When patients present with disruptive symptoms after Metabolic Bariatric Surgery (MBS), delivery of effective therapy requires identification of the cause(s) of the symptoms. There are, however, no diagnostic schema radiologically, endoscopically, manometrically or using pH/Impedance studies that are validated for patients with abnormal or post-surgical anatomy. In addition to this, assumptions that bypass conversions are reliable for reflux control have proven incorrect when post-surgical patients are followed in the longer term. Despite these problems, combined modality investigations, when interpreted together can give correlative information that can be used to assist in decision making. In a series of 65 patients undergoing anatomic studies and physiology studies for foregut symptoms after MBS, only 20% of patients did not have identifiable anatomic or manometric abnormalities. In this cohort 50% of patients with reported normal anatomy had abnormal manometry whereas only 14% of patients with abnormal anatomy did not have abnormal manometry. This suggests that anatomic reporting can be insufficiently sensitive and raises the possibility of insufficient specificity/oversensitivity of oesophageal physiology studies. Accordingly, this presentation discusses enhanced anatomical reporting of the stomach and oesophagus, and how this can be related to symptoms, physiologic derangement and treatment outcomes.

To determine the incidence, timing, type, and indications for revisional surgery (defined as any operation performed after primary MBS up to 10 y). Understanding long-term reoperation rates is essential for patient counselling and service planning in metabolic bariatric surgery (MBS). While primary MBS is well established as the most effective treatment for severe obesity, revisional procedures are increasingly required due to weight regain, complications or intolerance of the index procedure. However, high-quality population-level data on revision risk after metabolic bariatric surgery is limited. We conducted a retrospective cohort study using prospectively collected data from the Australian and New Zealand Bariatric Surgery Registry. Patients undergoing primary MBS on or before December 31, 2023, were followed for up to 10 years. Kaplan-Meier analysis was conducted. 145,193 patients (median age 42 (IQR 33-50) years 78.7% female) underwent primary MBS. Over a median 5.6 y (IQR 2.9–8.1), 5,681 patients (4%) underwent a first revisional surgery (7.3 per 1,000 person-years; 95% CI, 7.1-7.4). The observed incidence was highest after AGB (28.7%; 46.7% reversals), followed by RYGB (4.8%; 94.8% corrective), OAGB (3.5%; 52.7% corrective) and SG (2.5%; 69.6% conversions). AGB revisions were mostly due to recurrent weight gain (13.3%) and port-related issues (12.7%); reflux was the most common reason after SG (29.1%) and OAGB (27.3%), while strictures were the most frequent indication following RYGB (23.4%). Incidence, type, and indication of revisional procedures differ from those of the primary procedure. These findings may guide patient decision-making and health system planning.

OBJECTIVE:To determine the incidence, timing, type, and indications for revisional surgery (defined as any operation performed after primary MBS up to 10 y). BACKGROUND:Understanding long-term reoperation rates is essential for patient counselling and service planning in metabolic bariatric surgery (MBS). While primary MBS is well established as the most effective treatment for severe obesity, revisional procedures are increasingly required due to weight regain, complications or intolerance of the index procedure. However, high-quality population-level data on revision risk after metabolic bariatric surgery is limited. METHODS:We conducted a retrospective cohort study using prospectively collected data from the Australian and New Zealand Bariatric Surgery Registry. Patients undergoing primary MBS on or before December 31, 2023, were followed for up to 10 years. Kaplan-Meier analysis was conducted. RESULTS:145,193 patients (median age 42 (IQR 33-50) years 78.7% female) underwent primary MBS. Over a median 5.6 y (IQR 2.9-8.1), 5,681 patients (4%) underwent a first revisional surgery (7.3 per 1,000 person-years; 95% CI, 7.1-7.4). The observed incidence was highest after AGB (28.7%; 46.7% reversals), followed by RYGB (4.8%; 94.8% corrective), OAGB (3.5%; 52.7% corrective) and SG (2.5%; 69.6% conversions). AGB revisions were mostly due to recurrent weight gain (13.3%) and port-related issues (12.7%); reflux was the most common reason after SG (29.1%) and OAGB (27.3%), while strictures were the most frequent indication following RYGB (23.4%). CONCLUSIONS:Incidence, type, and indication of revisional procedures differ from those of the primary procedure. These findings may guide patient decision-making and health system planning.

Abstract Topic Benign Disease: Gastro-Esophageal Reflux and Hiatal Hernia Background Fundoplication is often performed during hiatus hernia (HH) repair to control reflux, but whether routine fundoplication improves long-term gastrointestinal outcomes remains uncertain. This study assessed the differences in the impact of routine and selective fundoplication approaches on symptomatic recurrence and reoperation rates after HH repair. Methods This retrospective, single-surgeon cohort study included 410 patients who underwent HH repair between February 2005 to October 2020. Patients who underwent HH repair prior to June 2014 routinely received fundoplication (non-selective era cohort; NSEC), whereas from June 2014 onwards, fundoplication was selectively performed (selective era cohort; SEC). Symptomatic recurrence rates, reoperation rates and cumulative rates were compared between the two cohorts. Statistical analyses consisted of Chi-square, Kaplan-Meier, and Cox regression analyses. Results Median follow-up period of entire cohort was 32 months (IQR 3-78). The NSEC had significantly higher rates of symptomatic recurrence (p=0.027), reoperation (p<0.001), and cumulative reoperation (Log-rank p=0.002) compared to the SEC. Selective fundoplication and no fundoplication in the SEC were associated with lower hazard of reoperation compared to routine fundoplication (aHR 0.267, 95% CI 0.080–0.890, p=0.032; HR 0.402, 95% CI 0.176–0.919, p=0.031). Conclusion In this cohort, routine fundoplication did not prevent symptomatic recurrence. On the other hand, selective fundoplication approach achieves acceptable outcomes and lowers risk of reoperation. Selective fundoplication offered physiological benefit without exposing patients without reflux to unnecessary surgical complications. However, interpretation must account for surveillance bias. Further prospective studies with standardised pre- and post-operative assessment, and follow-up protocols are needed to confirm these results.

BACKGROUND:To determine if the positive outcomes from clinical trials regarding the safety and efficacy of metabolic bariatric surgery are reproducible at a national level. METHODS:A longitudinal registry-based observation study with data collected from all persons undergoing metabolic bariatric surgery in Australia from 28 February 2012-31 December 2021 including data from 122,567 index patients who underwent 134,625 completed bariatric procedures. MAIN OUTCOMES AND MEASURES:Defined adverse outcomes at 90-days (unplanned readmission, intensive care admission and re-operation; death), annual change in weight (percent total body weight loss (TBWL)), diabetes treatment and need for re-operation. RESULTS:79.0% of participants were female. Mean age on the day of surgery was 44.0 years (SD 11.8; range 12.9-87.9 years) and mean BMI 41.7 kg/m2 (SD 7.6). At 5-years participants who underwent one anastomosis gastric bypass had TBWL 34.88% (SD 8.67%), roux-en-Y gastric bypass 30.73 % (SD 9.47%); sleeve gastrectomy 26.5% (SD 10.5%) and adjustable gastric bands 17.6% (SD 12.1%). At 90-days 3.6% of procedures recorded a defined adverse event. 13,904 (13.6%) primary participants reported being treated for diabetes at baseline. No medication for diabetes was required by 71.6% (follow-up 58%) at 1-year and 61% (follow-up 22%) at 5-years. 13 904 (13.6%) primary participants reported being treated for diabetes at baseline. No medication for diabetes was required by 71.6% (follow-up 58%) at 1-year and 61% (follow-up 22%) at 5-years. CONCLUSIONS:Metabolic bariatric surgery is safe and induces substantial weight loss with reduced need for diabetes medications in the real-world. CLINICALTRIALS: GOV ID:NCT03441451.

BACKGROUND:Inguinal hernia repair in patients with high body mass index (BMI) ≥25 kg/m2 is associated with higher technical difficulties and longer perioperative time. Few studies, however, have compared the outcomes of laparoscopic versus open inguinal hernia repair in patients with high BMI in the Australian population. METHODS:In this retrospective observational study, we analyzed the data from 315 adult patients with a healthy BMI of 18.5-24.9, overweight BMI of 25-29.9, and obese BMI of 30-≥40 and analyzed the operative time and recovery time considering the type of surgery, patient comorbidities, BMI category, and operator expertise. RESULTS:There is a significant positive relationship between the BMI of the patient and the type of surgery performed (laparoscopic/open) as well as the BMI and recovery time p < 0.001. CONCLUSION:Post-operative recovery time was measurably longer in patients with BMI > 25, with an average of 28 extra minutes compared to patients with a normal BMI. Open inguinal hernia repair was mainly offered to morbidly obese patients (obesity class 3) and elderly patients, and laparoscopic surgery was offered to younger patients with lower BMI.

BACKGROUND:There is currently a lack of consensus regarding the timing of ventral hernia repair relative to bariatric surgery. OBJECTIVES:To compare outcomes between patients undergoing simultaneous and selectively deferred ventral hernia repair and bariatric surgery. SETTING:High volume UPPER gastrointestinal and Bariatric Unit. Sydney, Australia. METHODS:A retrospective case series from a single institution's prospectively collected database (2003-21) was performed to determine the characteristics and outcomes in patients having simultaneous and deferred hernia repair relative to their bariatric surgery. RESULTS:In our patient cohort (N = 134), 111 patients underwent simultaneous repair and 23 had a deferred procedure. Of the simultaneous patients, 95 (85.6%) underwent resection bariatric surgery. The median operative time in the simultaneous versus deferred groups was 155 versus 287 minutes and the length of stay was 3 versus 7 days. There has been one (.9%) mesh infection requiring explant, in an open, simultaneous repair undertaken in a gastric band patient, 3 (2.8%) infected seromas, 1 (.9%) surgical site infection, and 8 (7.5%) hernia recurrences in the simultaneous group. The deferred group has had no mesh infections, no hernia recurrence, and 2 (9.5%) infected seromas to date. There was 1 mortality in the simultaneous cohort (simultaneous gastric bypass group), from a massive Pulmonary Embolism (<30 days postoperatively) and one in the deferred group from an interval small bowel obstruction. CONCLUSIONS:Simultaneous ventral hernia repair with bariatric surgery had a low rate of infection and a low mesh explant rate, even when coupled with resection bariatric surgery in this series. A combined approach may be safe, even in the clean-contaminated surgical context.

Laparoscopic sleeve gastrectomy (LSG) is currently the most commonly performed bariatric surgery in the world and is widely considered safe and effective for weight loss in the obese population. However, intractable gastroesophageal reflux disease (GERD) following LSG poses a clinical challenge, with significant impact on quality of life and the potential for development of Barrett’s esophagus This review aims to provide clinicians with a systematic approach to investigating and managing patients with intractable GERD following LSG. Management of GERD following LSG requires thorough clinical, anatomical and functional assessment in order to accurately diagnose GERD. Management should then be tailored to the patient in an integrated approach, with medical, endoscopic and/or operative interventions. Medical therapy includes PPIs and lifestyle therapy and are well established for GERD in the post-LSG population but limited in efficacy for severe disease. Endoscopic treatments such as anti-reflux mucosectomy and endoscopic radiofrequency ablation are novel, and benefits are still unclear. Operative interventions include conversion to Roux-en-Y gastric bypass with or without hiatal hernia repair, one anastomosis gastric bypass, duodenal switch, hiatal hernia repair or insertion of a Linx ™ device. These options have predominantly been studied in weight-loss failure post-LSG, with emerging evidence now in the treatment of intractable GERD following LSG. A three-pronged assessment including clinical factors, anatomical evaluation and functional studies are required to accurately diagnose intractable GERD following LSG. Following this, individualised management with medical therapy, endoscopic and/or operative interventions should be considered with the patient within a multidisciplinary healthcare setting.

The aim of this report is to describe the management of an iatrogenic diaphragmatic eventration following surgery to relieve neurogenic symptoms of thoracic outlet syndrome in a patient with a prior history of sleeve gastrectomy. We discuss the case of a 46-year-old woman with a 6-month history of gastro-oesophageal reflux and dyspnoea. Imaging demonstrated a left hemidiaphragm eventration and hiatus hernia. The patient underwent laparoscopic plication of the left hemidiaphragm, repair of the hiatus hernia, and an omega loop gastric bypass, with satisfactory resolution of her symptoms. This demonstrates that surgical diaphragmatic plication has good outcomes in cases where the abdominal anatomy is already altered as a result of previous bariatric surgery, and that concurrent hiatus hernia repair, plication of iatrogenic diaphragm eventration, and sleeve to gastric bypass conversion satisfactorily relieve reflux and dyspnoea in a morbidly obese patient.

Purpose Revision bariatric surgery may be undertaken after weight loss failure and/or complications following primary bariatric surgery. This study aims to compare the efficacy and safety of revision laparoscopic sleeve gastrectomy (RLSG) after gastric banding (GB) to those of primary laparoscopic sleeve gastrectomy (PLSG). Materials and Methods A retrospective, propensity-score matched study was conducted to compare between PLSG (control) patients and RLSG after GB (treatment) patients. Patients were matched using 2:1 nearest neighbor propensity score matching without replacement. Patients were compared on weight loss outcomes and postoperative complications for up to five years. Results 144 PLSG patients were compared against 72 RLSG patients. At 36 months, PLSG patients had significantly higher mean %TWL than RLSG patients (27.4 ± 8.6 [9.3–48.9]% vs. 17.9 ± 10.2 [1.7–36.3]%, p < 0.01). At 60 months, both groups had similar mean %TWL (16.6 ± 8.1 [4.6–31.3]% vs. 16.2 ± 6.0 [8.8–22.4)]%, p > 0.05). Early functional complication rates were slightly higher with PLSG (13.9% vs. 9.7%), but late functional complication rates were comparatively higher with RLSG (50.0% vs. 37.5%). The differences were not statistically significant ( p > 0.05). Both early (0.7% vs 4.2%) and late (3.5% vs 8.3%) surgical complication rates were lower in PLSG patients compared to RLSG patients but did not reach statistical significance ( p > 0.05). Conclusion RLSG after GB has poorer weight loss outcomes than PLSG in the short-term. Although RLSG may carry higher risks of functional complications, the safety of RLSG and PLSG are overall comparable. Graphical abstract

Purpose Despite the benefits of bariatric surgery for many patients, there are a proportion of patients who do not achieve adequate weight loss. We evaluate the role of liraglutide as adjuvant pharmacotherapy in those who respond poorly to weight loss surgery. Materials and Methods A non-controlled, prospective, open-label cohort study in which participants are prescribed liraglutide following inadequate response to weight loss surgery. The efficacy and tolerability of liraglutide was measured through measurement of BMI and monitoring of side effect profile. Results A total of 68 partial responders to bariatric surgery were included in the study, 2 participants were lost to follow-up. Overall 89.7% lost weight on liraglutide, with 22.1% showing a good response (>10% total body weight loss). There were 41 patients who discontinued liraglutide mainly due to cost. Conclusion Liraglutide is efficacious in achieving weight loss and reasonably well tolerated in patients who have inadequate weight loss post-bariatric surgery.

Hereditary diffuse gastric cancer (HDGC) caused by the CDH1 gene mutation is an inherited cancer syndrome that increases the risk of diffuse gastric cancer and is nearly impossible to detect by screening gastroscopy. The recommended preventative treatment is a total gastrectomy. Robotic surgery facilitates the use of minimally invasive surgical (MIS) techniques for anastomoses and posterior vagus preservation to potentially reduce adverse functional outcomes. An asymptomatic 24 year old male with the CDH1 gene mutation proven by genetic testing and a family history of a brother having a total gastrectomy for HDGC was treated with this technique. This video case report demonstrates the techniques and pitfalls of robotic surgery in terms of the patient positioning and port placement, posterior vagus-preserving dissection, sutured esophagojejunostomy, jejunal pouch formation, and Roux-en-Y reconstruction with a staple-stapled jejunojejunostomy. While these techniques are demonstrated in the case of prophylactic gastrectomy, many of them can be applied to other benign and bariatric foregut and general surgery types.Robotic surgery can facilitate the foregut MIS technique, as described in this case of a vagus-sparing total gastrectomy.

Introduction Bariatric surgery predisposes patients to nutritional deficiencies. There are limited studies on zinc and copper abnormalities in this cohort. Purpose The aim of this study was to identify the prevalence of these abnormalities in a cohort of Australian bariatric patients. Inflammatory markers, adherence to multivitamin supplementation (MVS) and the presence of gastrointestinal (GI) symptoms were also investigated. Material and Methods Data was collected on all patients who attended a single clinic in Sydney, Australia, from August 2020 to August 2021. Results The study cohort consisted of 231 patients (76.2% female; mean pre-operative body mass index of 43.4 ± 7.1 kg/m 2 ), most of whom underwent sleeve gastrectomy (78.8%). Data were collected preoperatively and then at ≤ 6 months, 1 and > 2 years postoperatively. Prior to surgery, low levels of zinc (2.1%) and copper (0.7%) were rare, but elevated copper levels were common (16.7%) and potentially related to an elevated C-reactive protein (CRP) (47.7%). Following surgery at > 2 years, the mean total weight loss (TWL) was 33.5 ± 12.4. CRP levels improved over time. Post operatively, low zinc (2.7–3.6%) and copper (1.5%) levels were rare. Patients with low levels in zinc and copper were a higher-risk group and generally exhibited GI symptoms, despite taking MVS. Conclusion In the initial post-operative stages and with good adherence to MVS containing copper and zinc, abnormalities may not be a concern. Patients with GI symptoms appear to be at higher risk of abnormalities; increasing awareness, thorough screening, and more comprehensive supplementation are recommended. Graphical Abstract