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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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Author information

Authors and Affiliations

  1. Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Minimally Invasive Surgery Research Center, School of Medicine, Rasool‑E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran

    Mohammad Kermansaravi

  2. Whittington Hospital, London, UK

    Chetan Parmar

  3. Bariatric and Metabolic Surgery Unit, Ospedale Evangelico Betania, Naples, Italy

    Sonja Chiappetta

  4. Department of Surgery Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Scott Shikora

  5. Department of General Surgery, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA

    Ali Aminian

  6. Iranian Hospital, Dubai, UAE

    Syed Imran Abbas

  7. Department of Public Health, Federico II University of Naples, Naples, Italy

    Luigi Angrisani

  8. Minimally Invasive and Bariatric Surgery, Gastrointestinal Bariatric and Metabolic Center (GBMC)-Jordan Hospital, Amman, Jordan

    Ahmad Bashir & Ashraf Haddad

  9. New Life Center, Guatemala, Guatemala

    Estuardo Behrens

  10. Mohak Bariatrics and Robotics Center, Indore, India

    Mohit Bhandari

  11. Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX, USA

    Benjamin Clapp

  12. Center for Obesity and Diabetes, Oswaldo Cruz German Hospital, São Paulo, Brazil

    Ricardo Cohen

  13. Polyclinique Lyon Nord, Rillieux-La-Pape, France

    Jerome Dargent

  14. Department of General Surgery, AZ Sint Jan Brugge-Oostende, Brugge, Belgium

    Bruno Dilemans

  15. Department of General Surgery, Rovigo Hospital, Rovigo, Italy

    Maurizio De Luca

  16. Bariatric Surgery Unit, Faculty of Medicine, Ain Shams University, Cairo, Egypt

    Khaled Gawdat

  17. Makassed General Hospital, Beirut, Lebanon

    Mohamed Hayssam Elfawal

  18. Bariatric Surgery Unit, Delta Chirec Hospital, Brussels, Belgium

    Jaques Himpens

  19. Body Science and Metabolic Disorders International Medical Center, China Medical University Hospital, Taichung City, Taiwan

    Chih-Kun Huang

  20. University of Arizona College of Medicine, Phoenix, USA

    Farah Husain

  21. Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan

    Kazunori Kasama

  22. Department of Digestive Surgery, CHU Félix Guyon, Saint Denis, La Réunion, France

    Radwan Kassir

  23. Walsall Healthcare NHS Trust, Walsall, UK

    Amir Khan

  24. Flinders Medical Centre, Adelaide, Australia

    Lilian Kow

  25. Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA

    Matthew Kroh

  26. Sir H N Reliance Foundation Hospital, Mumbai, India

    Muffazal Lakdawala

  27. Hospital Ángeles Tijuana Mexico, Tijuana, Mexico

    Juan Antonio Lopez Corvala

  28. Diakonissen Wehrle Private Hospital, Salzburg, Austria

    Karl Miller

  29. Advanced Biomedical Sciences Department, “Federico II” University, Naples, Italy

    Mario Musella

  30. Atrium Health, Charlotte, NC, USA

    Abdelrahman Nimeri

  31. Clinique Bouchard, Elsan, 13006, Marseille, France

    Patrick Noel

  32. Department of Surgery, Centro CIEN-Diagnomed, University of Buenos Aires, Buenos Aires, Argentina

    Mariano Palermo

  33. Department of Surgery Clinica Anglo Americana, Universidad Nacional Mayor de San Marcos, Lima, Peru

    Luis Poggi

  34. Department of Digestive, Oeso-Gastrique and Bariatric Surgery, Hôpital Bichât, AP-HP, Université de Paris Cité, Paris, France

    Tigran Poghosyan

  35. Medical University of Vienna, Vienna, Austria

    Gerhard Prager

  36. Apollo Hospital, New Delhi, India

    Arun Prasad

  37. New You Medical Center, Obesity Chair, King Saud University, Riyadh, Saudi Arabia

    Aayad Alqahtani

  38. Department of Bariatric, Metabolic and Plastic Surgery, St. Franziskus Hospital, Cologne, Germany

    Karl Rheinwalt

  39. Centro Multidisciplinar do Tratamento da Obesidade, Hospital Lusíadas Amadora e Lisbon, Amadora, Portugal

    Rui Ribeiro

  40. National University of Singapore, Singapore, Singapore

    Asim Shabbir

  41. Department of Surgery, Hospital Clínico San Carlos, Complutense University of Madrid, Calle del Prof Martín Lagos, S/N, 28040, Madrid, Spain

    Antonio Torres

  42. Endocrine, Bariatric and Metabolic Surgery Department, Universitary Hospital Vall Hebron, Barcelona, Spain

    Ramon Villalonga

  43. Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China

    Cunchuan Wang

  44. South Tyneside and Sunderland Foundation NHS Trust, Sunderland, UK

    Kamal Mahawar

  45. Department of Surgery, State University of New York, Buffalo, NY, USA

    Natan Zundel

Authors
  1. Mohammad Kermansaravi
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  2. Chetan Parmar
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  3. Sonja Chiappetta
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  4. Scott Shikora
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  5. Ali Aminian
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  6. Syed Imran Abbas
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  7. Luigi Angrisani
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  8. Ahmad Bashir
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  9. Estuardo Behrens
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  10. Mohit Bhandari
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  11. Benjamin Clapp
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  12. Ricardo Cohen
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  13. Jerome Dargent
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  14. Bruno Dilemans
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  15. Maurizio De Luca
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  16. Ashraf Haddad
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  17. Khaled Gawdat
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  18. Mohamed Hayssam Elfawal
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  19. Jaques Himpens
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  20. Chih-Kun Huang
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  21. Farah Husain
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  22. Kazunori Kasama
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  23. Radwan Kassir
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  24. Amir Khan
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  25. Lilian Kow
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  26. Matthew Kroh
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  27. Muffazal Lakdawala
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  28. Juan Antonio Lopez Corvala
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  29. Karl Miller
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  30. Mario Musella
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  31. Abdelrahman Nimeri
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  32. Patrick Noel
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  33. Mariano Palermo
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  34. Luis Poggi
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  35. Tigran Poghosyan
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  36. Gerhard Prager
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  37. Arun Prasad
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  38. Aayad Alqahtani
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  39. Karl Rheinwalt
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  40. Rui Ribeiro
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  41. Asim Shabbir
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  42. Antonio Torres
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  43. Ramon Villalonga
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  44. Cunchuan Wang
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  45. Kamal Mahawar
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  46. Natan Zundel
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Corresponding authors

Correspondence to Mohammad Kermansaravi or Natan Zundel.

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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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