Marginal ulcers (MUs) are a well- recognized complication after Roux-en-Y gastric bypass (RYGB) and one-anastomosis gastric bypass (OAGB). When medical therapy fails or complications occur, revisional surgery may become necessary. In addition, revisional surgery may be required in case of other gastric pouch pathologies, such as gastric pouch neoplasms. Laparoscopic gastric pouch resection with esophago-jejunostomy (LGPREJ) represents a feasible salvage option. This study aimed to evaluate LGPREJ as a salvage surgical option after pouch complications following gastric bypass surgery. We performed a retrospective analysis of all adults undergoing LGPREJ at a high‑volume Swiss bariatric center between January 2018 and December 2023. Patients had prior RYGB or OAGB and at least two years of follow-up. Primary outcomes were late morbidity, including recurrent MU and need for additional surgical or endoscopic interventions. Secondary outcomes included early complications, changes in Body Mass Index (BMI), and nutritional parameters. Eighteen patients (median age 47.5 years, 77.8

This study reports mid-term results on weight loss and T2D remission in patients undergoing Roux-en-Y gastric bypass (RYGB) with short versus long biliopancreatic limb (BPL). All patients with obesity undergoing RYGB procedures with long BPL (150 cm) versus short BPL (60 cm) between 2016 and 2021 at a tertiary reference center for bariatric surgery were compared using propensity score matching to assess for T2D remission, HbA1c evolution, weight loss and nutritional deficiencies. A total of 165 patients were included, 69 patients (71

INTRODUCTION:The aim of this study is to compare the outcomes between patients undergoing very-very long limb RYGB (VVLL-RYGB) and proximal RYGB (PRYGB) after adjustable gastric banding (LAGB). METHODS:All patients undergoing conversion from LAGB to RYGB in a bariatric reference center between 2010 and 2016 were analyzed. RESULTS:Sixty-six patients (80 ​% female, mean age 44.5 ​± ​9 years, pre-revisional BMI 40.2 ​± ​7.4 ​kg/m2) underwent conversion from LAGB to VVLL-RYGB, and 26 patients (88 ​% female, mean age 46.9 ​± ​7.6 years, pre-revisional BMI 37.2 ​± ​5.3 ​kg/m2) to PRYGB. ΔBMI 5 years after conversion was 8.2 ​± ​6.1 ​kg/m2 in VVLL-RYGB compared to 6.7 ​± ​5.1 ​kg/m2 in PRYGB (p ​= ​0.35). There was no significant difference in long-term morbidity. Further revisional procedures after VVLL-RYGB occurred in 10 (15.1 ​%) and 8 (30.8 ​%) after PRYGB (p ​= ​0.136). CONCLUSION:VVLL-RYGB and PRYGB after LAGB are safe and lead to significant and sustainable additional weight loss without difference in BMI loss between the procedures after 5 years.

AIMS: A wide range of reproductive health issues, including fertility, pregnancy outcomes and contraceptive practices can be affected by morbid obesity and weight loss subsequent to bariatric surgery. This study aimed to explore the attitudes and practices of bariatric healthcare professionals in Switzerland regarding reproductive health counselling in the context of bariatric surgery. METHODS: We conducted a national, cross-sectional, 36-question online survey among bariatric professionals in Switzerland. Survey topics included demographic factors, baseline characteristics of bariatric patients, perioperative reproductive health practices, attitudes and knowledge about contraception and recommendations regarding pregnancy. The survey was open from 1 October 2022 to 30 April 2023. RESULTS: A total of 75 healthcare professionals participated in the survey. The majority of participants responded that female patients of reproductive age constitute more than half of the referred bariatric patients. Forty participants (57%) recommended contraception for a duration of 18–24 months following a bariatric operation. Only twenty-three respondents (31%) stated that they always refer their female bariatric patients of reproductive age to a gynaecologist prior to bariatric surgery. Fifty-six participants (75%) replied that they always discuss family planning prior to surgery. There was high variation regarding the recommended methods of contraception after surgery.Only thirty-nine participants (52%) reported that they always inform their patients about the occurrence of possible surgery-related complications during future pregnancies. More than half of the participants reported inadequate knowledge regarding absorption and safety of contraceptive pills after bariatric surgery. Although most professionals routinely follow up and provide counselling on maternal and foetal risks in pregnant women with previous bariatric surgery, forty-nine participants (65%) have no standardised protocol for such patients who present with acute abdominal pain in their practice. CONCLUSION: Despite acknowledging the importance of reproductive health counselling, bariatric professionals address perioperative and contraception issues inconsistently and mostly reported a lack of adequate knowledge in the latter. Therefore, a stronger collaboration between bariatric professionals and women’s healthcare providers is needed to improve care of female bariatric patients of reproductive age.

One anastomosis gastric bypass (OAGB) has been proposed as an effective alternative to the current standard procedure in Switzerland, Roux-en-Y gastric bypass (RYGB). Prospective data comparing both procedures are scarce. Therefore, we performed a non-inferiority randomized controlled trial assessing the effectiveness and safety of these 2 operative techniques. Eighty patients were randomized 1:1. OAGB consisted of a very long gastric pouch with a 200 cm biliopancreatic limb, RYGB of a 150 cm ante-colic alimentary and a 60 cm biliopancreatic limb, respectively. Primary endpoint was the percent excess weight loss (

Abstract Background A significant proportion of bariatric patients are women of childbearing age. Bariatric patients may be at risk of nutritional and surgical complications that can be impacted by and can impact pregnancy. Aims We aimed to investigate perioperative reproductive health practices, knowledge and recommendations of bariatric professionals regarding reproductive health counseling, contraception and pregnancy in female bariatric patients of reproductive age. Methods We conducted a national, online survey among bariatric professionals. Survey topics included demographic factors, perioperative reproductive health practices, attitudes and knowledge about contraception and recommendations regarding pregnancy. Results A total of 72 healthcare professionals participated. The majority of participants responded that female patients of reproductive age are more than the half of the referred bariatric patients. Only 23 respondents (31.9%) referred always female patients of reproductive age to a gynecologist prior to a bariatric procedure, but 75% always discuss family planning. 51.4% of the participants do not recommend a certain type of bariatric operation in women of reproductive age, but 19 (26.4%) and 9 (12.5%) participants recommend Roux-en-Y gastric bypass and sleeve gastrectomy, respectively. There was a strong variance regarding the recommendations about contraception after surgery. Only 51.4% inform the patients about possible surgical, bariatric surgery-related complications during future pregnancies. More than half of the participants reported inadequate knowledge regarding absorption and safety of contraception pills after bariatric surgery. Although most professionals routinely follow- up and provide counselling on maternal and fetal risks in pregnant women with previous bariatric surgery, 65% have no standardized protocol for such patients who present with acute abdominal pain in their practice. Conclusions Despite acknowledging the importance of reproductive health counseling, bariatric professionals address perioperative and contraception issues inconsistently and mostly reported lack of adequate knowledge in the latter. Therefore, a stronger collaboration between bariatric professionals and women`s healthcare providers is needed to improve care of female bariatric patients in reproductive age.

Abstract Background Some patients who undergo laparoscopic Roux-en-Y gastric bypass (LRYGB) may present with insufficient weight loss or weight regain. Anatomical factors that may lead to failure of LRYGB include the size of the gastric pouch and the diameter of the gastro-jejunostomy. Aims This study explores the gastric pouch size and the size of the gastro-jejunostomy after LRYGB and investigates their impact on weight loss, appetite and quality of life (QoL). Methods Patients undergoing LRYGB in a single centre underwent computed tomography (CT) with oral contrast one day and one year after LRYGB. Volumetry of the gastric pouch and calculation of the size of the gastro-jejunostomy was performed. Appetite was assessed pre-operatively and one year after LRYGB using the Edmonton Appetite Assessment questionnaire. QoL was assessed pre-operatively one year after surgery using the GIQLI and BAROS questionnaires. Results 61 patients were included. Of those, 55 patients (90.2%) underwent CT one year after LRYGB. The mean preoperative Body Mass Index was 40.7±3.97kg/m2. The mean Excess weight loss (%EWL) one year after surgery was 82.1±21.5%. There was no significant change in mean gastric pouch size one day and one year after LYRGB (15.73±11.8cm3 and 14.4±11.5cm3, respectively, p=0.55). The mean size of the gastrojejunostomy increased significantly from 2.63cm2 to 3.60cm2 (p<0.0001). Mean GIQLI and BAROS values improved significantly one year after LRYGB, but no significant changes in the mean Edmonton Appetite Assessment values were found. %EWL and improvement in GIQLI and BAROS values one year after surgery did not correlate with the initial size of the gastric pouch and the increase of the size of the gastro-jejunostomy. Conclusions One year after LRYGB, the size of the gastro-jejunostomy increased significantly, but no difference in the gastric pouch volume was found. Both gastric pouch volume and dilatation of the gastro-jejunostomy did not correlate with weight loss and QoL outcomes.

Objective: Bariatric surgery has emerged as effective treatment for obesity not only for the substantial and durable weight loss, but also by improving several obesity-related comorbidities, including hypertension. Extracellular vesicles (EVs; membrane nanoparticles released by cells) and their cargo reflect endothelial dysfunction and inflammation, and may be used as indicators of post-surgical outcomes in these patients. The aim of the present study was to exploit an EV signature to assess cardiovascular (CV) risk, metabolic profile, and inflammatory fingerprint before and after bariatric surgery. Design and method: The study cohort was composed by 62 patients (age 39 years; 21% males); for each subject, clinical and biochemical parameters, disease status (including diabetes, dyslipidemia, and hypertension), medications, and EV profiling were evaluated at baseline (T0) and 1-/3-years (T1 and T2, respectively), after surgery (sleeve gastrectomy or Roux-en-Y gastric bypass). EVs were isolated from serum by beads-based immuno-capture and analyzed for the expression of 37 membrane-associated antigens. Results: After bariatric surgery, patients gradually lost weight from a median of 110 Kg at T0 down to 80 Kg at T2 (cumulative weight loss 31 Kg; 29.9% BMI reduction). Accordingly, the overall CV risk and metabolic-inflammatory profile of patients improved: systolic blood pressure, HbA1c, total cholesterol, triglycerides, LDL, uric acid, white blood cells, and C-reactive protein decreased, while HDL and renal function (expressed as eGFR) increased at follow-up (p < 0.05 for all comparisons); prevalence of hypertension, dyslipidemia, and diabetes decreased together with the number of assumed drugs (anti-hypertensives, statins, hypoglycemic, and anti-platelets agents). Consistently, levels of expression of EV specific markers (CD9-CD63-CD81) and 11 out of the 37 evaluated antigens (mainly from endothelium, platelets, and inflammatory cells) decreased at T1/T2, reflecting changes of main CV risk indicators. Interestingly, lower baseline levels of CD4, CD31, CD40, CD42a, and CD62P were associated to a complete post-surgical outcome, defined as no residual disease without medications, with a BMI at T2 lower than 30 Kg/sqm. Conclusions: EV-derived biomarkers reflect the improvement of CV profile in patients who underwent bariatric surgery and may become a new tool to predict post-surgical outcome.

Small bowel obstruction (SBO) due to internal hernias (IH) is a well-recognised complication after laparoscopic Roux-en-Y gastric bypass (LRYGB). Routine closure of the mesenteric defects (MDs) is recommended to reduce the risk of IH and subsequent SBO. However, data about the rates of reopening of the MDs after LRYGB is scarce. The main aim of this study was to evaluate the risk of reopening of the MDs after routine closure during LRYGB. The secondary objective was to determine any risk factors associated with the reopening of the MDs. Data of all patients who underwent reoperations after LRYGB with closure of both MDs between January 2010 and December 2018 were retrospectively reviewed. A total of 162 patients were included. The median time between LRYGB and reoperation was 17 months. At the time of reoperation, both MDs were closed in 83 patients (51.2%); thus, 79 patients (48.8%) presented at least one open MD. The group of patients with preoperative diagnosis of SBO or with recurrent abdominal pain showed significantly higher rates of open Petersen’s space compared to the group of patients with other preoperative diagnoses. Preoperative body mass index (BMI) less than 40 kg/m2 at time of LRYGB was associated with a higher risk for an open MD. At least one MD reopened in almost half of the patients despite routine closure during LRYGB. Therefore, the status of MDs should be routinely examined during every reoperation after LRYGB and closure of open MDs should be performed.

Marginal ulcer (MU) is a serious complication after Roux-en-Y gastric bypass (RYGB) procedures. This study reports the incidence, risk factors, and treatment outcomes of symptomatic and incidentally, at routine endoscopy diagnosed, MU. All patients undergoing RYGB procedures between 2013 and 2018 at a single center were included. Upper endoscopy was performed in case of symptoms and/or routinely 2 and 5 years postoperatively. In total, 568 patients (83.3% female) underwent RYGB procedure with a median age of 40 years and median initial body mass index of 41 kg/m2. The median time to follow-up was 2.99 years. Routine 2- and 5-year upper endoscopy was performed in 256 (55.3%) and 65 (38.0%) eligible patients, respectively. In 86 (15.1%) patients, MU was diagnosed at a median time of 14.2 months (4.58–26.2) postoperatively and 24.4% of patients with MU were asymptomatic. In total, 76.7% of MUs were located on the side of the Roux limb. 88.4% of MUs were treated conservatively; re-operation was necessary in 10 (11.6%) patients. Smoking and type 2 diabetes mellitus were the only independent risk factors for MU development in multivariate analysis with a hazard ratio of 2.65 and 1.18 (HbA1c per unit >6.0), respectively. MU is a common complication after gastric bypass surgery with 25% of patients being asymptomatic. Follow-up routine endoscopy is recommended for early MU detection and subsequent accurate therapy, especially in patients with the independent risk factors smoking and type 2 diabetes mellitus.

Purpose A subset of patients undergoing Roux-en-Y gastric bypass (RYGB) presents with either insufficient weight loss or weight regain. Data on the revisional restrictive options including laparoscopic adjustable gastric band (LAGB) is scarce. This study analyzes the mid-term efficacy and safety of LAGB as a revisional procedure after RYGB. Methods Data of all patients with revisional LAGB after primary RYGB between January 2011 and May 2019 were retrospectively reviewed. Outcomes included assessment of weight changes, resolution of comorbidities, and early and late complications during the study period. Results Twenty patients were included. The median Body Mass Index (BMI) before revisional LAGB was 34.8 (interquartile range [IQR] 31.9–38.1) kg/m 2 . After a median follow-up of 33.5 (IQR 19.5–76.5) months, the median BMI was 28.7 (IQR 26.1–32.2) kg/m 2 . The median additional Excess Weight Loss (EWL) was 37.6% (IQR 23–44.4), leading to a median total EWL of 79.5% (IQR 54.4–94.6). BMI and EWL post-LAGB improved significantly compared to BMI and EWL pre-LAGB (p<0.001 and p<0.001, respectively). Obstructive sleep apnea syndrome resolved 6 months after LAGB in one patient. Three band deflations occurred during the follow-up. Six patients underwent band removal after a median time of 19 (IQR 15.8–26) months. Overall, thirteen patients underwent a reoperation. There was no loss of follow-up until 5 years. After that, two patients were lost to follow-up. Conclusion LAGB may be a salvage option after failed RYGB. However, the high rate of revisions after secondary LAGB needs to be taken into consideration.

Weight regain after laparoscopic Roux-en-Y gastric bypass (RYGB) occurs in up to 35% of patients. Revisional surgery may be applied. Conversion from RYGB to a long biliopancreatic limb (BPL) RYGB is a potential option for revisional surgery and short-term results are promising. All patients who underwent conversion to long BPL RYGB due to weight loss failure, defined as excess weight loss (EWL) < 50% or body mass index (BMI) > 35 kg/m2, were assessed. Proximal RYGB or very very long limb RYGB (VVLL RYGB) was modified by shortening of the total alimentary limb length (TALL) to create a long BPL. A total of 28 patients received revisional surgery from either PRYGB (n = 22) or VVLL RYGB (n = 6). Mean age at operation was 45.3 ± 10.4 years, with 78% females. Mean prerevisional BMI was 41.7 ± 4.4 kg/m2. Mean time to revision was 76.5 ± 38.5 months. Limb lengths were 150 cm (95% CI 133–156 cm) for RL and 100 cm (95% CI 97–113 cm) for CC, thus providing a total median alimentary limb length of 250 (95% CI 238–260 cm). Additional %EWL and TWL improved significantly in long-term. Five years postoperatively, all patients (n = 9) had an EWL% > 50%. Six patients (21.4%) required reoperation due to severe malnutrition during the postoperative course. Conversion from RYGB to BPL RYGB leads to significant additional weight loss in the long term. However, the morbidity is relevant, especially severe protein malnutrition and the frequency of revisional surgery. Therefore, this type of surgery should not be done routinely.

Purpose Laparoscopic sleeve gastrectomy (SG) may be associated with long-term problems such as insufficient weight loss or weight regain, persistence or relapse of comorbidities, and gastroesophageal reflux disease (GERD). This study analyzes the outcome of patients that underwent conversion of SG to a gastric bypass procedure. Materials and Methods All patients that underwent conversion from SG to the following four different gastric bypass procedures were analyzed: short biliopancreatic limb (BPL) bypass types such as proximal Roux-en-Y gastric bypass (PRYGB) or type 2 distal Roux-en-Y gastric bypass (type 2 DRYGB) and long BPL types such as long BPL RYGB or one anastomosis gastric bypass (OAGB). Results Between 2012 and 2016, 52 patients received the following revisional procedures after primary SG: proximal RYGB ( n = 12, 23.1%), type 2 DRYGB ( n = 8, 15.4%), long BPL RYGB ( n = 20, 38.5%), and OAGB ( n = 12, 23.1%). The long BPL type procedures (long BPL RYGB, OAGB) resulted in a significant long-term additional %EWL (33.8%; 33.2%) at 3 years. In the PRYGB, the effect lasted only for 2 years. In all patients with GERD and dysphagia as the dominant post-SG symptoms, the conversion to a bypass procedure resulted in the complete resolution of these. Conclusion In case of weight regain or insufficient weight loss after SG, revisional surgery with a long BPL should be considered. The OAGB provides effective additional weight loss, with low morbidity and malnutrition rates, respectively. Conversion to the malabsorptive long BPL RYGB with a total alimentary limb length below 400 cm should be avoided. Patients that suffer primarily from post-SG GERD or dysphagia should undergo conversion to PRYGB.

The influence of the Roux limb (RL) length on weight loss in Roux-en-Y (RYGB)-type gastric bypass procedures is still unclear. This study analyzes the true impact of RL length by comparing the long-term outcomes of proximal RYGB (PRYGB) and very-very long limb RYGB (VVLL-RYGB). RL length in PRYGB was 150 cm. In VVLL-RYGB, common channel length was 100 cm. In both groups, biliopancreatic limbs measured 50–60 cm, resulting in equal total alimentary limb lengths. To adjust for pre-operative differences between groups, and to predict the long-term outcome, a mixed model analysis was performed. Two hundred thirty-two patients with VVLL-RYGB (73.7% female, mean age 41.1 ± 10 years, initial BMI 45.8 ± 6.3 kg/m2) and 223 with PRYGB (83.9% female, mean age 38.5 ± 11 years, initial BMI 42.9 ± 4.9 kg/m2) were included. Mean follow-up was 9.4 ± 4 years in VVLL-RYGB and 5.3 ± 1.9 years in PRYGB. After 5 years, mean BMI reduction was 15.7 ± 5.9 kg/m2 in VVLL-RYGB and 11.9 ± 4.1 kg/m2 in PRYGB (p < 0.001), and mean %EWL was 78.3 ± 23.1% and 70.2 ± 23.7% (p = 0.002) with a follow-up rate of 78% and 75.9%, respectively. The mixed model analysis showed a significantly higher weight rebound after PRYGB. Frequency of revisional surgery (i.e., limb length alteration, pouch banding) was similar between VVLL-RYGB and PRYGB (25 vs. 29 revisions, p = 0.463). The VVLL-RYGB has a significantly higher long-term BMI reduction and a significantly lower weight rebound. The length of the Roux limb significantly influences long-term outcome.