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Best practice approach for redo-surgeries after sleeve gastrectomy, an expert's modified Delphi consensus

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Abstract

Background

Sleeve gastrectomy (SG) is the most common metabolic and bariatric surgical (MBS) procedure worldwide. Despite the desired effect of SG on weight loss and remission of obesity-associated medical problems, there are some concerns regarding the need to do revisional/conversional surgeries after SG. This study aims to make an algorithmic clinical approach based on an expert-modified Delphi consensus regarding redo-surgeries after SG, to give bariatric and metabolic surgeons a guideline that might help for the best clinical decision.

Methods

Forty-six recognized bariatric and metabolic surgeons from 25 different countries participated in this Delphi consensus study in two rounds to develop a consensus on redo-surgeries after SG. An agreement/disagreement ≥ 70.0% on statements was considered to indicate a consensus.

Results

Consensus was reached for 62 of 72 statements and experts did not achieve consensus on 10 statements after two rounds of online voting. Most of the experts believed that multi-disciplinary team evaluation should be done in all redo-procedures after SG and there should be at least 12 months of medical and supportive management before performing redo-surgeries after SG for insufficient weight loss, weight regain, and gastroesophageal reflux disease (GERD). Also, experts agreed that in case of symptomatic GERD in the presence of adequate weight loss, medical treatment for at least 1 to 2 years is an acceptable option and agreed that Roux-en Y gastric bypass is an appropriate option in this situation. There was disagreement consensus on efficacy of omentopexy in rotation and efficacy of fundoplication in the presence of a dilated fundus and GERD.

Conclusion

Redo-surgeries after SG is still an important issue among bariatric and metabolic surgeons. The proper time and procedure selection for redo-surgery need careful considerations. Although multi-disciplinary team evaluation plays a key role to evaluate best options in these situations, an algorithmic clinical approach based on the expert's consensus as a guideline can help for the best clinical decision-making.

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Abbreviations

SG:

Sleeve gastrectomy (SG)

GERD:

Gastroesophageal reflux disease

MDT:

Multi-disciplinary team

EGD:

Esophagogastroduodenoscopy (EGD)

UGI:

Upper gastrointestinal

RYGB:

Roux-en Y gastric bypass

OAGB:

One anastomosis gastric bypass

BPD/DS:

Biliopancreatic diversion/duodenal switch

SADI-S:

Single Anastomosis Duodeno-Ileal bypass with Sleeve Gastrectomy

SASI:

Single Anastomosis Sleeve Ileal Bypass

SG-TB:

Sleeve gastrectomy with transit bipartition

HH:

Hiatal hernia

ESG:

Endoscopic sleeve gastroplasty

BPL:

Biliopancreatic limb

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Authors and Affiliations

Authors

Corresponding authors

Correspondence to Mohammad Kermansaravi or Natan Zundel.

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Disclosures

Dr. Bruno Dilemans has an equity interest in Johnson & Johnson and Medtronic& Olympus. Dr. Farah Husain has an equity interest in Ethicon J&J. Dr. Ashraf Haddad has an equity interest consultant for Medtronic and Speaker for EziSurge Medical. Dr. Sonja Chiappetta has an equity interest in Novo Nordisc and Johnson and Johnson. Dr. Ricardo Cohen has an equity interest in Johnson & Johnson and Medtronic and Scientific Advisory Board for Baritek; GI Dynamics. Dr. Karl Miller has an equity interest in J&J as consultant. Dr. Ali Aminian has an equity interest in Honorarium and research support from Medtronic and Ethicon. Dr. Kamal Mahawar has been paid honoraria by Medtronic, Ethicon, Olympus, Gore, and several NHS truts for education activities and mentoring in the field of bariatric surgery (predominantly One Anastomosis Gastric Bypass). Dr. Natan Zundel has an equity interest in Johnson & Johnson and Medtronic, Olympus, Apolo, VHP, LivsMed. Drs Mohammad Kermansaravi, Chetan Parmar, Scott Shikora, Syed Imran Abbas, Luigi Angrisani, Ahmad Bashir, Estuardo Behrens, Mohit Bhandari, Benjamin Clapp, Jerome Dargent, Maurizio De Luca, Khaled Gawdat, Mohamed Hayssam Elfawal, Jaques Himpens, Chih-Kun Huang, Kazunori Kasama, Radwan Kassir, Amir Khan, Lilian Kow, Matthew Kroh, Muffazal Lakdawala, Juan Antonio Lopez Corvala, Mario Musella, Abdelrahman Nimeri, Patrick Noel, Mariano Palermo, Luis Poggi, Tigran Poghosyan, Gerhard Prager, Arun Prasad, Aayad Alqahtani, Karl Rheinwalt, Rui Ribeiro, Asim Shabbir, Antonio Torres, Ramon Villalonga, and Cunchuan Wang have no conflict of interest or financial ties to disclose.

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Appendix: List of modified Delphi consensus experts (in alphabetical order)

Appendix: List of modified Delphi consensus experts (in alphabetical order)

Name

Country

1. Syed Imran Abbas

UAE

2. Ali Aminian

USA

3. Luigi Angrisani

Italy

4. Ahmad Bashir

Jordan

5. Estuardo Behrens

Guatemala

6. Mohit Bhandari

India

7. Sonja Chiappetta

Italy

8. Ben Clapp

USA

9. Ricardo Cohen

Brazil

10. Jerome Dargent

France

11. Maurizio De Luca

Italy

12. Bruno Dillemans

Belgium

13. Mohamed Hayssam Elfawal

Lebanon

14. Khaled Gawdat

Egypt

15. Ashraf Haddad

Jordan

16. Jaques Himpens

Belgium

17. Chih-Kun Huang

Taiwan

18. Farah Hussain

USA

19. Kazunori Kasama

Japan

20. Radwan Kassir

France

21. Mohammad Kermansaravi

Iran

22. Amir Khan

UK

23. Lilian Kow

Australia

24. Matthew Kroh

USA

25. Muffazal Lakdawala

India

26. Juan Antonio Lopez Corvala

Mexico

27. Kamal Mahawar

UK

28. Karl Miller

Austria

29. Mario Musella

Italy

30. Abdelrahman Nimeri

USA

31. Patrick Noel

UAE

32. Mariano Palermo

Argentina

33. Chetan Parmar

UK

34. Luis Poggi

Peru

35. Tigran Poghosyan

France

36. Gerhard Prager

Austria

37. Arun Prasad

India

38. Aayad Alqahtani

Saudi Arabia

39. Karl Rheinwalt

Germany

40. Rui Ribeiro

Portugal

41. Asim Shabbir

Singapore

42. Scott Shikora

USA

43. Antonio Torres

Spain

44. Ramon Villalonga

Spain

45. Cunchuan Wang

China

46. Natan Zundel

USA/Colombia

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Kermansaravi, M., Parmar, C., Chiappetta, S. et al. Best practice approach for redo-surgeries after sleeve gastrectomy, an expert's modified Delphi consensus. Surg Endosc 37, 1617–1628 (2023). https://doi.org/10.1007/s00464-023-09879-x

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