Gastric pouch resizing (GPR) for recurrent weight gain after primary RYGB is a safe procedure promoting weight stabilisation or even mild weight loss, as well as a resolution of obesity-associated comorbidities in well-selected patients, according to researchers from the University of Zurich, Zurich, Switzerland. The findings were reported in the paper, ‘Gastric Pouch Resizing for Recurrent Weight Gain After Roux-en-Y Gastric Bypass - Does It Have Its Rational?’, published in Obesity Surgery.
The researchers noted that whilst bariatric surgery is the most effective treatment for obesity and its associated comorbidities, recurrent weight gain is reported in up to 40% of patients after Roux-en-Y gastric bypass (RYGB), and can result in a recurrence of obesity-associated comorbidities. Gastric pouch resizing (GPR) is performed as a low-risk secondary surgery to cease weight regain.
Therefore, they analysed the effect of GPR after primary RYGB on long-term weight loss, course of comorbidities, safety, and patient satisfaction, from their patients at the University Hospital of Zurich. In total, 48 patients underwent GPR between 2016 and 2020. Additionally, 37 patients participated in a survey to evaluate patient-reported outcome measures (PROMs).
The procedure was performed laparoscopically and included a resection of the enlarged gastric pouch and a redo of the gastrojejunostomy. All the adhesions around the gastric pouch were completely removed to assess the size of the gastric pouch and the gastrojejunostomy without restriction. Next, with a horizontal resection above the gastrojejunostomy, the gastric pouch was detached from the jejunum.
After inserting a large gastric tube, lateral resection towards the angle of His along the tube was performed to create a slim gastric pouch. The jejunum was mobilised in such a way that a tension-free anastomosis was possible. The gastrojejunostomy was performed with a circular (until 2016) or linear stapler (after 2016). The resected part of the gastric pouch as well as the primary gastrojejunostomy were excised from the jejunum close to the new anastomosis and were removed via an access port in an endo bag. Finally, a blue-dye test was performed to rule out leakage on the new gastrojejunostomy.
Of the 48 patients, 39 (81.3%) were female, the mean age was 46±10 years at the time of GPR. The mean operation time was 117 ± 33 min. The mean time after the primary RYGB until the GPR operation was 106±45.5 months (minimum of 23 months and a maximum of 229 months).
Following upper endoscopy in 81.3% (n=39), an enlarged gastric pouch with a volume greater than 60ml was documented in 64.1% (25 out of 39) patients, whereas a widening of the gastrojejunal anastomotic diameter greater than 2cm was observed in 5.1% (2 out of 39) patients. A total of 95.8% (n = 46) patients received contrast imaging before GPR. An enlarged gastric pouch was documented in 87% (40 out of 46) on contrast imaging, with delayed gastric pouch emptying recorded in 67.4% (31 out of 46) patients.
Overall, a total of 22 (45.8%) patients had recurrent weight gain alone and an enlarged gastric pouch. Eight (16.7%) patients exhibited both recurrent weight gain and recurrence of one or more comorbidities along with an enlarged gastric pouch. Eighteen patients (37.5%) experienced a recurrent weight gain of less than 20% from their nadir weight, but at the time of GPR had high BMI levels (ten patients had a BMI≥40kg/m2; seven patients had a BMI between 35 and 39 kg/m2) with an enlarged gastric pouch and/or recurrence of comorbidity. One patient was indicated for GPR with a BMI below 30 kg/m2 due to the recurrence of a major comorbidity and an endoscopically confirmed wide gastrojejunostomy.
In 91.7% (44 out of 48) of GPR, a redo of the gastrojejunostomy was performed - 25% (12 out of 48) were performed using a circular-stapled anastomosis (CSA), while 66.7% (32 out of 48) were performed with a linear stapler anastomosis (LSA). An additional 8.3% of patients (4 out of 48) underwent resection of a massively enlarged gastric fundus alone without redoing the gastrojejunostomy.
The initial mean BMI before RYGB was 49±7.3 kg/m2. A mean nadir-BMI of 31±5.2 kg/m2 was reached after 26.3±19.4 months. GPR was performed at a mean BMI of 39±5.4kg/m2. The overall mean follow-up after GPR was 55.9±18 months, with follow-ups of three months, one and five years were available for 47 (97.9%), 41 (85.4%) and 25 (52.1%) patients, respectively. The researchers reported no difference in weight course after GPR for patients with a circular- or linear-stapled gastrojejunostomy.
With regards to obesity-associated diseases, the researchers noted:
Prior to RYGB, pre-diabetes was observed in 12 (25%) patients, decreasing to 2 (4.2%) patients post-RYGB. Diabetes was present in 8 (16.7%) patients before RYGB with a 100% remission rate after surgery. However, 2 (4.2%) patients experienced a relapse before GPR. At follow-up, none of the patients was still suffering from pre-diabetes or continuing antidiabetic medication.
Arterial hypertension was present in 28 (58.3%) patients before and decreased to five (10.4%) patients after RYGB. Ten patients experienced a relapse, accounting for 15 (31.3%) patients with arterial hypertension at the time of GPR. At follow-up, 8 (18.2%) patients were continuing antihypertensive medication.
OSAS was present in seven (14.6%) patients before and decreasing to one (2.1%) after RYGB. Before GPR, 2 (4.2%) patients were treated for OSAS and were continuing CPAP therapy at follow-up. Dyslipidaemia was present in 26 (54.2%) patients before and decreased to four (8,3%) after RYGB. Nine patients experienced a relapse, accounting for 13 (27.1%) patients with dyslipidaemia at the time of GPR. Six (13.6%) patients were still not within reach of normal lipid values at follow-up.
Overall, obesity-associated comorbidities present prior to GPR resolved in 52.9% (in 18 of 34, p<0.05) of patients (Figure 1).
There was no mortality, whilst minor complications occurred in 12.5%of patients, with major complications occurring in 10.4% of patients within the first year of follow-up.
The re-operation rate was 8.3% over a mean follow-up of 55.9 ± 18.5 months. Two patients underwent revisional surgery for internal hernias during the first year of follow-up. Two other patients received additional secondary bariatric surgery for recurrent weight gain within 5 years after GPR.
Ninety-seven percent of patients stated that primary RYGB had a positive impact on their quality of life, and 67.2% of patients indicated that surgery also positively influenced their comorbidities. A total of 78.4% of patients confirmed that they had expected more weight loss after GPR, with 94.6% of the survey participants saying they would choose both surgeries again.
“The goal in the future needs to be the evaluation of combinational therapies including surgical and pharmacological means based on different stages of the disease as well as timeline regimes while the benefits must outweigh the risk of postoperative complications,” the researchers concluded. “Hence, personalised surgery with individualised indication appears to be key.”
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