Bariatric Surgery and Relevant Comorbidities: A Systematic Review and Meta-Analysis

Authors

Claire Wunker¹, Sunjay Kumar², Peter Hallowell³, Amelia Collings⁴, Lindsey Loss⁵, Varun Bansal⁶, Bradley Kushner⁷, Theofano Zoumpou⁸, Tammy Lyn Kindel⁹, D. Wayne Overby¹⁰, Julietta Chang¹¹, Subhashini Ayloo¹², Andrew F. Sabour¹³, Omar M. Ghanem¹⁴, Essa Aleassa¹⁵, Adam Reid¹⁶, Noe Rodriguez¹⁵, Ivy N. Haskins¹⁷, L. Renee Hilton¹⁸, Bethany J. Slater¹⁹, Francesco Palazzo²⁰

ABSTRACT

Background: Obesity is a growing epidemic in the United States and, with this, has come an increasing volume of metabolic surgery operations. The ideal management of obesity-associated medical conditions surrounding these operations is yet to be determined. This review sought to investigate the routine use of intraoperative cholangiogram (IOC) with cholecystectomy during or after a bypass-type operation, the ideal management of post-sleeve gastrectomy gastroesophageal reflux disease (GERD), and the optimal bariatric operation in patients with known inflammatory bowel disease (IBD).

Methods: Using medical literature databases, searches were performed for randomized controlled trials (RCTs) and nonrandomized comparative studies from 1990 to 2022. Each study was screened by two independent reviewers from the SAGES Guidelines Committee for eligibility. Data were extracted while assessing the risk of bias using the Cochrane Risk of Bias 2.0 Tool and the Newcastle–Ottawa Scale for RCTs and cohort studies, respectively. A meta-analysis was performed using random effects.

Results: Routine use of IOC was associated with a significantly decreased rate of common bile duct injury, and a trend towards decreased intraoperative complications, perioperative complications, and mortality. The rate of reoperation, postoperative pancreatitis, cholangitis, and choledocholithiasis were low in the routine use of IOC group but no non-routine use studies evaluated these outcomes. After sleeve gastrectomy, GERD-specific quality of life was significantly higher in the surgically treated group compared to the medically treated group. Bypass-type operations had worse outcomes of IBD sequelae than sleeve gastrectomy, including pain, patient perception, and fistula formation. Sleeve patients had lower mortality and fewer short- and long-term complications.

Conclusions: Low quality data limited the conclusions that could be drawn; however, trends were observed favoring the routine use of IOC during cholecystectomy for patients with bypass-type anatomy, surgical treatment of GERD post-sleeve gastrectomy, and sleeve gastrectomy in IBD patients. Further research is needed to conclusively answer the questions posed in this review.

Keywords: Metabolic surgery · Cholangiogram · IBD · GERD · Bariatric · Comorbidities

Introduction

Almost 42% percent of American patients have obesity [1]. As this epidemic continues, metabolic surgery procedures are becoming more common [2], and thus, bariatric surgery’s impact on the care of other obesity-associated medical conditions is an important consideration both pre- and postoperatively. This review sought to evaluate three obesity-associated medical conditions that can impact the care of patients with obesity who have undergone or are being evaluated for weight loss surgery: cholelithiasis, gastroesophageal reflux disease (GERD), and inflammatory bowel disease (IBD).

Patients who undergo metabolic surgery procedures have an increased incidence of gallstones: up to 25% compared to 10-20% in the general population [3–5]. When these patients develop choledocholithiasis, the altered anatomy typically precludes endoscopic retrograde cholangiopancreatography (ERCP), and alternative treatment strategies must be pursued. We sought to determine if bariatric patients with bypass-type anatomy should undergo routine intraoperative cholangiogram at the time of cholecystectomy.

Approximately half of all patients with obesity suffer from concurrent GERD and sleeve gastrectomy has been shown to worsen or promote the development of GERD [6]. For this reason, Roux-en-Y gastric bypass (RYGB) is often the operation of choice in patients with obesity and GERD. However, little is known about optimal treatment of worsening or de novo GERD post-sleeve gastrectomy. We investigated whether medical treatment with proton pump inhibitors or surgical treatment, including conversion to a RYGB, leads to superior outcomes in these patients.

The final medical condition we investigated in conjunction with bariatric surgery was inflammatory bowel disease (IBD). While only 0.7% of the US population is affected, 15-40% of IBD patients also have obesity [7, 8]. Pre-operative assessment of IBD patients is important when considering which bariatric procedure to perform. The bariatric principle of bypassing intestine in a malabsorptive operation is at odds with the goal of preserving as much intestine as possible in a patient with IBD [9]. For this reason, we aimed to determine if sleeve gastrectomy was superior to intestinal bypass in patients with both obesity and IBD.

Methods and materials 

A working group was formed from members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee. This group received formal training in systematic review methodology consistent with the Preferred Reporting Items for Systemic Reviews and Meta-Analysis (PRISMA) guidelines [9]. Three key questions (KQs) were devised using the Population, Intervention, Comparator, Outcomes (PICO) format.

KQ 1) Should routine IOC or no routine IOC be used for patients undergoing cholecystectomy during or after gastrointestinal bypass-type bariatric procedures (RYGB and duodenal switch (DS) and others)? Outcomes included: postoperative choledocholithiasis, intraoperative complications, perioperative complications, long-term postoperative complications, mortality, ERCP, reoperation, postoperative pancreatitis, postoperative cholangitis, common bile duct (CBD) injury, percutaneous transhepatic cholangiography, cost, quality of life. 30-day perioperative complications included grade 2 or greater on the Clavien-Dindo scale. Long-term complications were those occurring greater than 30 days postoperatively..

KQ 2) Should surgical or medical therapy be used for GERD after laparoscopic sleeve gastrectomy? Outcomes included: DeMeester score, impedance score, acid exposure time, mean number of reflux episodes in 24 hours, mean number of endoscopies in follow up, Barrett’s esophagus presence, esophagitis presence, patient reported long-term symptom control, overall quality of life, GERD-specific quality of life, drug related serious adverse events, complications, mortality. Patient reported long-term symptom control was measured at least 6 months postoperatively.

KQ 3) Should sleeve gastrectomy or intestinal bypass-type procedures be used in obese patients with IBD? Outcomes included: Worsening pain, worsening of other IBD symptoms (obstruction, bleeding, fistula, perforation), ulceration, overall quality of life, gastrointestinal (GI)-specific quality of life, patient reported worsening of IBD, drug related serious adverse events, perioperative complications, long-term postoperative complications (>30d), mortality, and reoperation. Perioperative complications again included those occurring up to 30 days postoperatively and grade 2 or greater on the Clavien-Dindo scale. Long-term complications were defined as those occurring greater than 30 days postoperatively.

Included studies

Search criteria included English language, peer-reviewed, randomized controlled trials and observational studies, including single-arm studies, from 1990 to 2022. This timeframe was chosen to encompass the available literature on bariatric procedures. Individual case reports were excluded while case series were included. Non-English articles and studies with only abstracts available were also excluded.

Included participants

All KQs addressed the adult population only.

• KQ1 included patients with a prior bypass-type operation who were undergoing cholecystectomy. Bypass-type procedures included RYGB, one anastomosis gastric bypass (OAGB), duodenal switch (DS), and single anastomosis duodeno-ileal bypass (SADI).
• KQ2 included patients who had been diagnosed with GERD and sleeve gastrectomy anatomy.
• KQ3 included patients with both IBD and obesity who were undergoing bariatric surgery. Patients with ulcerative colitis and Crohn’s disease were both included.

Interventions

In KQ1, the intervention of routine intraoperative cholangiography during cholecystectomy was compared against not performing intraoperative cholangiography during cholecystectomy.

In KQ2, all interventional treatments for reflux, including conversion to RYGB, hiatal hernia repair, magnetic sphincter augmentation (MSA), Stretta, fundoplication, fundectomy, falciform ligament wrap, transoral incisionless fundoplication, and other less commonly used surgical techniques were compared against medical therapy, including both proton pump inhibitors (PPIs) and H2 blockers.

In KQ3, the intervention was sleeve gastrectomy which was compared against any type of intestinal bypass operation for weight loss, including RYGB, OAGB, DS, and SADI.

Search strategies

The working group devised search strategies for each KQ with the assistance of a medical librarian. PubMed, Embase, Cochrane, and ClinicalTrials.gov were searched. Our search parameters had limitations of January 1990-March 2022. The results were collected and combined and then exported to Covidence (Veritas Health Innovation, Melbourne, Australia) for further screening and extraction. Full search strategies for each KQ are available in Appendix 1.

 Study selection

The working group underwent calibration of study selection using Abstrackr (Brown University, Providence, Rhode Island, US). The standard operating procedure followed has been outlined previously [11]. After completing this step, the studies were uploaded to Covidence and screened, first at the title and abstract level and then at the full-text level. Two reviewers screened each paper at both phases. Disagreements in screening were resolved through consensus, and if consensus was not achieved, then a third reviewer was utilized.

Data extraction and management

Data were extracted by two members of the working group using a standardized extraction form that had been imported into Covidence. Data included study characteristics, patient demographics, details of the interventions, and outcomes. Consensus was obtained between reviewers through discussion. Authors were not contacted for missing study data. The data was then exported from Covidence and reviewed for accuracy and consistency.

Assessment of bias

Each study was evaluated by two reviewers to assess bias. The Cochrane Risk of Bias 2.0 Tool was used for RCTs and the modified Newcastle-Ottawa Scale (NOS) was used for non-randomized studies. Discrepancies between the two reviewers were discussed and if unable to reach consensus a third reviewer would act as tiebreaker.

Data analysis

RevMan (Version 5.3.5) was used to perform meta-analysis using a Mantel-Haenszel random-effects model. Risk ratios (RR) and odds ratios (OR) were calculated for dichotomous outcomes from randomized and non-randomized studies, respectively. Inverse variance weighted mean difference for continuous outcomes was utilized. For continuous outcomes using multiple scales, a standardized mean difference (SMD) was used. Heterogeneity between studies was assessed using measures of I² and χ². All comparative studies, including observational and high risk of bias, are presented, but results and conclusions focus on randomized controlled trials and low risk of bias studies when available.

Results

Question 1: Should routine IOC or no IOC be used for patients undergoing cholecystectomy during or after gastrointestinal bypass-type bariatric procedures (RYGB and DS, etc.)?

A total of 1068 publications were identified during the literature search which resulted in 1009 publications after removing duplicates. These were then screened by their title and abstract further reducing that number to 52 which were then further assessed at the full text level for data extraction. Data were extracted from 9 articles which were all included in the final analysis (Table 1) [12–20]. The PRISMA flow diagram for the systematic review is seen in Fig. 1. There were no randomized controlled trials for KQ1 and only one study directly comparing routine and non-routine use of IOC. The results can be found in tables 2 (routine use of IOC) and Table 3 (non-routine use of IOC). The risk of bias assessment for the included studies is in Fig. 2.

Fig. 1 PRISMA Diagram for KQ 1

Table 1 Summary of included studies for KQ1

Fig. 2 Stoplight chart of risk of bias for the included studies

Table 2 Outcomes data for the routine use of IOC in post-bariatric surgery patients

Table 3 Outcomes data in non-routine IOC use

CBD injury

Three single-arm studies used routine IOC and evaluated CBD injury, while only a single study evaluated CBD injury without routine IOC. In the routine IOC group the cumulative rate of injury was 0.40% (CI 0.17-0.97%, I²=0) compared to the single study that evaluated CBD injury without routine use of IOC with an event rate of 0.53% (CI 0.03-7.85%) which was not statistically significant.

ERCP required intraoperatively

There were four observational studies that categorized whether an ERCP was required intraoperatively. In the routine IOC group the cumulative event rate was 3.73% (CI 1.74-7.82%, I²=0). In Mishra et al (2016) ERCP intraoperatively without routine use of IOC had an event rate of 12.12% (CI 4.62-28.18%) however this was not statistically significant [16].

Intraoperative complications

There were three single-arm studies (two with routine use of IOC and one without routine use of IOC) that evaluated intraoperative complications. The two routine use of IOC studies had an event rate of 2.72% (CI 0.79-8.96%, I²=0.00%) while the single study without routine use of IOC had an event rate of 14.71% (CI = 6.26-30.82%); however this was not statistically significant.

Mortality

Mortality was the most consistently reported outcome but also did not achieve statistical significance. Nine studies that evaluated mortality. The cumulative event rate in the routine IOC studies was 0.6% (CI=0.19-1.84%, I²=0.00%). The event rate in the non-routine IOC use group was 1.04% (CI=0.30-3.52%, I²=0.00%). There was one comparative study by Chang et al (2016) where mortality without routine IOC the mortality was 0.51% (95% CI=0.03-7.63%) and 1.09% (95% CI = 0.07-15.14%) with routine use.

Perioperative complications

There were five single-arm studies that evaluated perioperative complications within 30 days. In the studies that evaluated no routine use of IOC, the event rate was 18.06% (CI=12.30-25.72%, I²=0.00%), which was higher than routine use of IOC where the event rate was 10.6% (CI=5.93-18.24%, I²=55.20%) but not to a significant level. In addition, the I² value for the routine use studies was 55.20%.

Remaining outcomes

Of note, during our data extraction there were several outcomes for which there was data available for the routine use of IOC group but not for the non-routine use of IOC group. This meant that comparison was not possible. The data for the routine use of IOC group is presented in table 2. The outcomes and number of studies that reported each outcome in which comparison was not possible included ERCP postoperatively (4 studies, event rate 0.95%, 95% CI 0.53-1.68%, I²=0.00), postoperative cholangitis (2 studies, event rate 0.31%, 95%CI 0.11-0.89%, I²=0.00), postoperative choledocholithiasis (3 studies, event rate 0.56%, 95% CI 0.21-1.49%, I²=13.20), postoperative complications over 30 days (1 study, event rate 0.86%, 95% CI 0.05-12.33%), postoperative pancreatitis (4 studies, event rate 0.75%, 95% CI 0.40-1.41%, I²=0.00), and reoperation (4 studies, event rate 3.87%, 95%CI 2.93-5.10%, I²=0.00).

Question 2: Should surgical versus medical therapy be used for GERD status post Laparoscopic Sleeve Gastrectomy (LSG)?

A second literature search was completed for KQ2. Using the databases mentioned, 844 publications were identified during the literature search. After accounting for duplicates 800 articles were screened with title and abstract. This yielded 130 articles for full text screening and then 39 for data extraction. 39 articles were included in the meta-analysis (Table 4) [21–58]. The PRISMA flow diagram for the systematic review is seen in Fig. 3. The risk of bias assessment for the included studies is in Fig. 4. The results from the data extraction are in Tables 5, 6, 7, and 8.

Fig. 3 PRISMA Diagram for KQ 2

Table 4 All included studies for KQ2

Fig. 4 Stoplight diagram for studies included in KQ2

Table 5 Continuous outcomes for medical treatments in KQ2

Table 6 Continuous variables assessed for surgical treatments

Acid exposure time (total)

There were two studies that evaluated medical treatment and one study that evaluated surgical treatment with bypass and the effect on acid exposure time. These were all single-arm studies. The mean time in the medical treatment group was 9.70 minutes (95% CI 6.15-13.25, I²=0.00%) and 3.80 minutes (95% CI 0.79-6.81 minutes, I²=0%).

DeMeester score

There was only one single-arm medical study and two single-arm surgical bypass studies that evaluated the DeMeester score. In the medical arm the mean score was 44.10 (95% CI 27.96-60.24, I²=0.00%) and in the surgical studies the mean score was 30.5 (95% CI 21.35-59.69, I²=90.38%).

Impedance score post-intervention mean

Only a single study, Felsenreich et al., evaluated the impedance score in bypass surgical patients. The mean score was 16.30 (95% CI 13.62-18.98, I²=0%).

 Mean number of reflux episodes in 24hrs

Only a single study, Felsenreich et al., evaluated the mean number of reflux episodes in 24 hours in bypass surgical patients. The mean number of episodes was 49.00 (95% CI 26.13-71.87, I²=0%).

Quality of life, GERD specific

There were six studies that evaluated GERD specific quality of life in surgical patients, which included bypass, magnetic sphincter augmentation (MSA), or other surgical treatments, and one study that evaluated medical treatment specifically at 10 years. In Felsenreich et al. (2020), the Gastro-Intestinal Quality of Life Index was used and the medical treatment had a mean score of 8.40 (95% CI 3.81-12.99, I²=0.00%). The mean scores in surgical patients varied among treatment modalities and in the used QoL. The three bypass studies had scores of 1.22 (95% CI 0.97-1.47, I²=0.00%, Visick Score) [24] 7.29 (95% CI 4.38-10.20, I²=0.00%) (GERD-health-related quality of life) [44] and 113.50 (95% CI 98.19-128.81, I²=0.00%) (Gastro-Intestinal Quality of Life Index) [38].

Two studies evaluated MSA and two evaluated other procedures. In the MSA group the mean score of was 9.06 (95% CI 4.80-13.33, I²=0.00%) using the Health-Related Quality of Life score. The mean score in the other procedure group was 27.20 (95% CI -1.30-55.70, I²=98.49%) using the GERD-health-related quality of life questionnaire. The large heterogeneity in the other treatment group is likely related to different procedures performed (Stretta versus endoscopic interventions with or without plication).

Quality of life, GERD specific at 1, 6, and 12 months

Soong et al. evaluated QoL at 1, 6, and 12 months after hiatal hernia repair with gastropexy using the GERD-health-related quality of life questionnaire and found mean scores of 12.30 (95% CI 7.83-16.77, I²=0%), 16.80 (95% CI 10.47-23.13, I²=0%), and 17.40 (95% CI 9.56-25.24, I²=0%) respectively.

Quality of life, overall

Three studies evaluated post-surgical patients, one each of bypass, MSA or Stretta, and their QoL overall. Again, comparison between these three studies is difficult as the same scale was not used. The bypass group used the Gastro-Intestinal Quality of Life Index with a mean score of 5.10 (95% CI 3.64-6.56, I²=0.00%), the MSA group on the GERD score questionnaire had a mean score of 5.14 (95% CI 4.86-5.42, I²=0.00%) and the Stretta group on the GERD-health-related quality of life scale had a mean score of 41.80 (95% CI 36.23-47.37, I²=0.00%).

Table 7. Binary outcomes with medical treatment

Table 8 Binary outcomes of surgical treatments

Barrett’s esophagus

Three studies evaluated regression of Barrett’s esophagus in patients treated medically, and one study assessed this outcome after surgery. The medically treated patients had an event rate of 8.42% (95% CI 3.41-19.35%, I²=54.87%) which was lower than the single study of patients treated with bypass (20.00%, 95% CI 5.04-54.07%, I²=0.00%).

Complications (leak, DVT, blood loss, marginal ulcer, internal hernia, endoscopic mucosal injury, carcinoma in situ, or adenocarcinoma)

A single study evaluated patients treated medically and their rate of complications (0.24%, 95% CI 0.02-3.76%, I²=0.00%). In surgical patients they we stratified by type of surgery performed, bypass patients had the highest complication rate (15.21%, 95% CI = 11.73-19.49%, I²=6.88%, 13 studies), compared to MSA  (12.13%, 95% CI =3.95-31.69%, I²=0.00%) and other procedures (12.13%, 95% CI = 3.95-31.69%, I²=0.00%). The odds ratio was non-significant between MSA and bypass (1.03, 95% CI 0.15-7.19) with propensity for bypass (Fig. 5A). When comparing medical treatment to bypass the odds ratio was 52.10 (95% CI=2.74-988.82) favoring medical treatment (Fig. 5B).

Fig. 5 Forest plots evaluating comparisons of complication rates in MSA versus RYGB (A) and RYGB versus medical treatment (B)

Esophagitis present (Grade A, B, or C)

There were three studies of medical treatment that evaluated esophagitis compared to 12 studies that evaluated surgical treatment and postoperative esophagitis. The event rate of the medically treated patients was 29.02% (95% CI = 21.48-37.92%, I²=17.02%) compared to 15.00% with bypass (95% CI = 6.42-31.21%, I²=62.41%) and 37.18% with other surgical/endoscopic treatments (95% CI = 2.24-93.85%, I²=86.54%).

Long term symptom control (patient reported; >6months)

There were four studies that evaluated patients treated medically compared to 33 studies that compare postoperative surgical interventions. In the medically treated group, the rate of long-term symptom control was 71.54% (95% CI =48.96-86.82%, I²=85.83%). In surgical patients the event rate varied from 50.71% in the other treatment group (95% CI 29.26-71.90%, I²=74.14%) to 77.72% with magnetic sphincter augmentation (95% CI =36.37-95.51%, I²=68.74%) to 80.05% with bypass (95% CI 73.77-85.13%, I²=37.17%). Comparing medical treatment to MSA the odds ratio was 0.69 (95% CI 0.13-3.72, Fig. 6A) favoring medical treatment, while bypass compared to medical treatment had an odds ratio of 1.88 (95% CI 0.11-32.63, Fig. 6B), favoring bypass, neither of which were significant. When comparing the MSA to RYGB the OR was 2.12 (95% CI 0.20-22.90, Fig. 6C) favoring MSA.

Fig. 6 Comparative studies evaluating MSA versus medical treatment (A), MSA versus RYGB, and medical treatment versus RYGB

Mortality

No studies evaluated mortality in the medically treated group. Multiple studies commented on mortality in each surgically stratified group. In the other treatments group, the event rate was 3.74% (95% CI 1.56-8.70%, I²=0.00%), 4.67% in the magnetic sphincter augmentation group (95% CI 1.17-16.85%, I²=0.00%) and 2.58% in the bypass group (95% CI 1.36-4.81%, I²=0.00%).

Question 3: Should SG versus intestinal bypass procedures be used in obese patients with inflammatory bowel disease (IBD)?

A literature search was completed for KQ3 which yielded 116 articles after removal of duplications (n=5). After title and abstract screening that resulted in 31 articles for full text screening and then 10 articles for data extraction. 10 articles were included in the final meta-analysis (Table 9) [60–69]. The PRISMA flow diagram for the systematic review is seen in Fig. 7.  The risk of bias assessment of each study is found in Fig. 8. The results are found in Tables 10 and 11. In addition to the reported outcomes, we also attempted to extract data related to IBD quality of life, and drug serious adverse effects but found no data related to the aforementioned outcomes.

Fig. 7 PRISMA Diagram for KQ3

Table 9 Studies included in KQ3

Fig. 8 Stoplight diagram for KQ3 studies demonstrating the risk of bias

Table 10 Sleeve gastrectomy results in patients with IBD

Table 11 Outcomes in patients treated with bypass with concurrent IBD

IBD‑associated complications

There were three comparative studies and two single-arm studies of sleeve patients that evaluated worsening of IBD specifically looking at refractory disease or complications associated with the disease, including obstruction, hemorrhage, fistula, or perforation. Sleeve had an event rate of 5.89% (CI 2.22-14.68%, I² = 0.00%) whereas bypass had an event rate of 11.24% (CI=4.24-26.58%, I²=0.00%). Only Heshmati et al. of the comparative studies was used to estimate the odds ratio (OR 0.32 in favor of sleeve 95% CI 0.05-2.13, Fig. 9), as the other two studies had no occurrences of the outcome of interest.

Fig. 9 Forest plot demonstrating the comparative studies demonstrating non-significant favouring of sleeve gastrectomy

Pain requiring medical therapy

There were three comparative studies and four sleeve-only single-arm studies that evaluated worsening of pain requiring medical therapy. Sleeve had an event rate of 6.05% (95% CI 2.41-14.36% I²=0.00%) which was lower than bypass at 17.30% (CI 7.34-35.60%, I²=0.00%) but did not achieve statistical significance. When evaluating the comparative studies only Heshmati et al. reported any events, with an OR of 0.11 in favor of sleeve (95% CI 0.01-1.07, Fig. 10).

Fig. 10 Forest plot of comparative studies for IBD worsening requiring medical treatment of pain

Subjective recurrence of IBD

Two comparative studies and two single-arm studies evaluated sleeve patients. The event rate trended towards being lower in the sleeve patients (7.23%, CI=2.89-16.96%, I²=0.00%) compared to the bypass patients (20.57%, CI 2.71-70.65%, I²=59.71%). Of the comparative studies, only Heshmati et al. reported events in both groups accounting for 100% of the weight of the odds ratio of 0.11 in favor of sleeve (95% CI 0.01-1.07, Fig. 11).

Fig. 11 Forest plot of comparative studies for IBD worsening that is patient reported

Long term complications (dumping syndrome, malabsorption, leaks, fistulas, etc)

There were four comparative studies, four single-arm studies on sleeve patients, and one single-arm study on bypass patients. The event rate of the sleeve patients (5.32%, 95% CI 2.61-10.51%, I²=0.00%) was lower than that of the bypass patients (18.25%, 95% CI 9.55-32.08%, I²=0.00%) and sleeve gastrectomy was favored (Fig. 12). Among the comparative studies, the OR was 0.22 (95% CI 0.06-0.83, I²=0%), indicating a lower odds of complications with sleeve gastrectomy.

Fig. 12 Forest plot of comparative studies of long-term complications

Mortality (all cause)

There were six comparative studies and four single-arm sleeve studies. Of the six comparative studies, only Heshmati et al. and Arminian et al. were included in the odds ratio calculation as the remaining four had no events. This was the only outcome that favored bypass (OR 2.24, 95% CI 0.22-22.96, Fig. 13). However, it was also non-significant and had a wide confidence interval. However, the overall events rate for sleeve patients was lower at 4.35% (95% CI 1.96-9.40%, I²=0.00%) compared to bypass at 5.67% (1.83-16.26%, I²=0.00%).

Fig. 13 Forest plot of comparative studies that evaluated mortality

Perioperative complications (<30d) Clavien dindo ≥2

There were five comparative studies and four single-arm studies of sleeve patients. Sleeve gastrectomies had fewer perioperative complications (OR 0.25, 95% CI = 0.08-0.75, Fig. 14). The overall event rate in sleeves was 11.09% (95% CI 6.47-18.36%, I²=8.63%) and in bypass was 26.83% (95% CI 13.91-45.41%, I²= 12.10%).

Fig. 14 Forest plot of comparative studies evaluating perioperative complications

Reoperations related to bariatric procedure

There were six comparative studies that evaluated reoperation in the setting of failure of primary bariatric procedure, IBD surgery or both, and three single-arm studies evaluating sleeve patients for reoperations. Four of the comparative studies were used for the odds ratio calculation which favored sleeve although this was not statistically significant (OR 0.29, 95% CI 0.07-1.15, Fig. 15). The overall event rate for sleeve patients was 7.00% (95% CI 4.01-11.95%, I²=0.00%) and 14.91% in bypass patients (95% CI 7.57-27.27%, I²=0.00%). Reoperation indications included internal hernias (n = 4), sleeve leaks (n = 2), gastric stricture (n = 1), mesenteric ischemia/small bowel perforation (n = 1), biliopancreatic limb obstruction (n = 1), bile reflux (n = 1), and gastro-gastric fistula (n = 1).

Fig. 15 Forest plot of the comparative studies evaluating re-operation rates

DISCUSSION 

Gallstones and Bariatric Surgery

Common bile duct stones in the patient with bypass-type anatomy is a challenging problem. Due to the altered anatomy, standard ERCP cannot be performed. In these cases, other potential options include double-balloon enteroscopy, operative gastrotomy with ERCP, or endoscopic ultrasound-directed transgastric ERCP, all of which are associated with additional morbidity.  We sought to evaluate if the routine use of IOC at the time of cholecystectomy was beneficial. There were no randomized controlled trials and few comparative observational studies that addressed this question.

Routine use of IOC was associated with a significantly decreased rate of CBD injury and a trend towards decreased intraoperative complications, perioperative complications, and mortality although not statistically significant. There was also a trend towards lower use of ERCP intra-operatively in the routine IOC group. Unfortunately, no studies evaluated the use of ERCP postoperatively in the non-routine use of IOC patients.  Use of ERCP intraoperatively was higher in the group undergoing sleeve gastrectomies than bypass however when evaluating the ERCP rate postoperatively this was higher in the patients who had undergone bypass. The rate of reoperation, postoperative pancreatitis, cholangitis, and choledocholithiasis was low in the routine use of IOC group but no non-routine IOC studies evaluated these outcomes, so it is impossible to say whether these outcomes were decreased.

GERD post-sleeve gastrectomy

Much has been written about the persistence or worsening of reflux symptoms after sleeve gastrectomy. There are multiple management options, ranging from medical therapy with PPIs to endoscopic and surgical interventions. We sought to determine if medical or surgical management was superior. Objective measures of GERD after sleeve gastrectomy, including acid exposure time and DeMeester Score, favored surgical treatment although neither outcome was statistically significant. Other objective measures were only available for surgical outcomes including impedance score and mean number of reflux episodes making their value challenging to interpret. Alternatively, medical treatment resulted in lower rates of Barrett’s esophagus though this was limited by a paucity of data on surgical patients. In terms of patient reported outcomes, GERD-specific quality of life was significantly higher in the surgically treated group. In Soong et al., quality of life increased with increasing time after surgery. The long-term patient reported symptom control showed medical treatment inferiority to bypass, similarity to MSA, and superiority to other surgical/endoscopic treatments (see Table 8); however none reached significance. Definitive conclusions are challenging based on the limited data. While many patients may benefit from conversion to gastric bypass for post-sleeve gastrectomy GERD, several factors must be considered prior to this decision. These include and are not limited to suboptimal clinical response, the presence of a hiatal hernia, abnormal GI motility, and psychosocial issues that may preclude conversion to RYGB. The complexity of this decision underlines the importance of multidisciplinary evaluation prior to pursuing a bypass-type operation.

 IBD and Bariatric Surgery

As the rates of both obesity and IBD increase [1, 70], determining the optimal surgical weight loss procedure in patients with both diseases is imperative. We sought to determine if there was a bariatric procedure that had improved outcomes in IBD patients. In our review, surgical bypass had worse outcomes measured in terms of IBD sequelae compared to sleeve gastrectomy including obstruction, hemorrhage, fistula, perforation, pain, patient perception, and ulceration. Patients with IBD who underwent sleeve gastrectomy also had lower complication both long and short term. Mortality was the only outcome that favored bypass in these patients; however, this was a rare event, making this effect estimate very fragile. The reoperation rate was higher in bypass patients. While none of the direct comparative studies had statistical significance the overall data is compelling evidence that a sleeve gastrectomy should be the first surgical option offered to these patients.

A similar meta-analysis has evaluated IBD and bariatric surgery and found that it is safe in these patients [71]. Interestingly, in that study they also evaluated the timing of the bariatric procedure in relation to the diagnosis of IBD and found that bariatric surgery may be a risk factor for developing IBD [71].

 Limitations

This review had several limitations. Overall, the lack of randomized controlled trials and even direct, comparative studies makes drawing accurate conclusions difficult. There were several outcomes each question that were missing data from an individual arm where conclusions were impossible.

There were also several outcomes with significant heterogeneity noted in the pooled data. In general, the study quality for these questions was poor, limiting the generalizability of this data. Much of the data analyzed in this review has been retrospectively collected or prospectively collected into databases that are searched retrospectively. Many of the studies gathered were determined to be at high risk of bias, which is a known problem with observational studies.

There was significant variability in the outcomes that study authors chose to report.

Specifically relating to the question of IBD, a perfectly designed question would distinguish the UC and CD populations, given their different pathophysiology and complication profile. However, most publications on the subject lump the patient populations together since there is such a small sample size. Given the limitations of the data, we did include all patients with IBD. Even doing so, we had very limited data to work with. In the design of the questions, we did not have a colorectal surgery representative included in formulating how we should evaluate the IBD patients which could have lead to optimized outcomes assessment.

Future research recommendations

There is much room for improvement in research regarding obesity-associated medical conditions in the setting of metabolic and bariatric surgical procedures. Many of the studies included in this review are single-arm retrospective reviews which provide the most biased outcomes for any of the questions posed. High quality, randomized trials are needed to evaluate the best treatment and management methods for these comorbidities including routine use of IOC in patients who are undergoing or have undergone bariatric surgery, optimal surgical management of IBD, and treatment of GERD after sleeve gastrectomy.

As research collaborations are established, the gathering of high-quality data on a large number of patients would be beneficial. In addition, evaluating patient databases that are not solely for bariatric surgery but also for comorbid conditions such as IBD can be utilized to broaden the patients available for analysis. It is also essential to report outcomes for UC and CD patients independently of each other in all studies on the intersection of IBD and metabolic and bariatric surgery.

 Conclusion

Our review summarizes three important questions regarding comorbid conditions in the setting of bariatric surgery. The routine use of intraoperative cholangiogram (IOC) in patients undergoing bariatric surgery or who have undergone bariatric surgery and are now undergoing cholecystectomy is supported by the limited data presented. Additionally, surgical treatment of GERD after sleeve gastrectomy favored surgical treatment but this depended on the surgical treatment used and thus further stratification is needed. Finally, in patients with IBD the procedure associated with the fewest complications is sleeve gastrectomy. Given the overwhelming number of single-arm studies that were used in this pooled data, there is a need for more direct comparative studies and high-quality randomized controlled trials for more generalizable data. The findings from this review will inform the SAGES Guidelines on the management of comorbidities for bariatric surgery patients.

Appendix

Appendix 1 – Search strategies

Acknowledgements

The authors would like to acknowledge Holly Ann Burt for performing the literature search for all included studies and Sarah Colón for her organization of the guidelines committee meetings and communications.

Disclosures

Bradley Kushner, Theofano Zoumpou, Julietta Chang, Adam Reid, L Renee Hilton, Omar Ghanem, Andrew Sabour, Lindsay Loss, Essa Aleassa, Noe Rodriguez, Subhashini Ayloo, Sunjay Kumar, D. Wayne Overby, and Claire Wunker have no disclosures. Peter Hallowell is President-Elect Midwest Surgical Association and on the Board of directors for Piedmont Liability Trust. Ivy N. Haskins receives royalties from Up To Date, Inc (unrelated to this work). Tammy Kindel has grants with the NHLBI and American College of Surgeons, receives honoraria from Translational Medicine Academy, Medtronic, and Intuitive, has patents pending under U.S. Provisional Patent Application No. 63/505,036 and does unpaid work for Treo Foundation. Varun Bansal has a grant from Yale University (unrelated to this work).

REFERENCES 

1. CDC (2022) Obesity is a Common, Serious, and Costly Disease. [Internet]. Available at: https://www.cdc.gov/obesity/data/adult.html. Accessed 7 Oct 2023
2. ASMBS (2022) Estimate of Bariatric Surgery Numbers, 2011-2021. [Internet]. Available at:  https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers. Accessed 7 Oct 2023
3. Shubayr N, Elbashir M, Alashban Y, Ali S, Jafaari M, Hendi A, Majrashi N, Alyami A, Alumairi N (2022) Incidence of Gallbladder Stone Formation After Bariatric Surgery Using Ultrasound Imaging in the Southern Region of Saudi Arabia. Cureus 14:e25948. https://doi.org/10.7759/cureus.25948
4. Gibney EJ (1990) Asymptomatic gallstones. Br J Surg 77:368–372. https://doi.org/10.1002/bjs.1800770405
5. Golzarand M, Toolabi K, Parsaei R, Eskandari Delfan S (2022) Incidence of Symptomatic Cholelithiasis Following Laparoscopic Roux-en-Y Gastric Bypass Is Comparable to Laparoscopic Sleeve Gastrectomy: A Cohort Study. Dig Dis Sci 67:4188–4194. https://doi.org/10.1007/s10620-021-07306-6
6. Laffin M, Chau J, Gill RS, Birch DW, Karmali S (2013) Sleeve Gastrectomy and Gastroesophageal Reflux Disease. J Obes 2013:741097. https://doi.org/10.1155/2013/741097
7. Lewis JD, Parlett LE, Jonsson Funk ML, Brensinger C, Pate V, Wu Q, Dawwas GK, Weiss A, Constant BD, McCauley M, Haynes K, Yang JY, Schaubel DE, Hurtado-Lorenzo A, Kappelman MD (2023) Incidence, Prevalence, and Racial and Ethnic Distribution of Inflammatory Bowel Disease in the United States. Gastroenterology 165:1197-1205.e2. https://doi.org/10.1053/j.gastro.2023.07.003
8. Singh S, Dulai PS, Zarrinpar A, Ramamoorthy S, Sandborn WJ (2017) Obesity in IBD: epidemiology, pathogenesis, disease course and treatment outcomes. Nat Rev Gastroenterol Hepatol 14:110–121. https://doi.org/10.1038/nrgastro.2016.181
9. Nordgren S, McPheeters G, Svaninger G, Oresland T, Hultén L (1997) Small bowel length in inflammatory bowel disease. Int J Colorectal Dis 12:230–234. https://doi.org/10.1007/s00380050095
10. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535. https://doi.org/10.1136/bmj.b2535
11. Rogers AT, Dirks R, Burt HA, Haggerty S, Kohn GP, Slater BJ, Walsh D, Stefanidis D, Pryor A (2021) Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines development: standard operating procedure. Surg Endosc 35:2417–2427. https:// doi. org/ 10. 1007/ s00464- 021- 08469-z
12. Brockmeyer JR, Grover BT, Kallies KJ, Kothari SN (2015) Management of biliary symptoms after bariatric surgery. Am J Surg 210:1010–1016; discussion 1016-1017. https://doi.org/10.1016/j.amjsurg.2015.07.003
13. Chang J, Corcelles R, Boules M, Jamal MH, Schauer PR, Kroh MD (2016) Predictive factors of biliary complications after bariatric surgery. Surg Obes Relat Dis 12:1706–1710. https://doi.org/10.1016/j.soard.2015.11.004
14. Fuente I, Beskow A, Wright F, Uad P, de Santibañes M, Palavecino M, Sanchez-Claria R, Pekolj J, Mazza O (2021) Laparoscopic transcystic common bile duct exploration as treatment for choledocholithiasis after Roux-en-Y gastric bypass. Surg Endosc 35:6913–6920. https://doi.org/10.1007/s00464-020-08201-3
15. Hamad GG, Ikramuddin S, Gourash WF, Schauer PR (2003) Elective cholecystectomy during laparoscopic Roux-en-Y gastric bypass: Is it worth the wait? Obes Surg 13:76–81. https://doi.org/10.1381/096089203321136638
16. Mishra T, Lakshmi KK, Peddi KK (2016) Prevalence of Cholelithiasis and Choledocholithiasis in Morbidly Obese South Indian Patients and the Further Development of Biliary Calculus Disease After Sleeve Gastrectomy, Gastric Bypass and Mini Gastric Bypass. Obes Surg 26:2411–2417. https://doi.org/10.1007/s11695-016-2113-4
17. Moon RC, Teixeira AF, DuCoin C, Varnadore S, Jawad MA (2014) Comparison of cholecystectomy cases after Roux-en-Y gastric bypass, sleeve gastrectomy, and gastric banding. Surg Obes Relat Dis 10:64–68. https://doi.org/10.1016/j.soard.2013.04.019
18. Papavramidis S, Deligianidis N, Papavramidis T, Sapalidis K, Katsamakas M, Gamvros O (2003) Laparoscopic cholecystectomy after bariatric surgery. Surg Endosc 17:1061–1064. https://doi.org/10.1007/s00464-002-9169-z
19. Popowicz A, Sanamrad S, Darkahi B, Zacharias R, Sandblom G (2021) Management of Common Bile Duct Stones Encountered During Cholecystectomy in Patients With Previous Gastric Bypass. Front Surg 8:789231. https://doi.org/10.3389/fsurg.2021.789231
20. Wanjura V, Sandblom G, Österberg J, Enochsson L, Ottosson J, Szabo E (2017) Cholecystectomy after gastric bypass—incidence and complications. Surg Obes Relat Dis 13:979–987. https://doi.org/10.1016/j.soard.2016.12.004
21. Amiki M, Seki Y, Kasama K, Hashimoto K, Kitagawa M, Umezawa A, Kurokawa Y (2020) Revisional Bariatric Surgery for Insufficient Weight Loss and Gastroesophageal Reflux Disease: Our 12-Year Experience. Obes Surg 30:1671–1678. https://doi.org/10.1007/s11695-019-04374-6
22. Bellorin O, Dolan P, Vigiola-Cruz M, Al Hussein Alawamlh O, Pomp A, Dakin G, Afaneh C (2021) Robotic-assisted approaches to GERD following sleeve gastrectomy. Surg Endosc 35:3033–3039. https://doi.org/10.1007/s00464-020-07753-8
23. Borbély Y, Bouvy N, Schulz HG, Rodriguez LA, Ortiz C, Nieponice A (2018) Electrical stimulation of the lower esophageal sphincter to address gastroesophageal reflux disease after sleeve gastrectomy. Surg Obes Relat Dis 14:611–615. https://doi.org/10.1016/j.soard.2018.02.006
24. Boru CE, Greco F, Giustacchini P, Raffaelli M, Silecchia G (2018) Short-term outcomes of sleeve gastrectomy conversion to R-Y gastric bypass: multi-center retrospective study. Langenbecks Arch Surg 403:473–479. https://doi.org/10.1007/s00423-018-1675-0
25. Braghetto I, Korn O, Burgos A, Figueroa M (2021) When should be converted laparoscopic sleeve gastrectomy to laparoscopic Roux-en-y gastric bypass due to gastroesophageal reflux? Arq Bras Cir Dig 33:e1553.  https://doi.org/10.1590/0102-672020200004e1553
26. Broderick RC, Smith CD, Cheverie JN, Omelanczuk P, Lee AM, Dominguez-Profeta R, Cubas R, Jacobsen GR, Sandler BJ, Fuchs KH, Horgan S (2020) Magnetic sphincter augmentation: a viable rescue therapy for symptomatic reflux following bariatric surgery. Surg Endosc 34:3211–3215. https://doi.org/10.1007/s00464-019-07096-z
27. Carandina S, Soprani A, Montana L, Murcia S, Valenti A, Danan M, d’Agostino J, Rivkine E, Nedelcu M (2020) Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass in patients with gastroesophageal reflux disease: results of a multicenter study. Surg Obes Relat Dis 16:732–737. https://doi.org/10.1016/j.soard.2020.02.009
28. Casillas RA, Um SS, Zelada Getty JL, Sachs S, Kim BB (2016) Revision of primary sleeve gastrectomy to Roux-en-Y gastric bypass: indications and outcomes from a high-volume center. Surg Obes Relat Dis 12:1817–1825. https://doi.org/10.1016/j.soard.2016.09.038
29. Chiappetta S, Stier C, Scheffel O, Squillante S, Weiner RA (2019) Mini/One Anastomosis Gastric Bypass Versus Roux-en-Y Gastric Bypass as a Second Step Procedure After Sleeve Gastrectomy-a Retrospective Cohort Study. Obes Surg 29:819–827. https://doi.org/10.1007/s11695-018-03629-y
30. Curell A, Beisani M, García Ruiz de Gordejuela A, Vilallonga R, Verdaguer Tremolosa M, González López Ó, Caubet Busquet E, Fort López-Barajas JM (2021) Outcomes of Conversion from Sleeve Gastrectomy to Roux-en-Y Gastric Bypass Due to GERD-a Retrospective Analysis of 35 Patients. Obes Surg 31:4100–4106. https://doi.org/10.1007/s11695-021-05541-4
31. Debourdeau A, Vitton V, Monino L, Barthet M, Gonzalez JM (2020) Antireflux Mucosectomy Band (ARM-b) in Treatment of Refractory Gastroesophageal Reflux Disease After Bariatric Surgery. Obes Surg 30:4654–4658. https://doi.org/10.1007/s11695-020-04753-4
32. De Montrichard M, Greilsamer T, Jacobi D, Bruley des Varannes S, Mirallié E, Blanchard C (2020) Predictive value of preoperative DeMeester score on conversion to Roux-en-Y gastric bypass for gastroeosophageal reflux disease after sleeve gastrectomy. Surg Obes Relat Dis 16:1219-1224. https://doi.org/10.1016/j.soard.2020.04.010
33. Desart K, Rossidis G, Michel M, Lux T, Ben-David K (2015) Gastroesophageal Reflux Management with the LINX® System for Gastroesophageal Reflux Disease Following Laparoscopic Sleeve Gastrectomy. J Gastrointest Surg 19:1782–1786. https://doi.org/10.1007/s11605-015-2887-z
34. Dijkhorst PJ, Al Nawas M, Heusschen L, Hazebroek EJ, Swank DJ, Wiezer RMJ, Aarts EO (2021) Single Anastomosis Duodenoileal Bypass or Roux-en-Y Gastric Bypass After Failed Sleeve Gastrectomy: Medium-Term Outcomes. Obes Surg 31:4708–4716. https://doi.org/10.1007/s11695-021-05609-1
35. D’Urso A, Vix M, Perretta S, Ignat M, Scheer L, Mutter D (2021) Indications and Long-Term Outcomes of Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass. Obes Surg 31:3410–3418. https://doi.org/10.1007/s11695-021-05444-4
36. Felsenreich DM, Kefurt R, Schermann M, Beckerhinn P, Kristo I, Krebs M, Prager G, Langer FB (2017) Reflux, Sleeve Dilation, and Barrett’s Esophagus after Laparoscopic Sleeve Gastrectomy: Long-Term Follow-Up. Obes Surg 27:3092–3101. https://doi.org/10.1007/s11695-017-2748-9
37. Felsenreich DM, Ladinig LM, Beckerhinn P, Sperker C, Schwameis K, Krebs M, Jedamzik J, Eilenberg M, Bichler C, Prager G, Langer FB (2018) Update: 10 Years of Sleeve Gastrectomy-the First 103 Patients. Obes Surg 28:3586–3594. https://doi.org/10.1007/s11695-018-3399-1
38. Felsenreich DM, Langer FB, Bichler C, Eilenberg M, Jedamzik J, Kristo I, Vock N, Gensthaler L, Rabl C, Todoroff A, Prager G (2020) Roux-en-Y Gastric Bypass as a Treatment for Barrett’s Esophagus after Sleeve Gastrectomy. Obes Surg 30:1273–1279. https://doi.org/10.1007/s11695-019-04292-7
39. Gálvez-Valdovinos R, Cruz-Vigo JL, Marín-Santillán E, Funes-Rodríguez JF, López-Ambriz G, Domínguez-Carrillo LG (2015) Cardiopexy with Ligamentum Teres in Patients with Hiatal Hernia and Previous Sleeve Gastrectomy: An Alternative Treatment for Gastroesophageal Reflux Disease. Obes Surg 25:1539–1543. https://doi.org/10.1007/s11695-015-1740-5
40. Hawasli A, Bush A, Hare B, Meguid A, Thatimatla N, Szpunar S (2015) Laparoscopic Management of Severe Reflux After Sleeve Gastrectomy, in Selected Patients, Without Conversion to Roux-en-Y Gastric Bypass. J Laparoendosc Adv Surg Tech A 25:631–635. https://doi.org/10.1089/lap.2015.0079
41. Hawasli A, Sadoun M, Meguid A, Dean M, Sahly M, Hawasli B (2019) Laparoscopic placement of the LINX(®) system in management of severe reflux after sleeve gastrectomy. Am J Surg 217:496–499. https://doi.org/10.1016/j.amjsurg.2018.10.040
42. Hawasli A, Foster R, Lew D, Peck L (2021) Laparoscopic Ligamentum Teres cardiopexy to the rescue; an old procedure with a new use in managing reflux after sleeve gastrectomy. Am J Surg 221:602–605. https://doi.org/10.1016/j.amjsurg.2020.12.036
43. Hendricks L, Alvarenga E, Dhanabalsamy N, Lo Menzo E, Szomstein S, Rosenthal R (2016) Impact of sleeve gastrectomy on gastroesophageal reflux disease in a morbidly obese population undergoing bariatric surgery. Surg Obes Relat Dis 12:511–517. https://doi.org/10.1016/j.soard.2015.08.507
44. Huynh D, Mazer L, Tung R, Cunneen S, Shouhed D, Burch M (2021) Conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass: patterns predicting persistent symptoms after revision. Surg Obes Relat Dis 17:1681–1688. https://doi.org/10.1016/j.soard.2021.05.025
45. Iannelli A, Debs T, Martini F, Benichou B, Ben Amor I, Gugenheim J (2016) Laparoscopic conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: indications and preliminary results. Surg Obes Relat Dis 12:1533–1538. https://doi.org/10.1016/j.soard.2016.04.008
46. Khidir N, Angrisani L, Al-Qahtani J, Abayazeed S, Bashah M (2018) Initial Experience of Endoscopic Radiofrequency Waves Delivery to the Lower Esophageal Sphincter (Stretta Procedure) on Symptomatic Gastroesophageal Reflux Disease Post-Sleeve Gastrectomy. Obes Surg 28:3125–3130. https://doi.org/10.1007/s11695-018-3333-6
47. Landreneau JP, Strong AT, Rodriguez JH, Aleassa EM, Aminian A, Brethauer S, Schauer PR, Kroh MD (2018) Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass. Obes Surg 28:3843–3850. https://doi.org/10.1007/s11695-018-3435-1
48. Langer FB, Bohdjalian A, Shakeri-Leidenmühler S, Schoppmann SF, Zacherl J, Prager G (2010) Conversion from sleeve gastrectomy to roux-en-y gastric bypass-indications and outcome. Obes Surg 20:835–840. https://doi.org/10.1007/s11695-010-0125-z
49. Lim CH, Lee PC, Lim E, Eng A, Chan WH, Tan HC, Ho E, Kovalik JP, Ganguly S, Tan J (2020) Resolution of Erosive Esophagitis After Conversion from Vertical Sleeve Gastrectomy to Roux-en-Y Gastric Bypass. Obes Surg 30:4751–4759. https://doi.org/10.1007/s11695-020-04913-6
50. Macedo FIB, Mowzoon M, Mittal VK, Sabir M (2017) Outcomes of Laparoscopic Hiatal Hernia Repair in Nine Bariatric Patients with Prior Sleeve Gastrectomy. Obes Surg 27:2768–2772. https://doi.org/10.1007/s11695-017-2880-6
51. Mandeville Y, Van Looveren R, Vancoillie PJ, Verbeke X, Vandendriessche K, Vuylsteke P, Pattyn P, Smet B (2017) Moderating the Enthusiasm of Sleeve Gastrectomy: Up to Fifty Percent of Reflux Symptoms After Ten Years in a Consecutive Series of One Hundred Laparoscopic Sleeve Gastrectomies. Obes Surg 27:1797–1803. https://doi.org/10.1007/s11695-017-2567-z
52. Parmar CD, Mahawar KK, Boyle M, Schroeder N, Balupuri S, Small PK (2017) Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass is Effective for Gastro-Oesophageal Reflux Disease but not for Further Weight Loss. Obes Surg 27:1651–1658. https://doi.org/10.1007/s11695-017-2542-8
53. Poghosyan T, Lazzati A, Moszkowicz D, Danoussou D, Vychnevskaia K, Azoulay D, Czernichow S, Carette C, Bouillot JL (2016) Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: an audit of 34 patients. Surg Obes Relat Dis 12:1646–1651. https://doi.org/10.1016/j.soard.2016.02.039
54. Quezada N, Hernández J, Pérez G, Gabrielli M, Raddatz A, Crovari F (2016) Laparoscopic sleeve gastrectomy conversion to Roux-en-Y gastric bypass: experience in 50 patients after 1 to 3 years of follow-up. Surg Obes Relat Dis 12:1611–1615. https://doi.org/10.1016/j.soard.2016.05.025
55. Rheinwalt KP, Schipper S, Plamper A, Alizai PH, Trebicka J, Brol MJ, Kroh A, Schmitz S, Parmar C, Neumann UP, Ulmer TF (2022) Roux-en-Y Versus One Anastomosis Gastric Bypass as Redo-Operations Following Sleeve Gastrectomy: A Retrospective Study. World J Surg 46:855-864. https://doi.org/10.1007/s00268-021-06424-6
56. Silecchia G, De Angelis F, Rizzello M, Albanese A, Longo F, Foletto M (2015) Residual fundus or neofundus after laparoscopic sleeve gastrectomy: is fundectomy safe and effective as revision surgery? Surg Endosc 29:2899–2903. https://doi.org/10.1007/s00464-014-4017-5
57. Soong TC, Almalki OM, Lee WJ, Ser KH, Chen JC, Wu CC, Chen SC (2019) Revision of Sleeve Gastrectomy with Hiatal Repair with Gastropexy for Gastroesophageal Reflux Disease. Obes Surg 29:2381–2386. https://doi.org/10.1007/s11695-019-03853-0
58. Termine P, Boru CE, Iossa A, Ciccioriccio MC, Campanelli M, Bianciardi E, Gentileschi P, Silecchia G (2021) Transhiatal Migration After Laparoscopic Sleeve Gastrectomy: Myth or Reality? A Multicenter, Retrospective Study on the Incidence and Clinical Impact. Obes Surg 31:3419–3426. https://doi.org/10.1007/s11695-021-05340-x
59. Walsh PR, Lamba M, Benias P, Lafta A, Hopkins G (2021) Feasibility of resection and plication RAP technique for management of medically refractory GERD in patients with altered gastric anatomy. Endosc Int Open 9:E1549–E1555. https://doi.org/10.1055/a-1535-1279
60. Ungar B, Kopylov U, Goitein D, Lahat A, Bardan E, Avidan B, Lang A, Maor Y, Eliakim R, Ben-Horin S (2013) Severe and morbid obesity in Crohn’s disease patients: prevalence and disease associations. Digestion 88:26–32. https://doi.org/10.1159/000351529
61. Reenaers C, de Roover A, Kohnen L, Nachury M, Simon M, Pourcher G, Trang-Poisson C, Rajca S, Msika S, Viennot S, Alttwegg R, Serrero M, Seksik P, Peyrin-Biroulet L, Picon L, Bourbao Tournois C, Gontier R, Gilletta C, Stefanescu C, Laharie D, Roblin X, Nahon S, Bouguen G, Carbonnel F, Attar A, Louis E, Coffin B (2021) Bariatric Surgery in Patients With Inflammatory Bowel Disease: A Case-Control Study from the GETAID. Inflamm Bowel Dis 28:1198-1206. https://doi.org/10.1093/ibd/izab249
62. McKenna NP, Habermann EB, Sada A, Kellogg TA, McKenzie TJ (2020) Is Bariatric Surgery Safe and Effective in Patients with Inflammatory Bowel Disease? Obes Surg 30:882–888. https://doi.org/10.1007/s11695-019-04267-8
63. Keidar A, Hazan D, Sadot E, Kashtan H, Wasserberg N (2015) The role of bariatric surgery in morbidly obese patients with inflammatory bowel disease. Surg Obes Relat Dis 11:132–136. https://doi.org/10.1016/j.soard.2014.06.022
64. Hudson JL, Barnes EL, Herfarth HH, Isaacs KL, Jain A (2019) Bariatric Surgery Is a Safe and Effective Option for Patients with Inflammatory Bowel Diseases: A Case Series and Systematic Review of the Literature. Inflamm Intest Dis 3:173–179. https://doi.org/10.1159/000496925
65. Honoréé M, McLeod G, Hopkins G (2018) Outcomes of laparoscopic sleeve gastrectomy in Crohn’s disease patients: an initial Australian experience. ANZ J Surg 88:E708-E712. https://doi.org/10.1111/ans.14449
66. Heshmati K, Lo T, Tavakkoli A, Sheu E (2019) Short-Term Outcomes of Inflammatory Bowel Disease after Roux-en-Y Gastric Bypass vs Sleeve Gastrectomy. J Am Coll Surg 228:893-901.e1. https://doi.org/10.1016/j.jamcollsurg.2019.01.021
67. Colombo F, Rizzi A, Ferrari C, Frontali A, Casiraghi S, Corsi F, Sampietro GM, Foschi D (2015) Bariatric surgery in patients with inflammatory bowel disease: An accessible path? Report of a case series and review of the literature. J Crohns Colitis 9:185–190. https://doi.org/10.1093/ecco-jcc/jju011
68. Aminian A, Andalib A, Ver MR, Corcelles R, Schauer PR, Brethauer SA (2016) Outcomes of Bariatric Surgery in Patients with Inflammatory Bowel Disease. Obes Surg 26:1186–1190. https://doi.org/10.1007/s11695-015-1909-y
69. Aelfers S, Janssen IMC, Aarts EO, Smids C, Groenen MJ, Berends FJ (2018) Inflammatory Bowel Disease Is Not a Contraindication for Bariatric Surgery. Obes Surg 28:1681–1687. https://doi.org/10.1007/s11695-017-3076-9
70. Caviglia GP, Garrone A, Bertolino C, Vanni R, Bretto E, Poshnjari A, Tribocco E, Frara S, Armandi A, Astegiano M, Saracco GM, Bertolusso L, Ribaldone DG (2023) Epidemiology of Inflammatory Bowel Diseases: A Population Study in a Healthcare District of North-West Italy. J Clin Med 12:641. https://doi.org/10.3390/jcm12020641
71. Wise J, Plescia T, Cummings BP, Lyo V (2022) Exploring the Relationship Between Bariatric Surgery and Inflammatory Bowel Disease: A Systematic Review. Crohns Colitis 360 4:otac013. https://doi.org/10.1093/crocol/otac013

 

Author information

Affiliations

Claire Wunker¹, Sunjay Kumar², Peter Hallowell³, Amelia Collings⁴, Lindsey Loss⁵, Varun Bansal⁶, Bradley Kushner⁷, Theofano Zoumpou⁸, Tammy Lyn Kindel⁹, D. Wayne Overby¹⁰, Julietta Chang¹¹, Subhashini Ayloo¹², Andrew F. Sabour¹³, Omar M. Ghanem¹⁴, Essa Aleassa¹⁵, Adam Reid¹⁶, Noe Rodriguez¹⁵, Ivy N. Haskins¹⁷, L. Renee Hilton¹⁸, Bethany J. Slater¹⁹, Francesco Palazzo²⁰

1. Department of Surgery, Saint Louis University, St. Louis, USA
2. Department of Surgery, Jefferson University, Philadelphia, USA
3. Department of Surgery, University of Virginia, Charlottesville, USA
4. Department of Surgery, University of Louisville, Louisville, USA
5. Department of Surgery, Oregon Health and Science University, Portland, USA
6. Department of Surgery, University of Colorado, Boulder, USA
7. Department of Surgery, Washington University in St. Louis, St. Louis, USA
8. Department of Surgery, Rutgers New Jersey Medical School, Newark, USA
9. Department of Surgery, Medical College of Wisconsin, Milwaukee, USA
10. Department of Surgery, University of North Carolina, Chapel Hill, USA
11. Department of Surgery, Kaiser Permanente Bellevue Medical Center, Bellevue, USA
12. Department of Surgery, Brown University, Providence, USA
13. Department of Surgery, University of Nevada, Reno, USA
14. Department of Surgery, Mayo Clinic, Arizona, USA
15. Department of Surgery, Cleveland Clinic, Cleveland, USA
16. Department of Surgery, Southern Illinois University School of Medicine, Springfield, USA
17. Department of Surgery, University of Nebraska Medical Center, Omaha, USA
18. Department of Surgery, Medical College of Georgia, Augusta, USA
19. Department of Surgery, University of Chicago, Chicago, USA
20. Department of Surgery, Medical Office Building, Thomas Jefferson University Hospital, Philadelphia USA