous HH repair. Twenty-nine patients had a closing position of 7cm and 21 of 7.5cm. Of the male patients 83.3% had a MiniMizer closing position of 7.5cm while 63.6% of the females had a closing position of 7cm.
Mean BMI at screening for SG was 45.9 kg/m2 (± 8.4) while the mean BMI at screening for the conversion was 37.7 kg/m2(+ 7.6). The one-year follow-up point was reached by all patients while data was available for 40/50 (80%) of patients. Of the 40 patients, the mean %TWL after one-year follow-up calculated from the conversion was 17.8±10. The weight loss resulted in a mean BMI of 31.1 kg/m2±6.7 after one-year.
At the moment of screening for conversion, patients had a mean %TWL of 17.9 (±13.4). After the one-year follow-up the cumulative %TWL, calculated from the primary surgery was 32±12.9.
The effect on weight was also compared for the subgroups, based on the indication for conversion. The patients who were operated due to weight recurrence had a significant higher mean BMI of 40.7+7.2 kg/m2 before conversion, compared to a BMI of 36.2±7.2 kg/m2 for the patients with gastrointestinal complaints (p=0.017). At one-year follow-up the %TWL was 18.9±8.2 for the weight recurrence group and 16.6±11.2 for the gastrointestinal complaints group (p = 0.470, Figure 1: %TWL loss over time).
A total of 17 patients reported 22 short- and long-term complications. Ten occurred in eight patients (16%) within 30 days. Of the short-term complications six were classified as Clavien-Dindo (CD) of ≤ CD3a and four were classified as ≥ CD3b. The short-term complications consisted of internal herniation, anastomotic stenosis, anastomotic leakage, anastomotic bleeding, wound infection and intra-abdominal abscess formation. Of these, six complications required reinterventions namely four laparoscopically (CD3b) and two endoscopically (CD3a). In all but one of the complications either prolonged admission or readmission was required.
Within the first year, three patients (6%) had a MiniMizer related complication. Two patients had slippage of the ring which was corrected surgically by repositioning of the ring. One patient had dysphagia complaints without signs of erosion or slippage of the ring resulting in the MiniMizer being laparoscopically removed. At one-year follow-up, the MiniMizer was still in situ in 47 of the patients. In addition to the removal due to dysphagia, the MiniMizer was removed within the 30-day post-operative time frame as part of the surgical treatment of anastomotic leakage in two patients.
During screening for conversion, the prevalence of the associated medical problems was available in all 50 patients and resulted in 35 medical problems being present. For hypertension the prevalence was 18%, for T2DM 2%, for sleep apoena 8%, for GERD 36% and for dyslipidaemia 6%. Of the 35 medical problems at one-year follow-up five (14.2%) remained unchanged, 15 (42.9%) improved and 15 (42.9%) achieved remission.
“The findings of our study suggest that conversion from SG to RaRYGB is safe and effective with favourable short-term outcomes,” the researchers concluded. “The RaRYGB seems especially suitable for patients experiencing weight recurrence. Our study aligns with these (previous studies) with an improvement of GERD in 94.4% and shows the RaRYGB is non-inferior to the standard RYGB. Therefore, the MiniMizer can be beneficial for many patients.”
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