Introduction: One anastomosis gastric bypass (OAGB) prevalence is increasing worldwide and shows good mid- to long-term results. Data on long-term outcomes of revisional OAGB (rOAGB) is limited. This study’s objective was to evaluate the long-term outcomes of patients undergoing primary OAGB (pOAGB) and rOAGB. Methods: A retrospective analysis of a prospectively maintained patient registry at a single-tertiary center. Patients undergoing OAGB from January 2015 to May 2016 were included and grouped into pOAGB and rOAGB. Results: There were 424 patients, of which 363 underwent pOAGB, and 61 underwent rOAGB. Baseline characteristics were insignificantly different between groups except for the type 2 diabetes (T2D) rate which was higher in pOAGB (26% vs. 11.5%, p = 0.01). The mean follow-up time was 98.5 ± 3.9 months, and long-term follow-up data were available for 52.5% of patients. The mean total weight loss (TWL) was higher in the pOAGB group (31.3 ± 14 vs. 24.1 ± 17.6, p = 0.006); however, TWL was comparable when relating to the weight at primary surgery for rOAGB. The rate of T2D and hypertension resolution was 79% and 72.7% with no difference between groups. Thirteen patients (5.9%) underwent OAGB revision during follow-up, with no difference between groups. Two deaths occurred during follow-up, both non-related to OAGB. Conclusion: OAGB is effective as a primary and as a revisional procedure for severe obesity with good long-term results in terms of weight loss and resolution of associated diseases. In addition, the revisional surgery rates and chronic complications are acceptable. Further large prospective studies are required to clarify these data.

Although awareness regarding the morbidity associated with severe obesity is increasing worldwide, severe obesity remains a significant global public health issue [1, 2]. Behavioral and dietary changes are inferior to metabolic and bariatric surgery (MBS) in terms of weight loss, and durability; in addition, MBS offers satisfactory results in terms of the resolution of obesity-related medical conditions [3, 4].

Different surgical approaches have been used and studied with reassuring reports regarding their short- and long-term results [3‒6]. Over the last decade, the one anastomosis gastric bypass (OAGB) surgery, first described by Dr. Robert Rutledge [7], is increasing in popularity owing to its safety profile, good weight loss outcomes, and resolution of severe obesity medical problems, and it is also a good option as a revisional procedure after a previous failed bariatric procedure due to insufficient weight loss or weight regain [7‒12].

OAGB has become the most common MBS in Israel, with revisional surgeries comprising nearly 15% of all MBS performed in the country [13]. Revisional MBS has become very common as several types of MBS, especially restrictive procedures, are associated with higher rates of insufficient weight loss and weight regain [14‒16].

Studies evaluating the long-term outcomes (>5 years) of OAGB have been reported, as well as comparative studies showing satisfactory results [17‒20]. Comparative studies evaluating long-term outcomes of patients undergoing primary versus revisional OAGB are lacking. The aim of this study was to evaluate the long-term outcomes (of at least 8 years) of patients undergoing OAGB comparing patients undergoing OAGB as a primary procedure (pOAGB) to patients undergoing OAGB as a revisional procedure (rOAGB).

Patients

Data were collected from a prospectively maintained database of a single-tertiary MBS center. All patients undergoing OAGB from January 2015 through May 2016 were included in this study.

Data captured included baseline characteristics of patients: age, gender, preoperative body mass index (BMI), obesity-associated medical conditions including type 2 diabetes (T2D), hypertension, hyperlipidemia, obstructive sleep apnea (OSA), gastroesophageal reflux disease (GERD), and metabolic-associated fatty liver disease. Patients were grouped into pOAGB and rOAGB, and data regarding previous bariatric procedures were withdrawn as well. All patients underwent a thorough evaluation by a multidisciplinary team and were found eligible for surgery. Patients undergoing OAGB due to severe obesity were included in the study and indications for surgery comply with the guidelines of the National Institution of Health (NIH) [21].

Follow-Up

Data regarding the patient follow-up were retrieved at 1, 3, 5, 8, and 9 years. All patients that completed at least 8-year follow-up were included in the study. Weight loss was calculated as a change in BMI points and percentage of total weight loss (TWL) (preoperative weight-postoperative weight at the time of measurement)/(preoperative weight *100). Resolution of T2D and hypertension was defined according to the recommended guidelines [22, 23].

Data regarding patients with chronic complications including patients undergoing revisional surgery during the follow-up and additional surgeries were retrieved. The surgical technique was described in our previous studies [24, 25] and is described briefly here.

Surgical Technique

All procedures were performed in a laparoscopic approach. The angle of His was exposed and cleared till the exposure of the left crus. The lesser sac was entered at the level of the crow’s foot. A long and narrow gastric pouch was constructed along a bougie by applying a single horizontal staple line, followed by serial applications of staple cartridges up to the Angle of His. A linear-stapled anastomosis was then created between the gastric pouch and the small bowel, at 180–200 cm from the ligament of Treitz and a manual closure of the opening. A routine blue dye leak test is performed. The mesenteric defect is not routinely closed.

When relating to revisional procedures, lysis of adhesions was performed as indicated. Conversion from silastic ring vertical gastroplasty was preceded by removal of the silastic ring and confirmation of adequate gastric pouch length. Conversion from laparoscopic adjustable gastric band (LAGB) was preceded by the removal of the band and fibrous capsule, unless previously performed. Conversion from sleeve gastrectomy (SG) was initiated with transection of the sleeve at the level of the crow’s foot, followed by trimming of the sleeve when indicated.

Statistical Analysis

Statistical analysis was performed using the IBM SPSS version 27 statistical data editor. Continuous data are expressed as mean values with the corresponding standard deviation. Categorical data are presented as number (percent). Fischer test and χ2 test were used for categorical data, and the Student’s t test was used for continuous data analysis. All p values were derived from two-tailed tests.

Patient Characteristics

Four hundred and twenty-four patients underwent OAGB between January 2015 and May 2016. Of these, 363 patients were in the pOAGB group (85.6%), and 61 patients (14.3%) were in the rOAGB group. Baseline characteristics are shown in Table 1. There was no difference between the groups in most baseline characteristics, including gender, age, BMI, and obesity-associated medical conditions, except T2D rate, which was higher in the pOAGB group (26% vs. 11.5%, p = 0.01). Previous procedures in the rOAGB group included LAGB (n = 38, 62.3%), SG (n = 14, 22.3%), silastic ring vertical gastroplasty (n = 5, 8.2%), and both LAGB and SG (n = 4, 6.6%). The mean BMI in the rOAGB group at primary surgery was 44.4 ± 6.3 kg/m2. The mean follow-up time was 98.5 ± 3.9 months with no difference between groups (p = 0.47). A total of 182 patients were available to last follow-up from the pOAGB group (50.1%), and 39 patients were available to follow-up from the rOAGB group (63.4%), constituting 52% of the entire cohort. Forty-nine patients had an 8-year follow-up and 173 patients had a 9-year follow-up. The long-term outcomes of patients are shown in Table 2. The mean TWL and BMI points decrease was higher in the pOAGB group (31.3 ± 14 vs. 24.1 ± 17.6, p = 0.006, and 13.7 ± 7.5 vs. 10.4 ± 8.3; p = 0.01). When considering poor clinical response, the number of patients reaching TWL <20% in the pOAGB group was 21% compared with 33% in the rOAGB group with no significant difference (p = 0.11). When considering the TWL from the primary surgery in the rOAGB group, there was no significant difference in TWL and BMI units lost when compared to pOAGB at the last follow-up – 33.6 ± 14 versus 31.3 ± 14; p = 0.44, and 15.2 ± 8.5 versus 13.7 ± 7.5; p = 0.33, respectively. The rate of T2D and HTN resolution was 79% and 72.7% in the entire cohort with no meaningful difference between groups. The last follow-up BMI was lower in the pOAGB group (28.3 ± 6.1 vs. 30.7 ± 7.9. p = 0.03), and the BMI trends throughout the follow-up are shown in Figure 1.

Table 1.

Patient baseline characteristics

Total (n = 424)pOAGB n = 363 (85.6%)rOAGB n = 61 (14.3%)p value
Gender – f, n (%) 249 (58.7) 212 (58.4) 36 (60.7) 0.74 
Age, years, mean±SD) 41.5±11.5 41.6±12.2 45.2±12.3 0.15 
BMI at OAGB in kg/m2, mean±SD 41.8±5.4 42±5.2 40.7±6.0 0.1 
T2D, n (%) 102 (24) 95 (26) 7 (11.5) 0.01 
Hypertension, n (%) 102 (24) 89 (24.5) 13 (21.3) 0.58 
Hyperlipidemia, n (%) 102 (24) 93 (25.6) 9 (14.7) 0.07 
GERD, n (%) 29 (6.8) 26 (7) 3 (4.9) 0.52 
OSA, n (%) 48 (11.3) 45 (12.4) 3 (4.9) 0.08 
FL, n (%) 108 (25.5) 98 (27) 10 (16.4) 0.08 
Previous bariatric procedure 
BMI at primary surgery *   44.4±6.3  
LAGB, n (%)   38 (62.3)  
LSG, n (%)   14 (22.3)  
SRVG, n (%)   5 (8.2)  
LAGB+LSG, n (%)   4 (6.6)  
Total (n = 424)pOAGB n = 363 (85.6%)rOAGB n = 61 (14.3%)p value
Gender – f, n (%) 249 (58.7) 212 (58.4) 36 (60.7) 0.74 
Age, years, mean±SD) 41.5±11.5 41.6±12.2 45.2±12.3 0.15 
BMI at OAGB in kg/m2, mean±SD 41.8±5.4 42±5.2 40.7±6.0 0.1 
T2D, n (%) 102 (24) 95 (26) 7 (11.5) 0.01 
Hypertension, n (%) 102 (24) 89 (24.5) 13 (21.3) 0.58 
Hyperlipidemia, n (%) 102 (24) 93 (25.6) 9 (14.7) 0.07 
GERD, n (%) 29 (6.8) 26 (7) 3 (4.9) 0.52 
OSA, n (%) 48 (11.3) 45 (12.4) 3 (4.9) 0.08 
FL, n (%) 108 (25.5) 98 (27) 10 (16.4) 0.08 
Previous bariatric procedure 
BMI at primary surgery *   44.4±6.3  
LAGB, n (%)   38 (62.3)  
LSG, n (%)   14 (22.3)  
SRVG, n (%)   5 (8.2)  
LAGB+LSG, n (%)   4 (6.6)  

OAGB, one anastomosis gastric bypass; pOAGB, primary OAGB, rOAGB, revisional OAGB; BMI, body mass index; T2D, type 2 diabetes; GERD, gastroesophageal reflux disease; OSA, obstructive sleep apnea; FL, fatty liver; LAGB, laparoscopic adjustable gastric band; SG, laparoscopic sleeve gastrectomy; SRVG, silastic ring vertical gastroplasty.

*Relates to the revisional group.

Table 2.

Long-term outcomes

Total (n = 221)pOAGB (n = 182)rOAGB (n = 39)p value
Follow-up time, months 98.5±3.9 98.5±3.9 98.9±3.9 0.47 
TWL from OAGB, % 30.1±15 31.3±14 24.1±17.6 0.006 
TWL from primary surgery*, % 32.4±14 31.3±14 33.6±14 0.44 
BMI at last follow-up 28.7±6.6 28.3±6.1 30.7±7.9 0.03 
BMI point decrease from OAGB 12.1±7.9 13.7±7.5 10.4±8.3 0.01 
BMI points decrease from primary surgery* 14.4±8 13.7±7.5 15.2±8.5 0.33 
TWL <20% at last follow-up, n (%) 52 (23.5) 39 (21) 13 (33) 0.11 
T2D resolution**, n (%) 42/53 (79) 38/48 (79.2) 4/5 (80) 0.96 
Hypertension resolution**, n (%) 40/55 (72.7) 33/46 (71.7) 7/9 (77.7) 0.71 
Total (n = 221)pOAGB (n = 182)rOAGB (n = 39)p value
Follow-up time, months 98.5±3.9 98.5±3.9 98.9±3.9 0.47 
TWL from OAGB, % 30.1±15 31.3±14 24.1±17.6 0.006 
TWL from primary surgery*, % 32.4±14 31.3±14 33.6±14 0.44 
BMI at last follow-up 28.7±6.6 28.3±6.1 30.7±7.9 0.03 
BMI point decrease from OAGB 12.1±7.9 13.7±7.5 10.4±8.3 0.01 
BMI points decrease from primary surgery* 14.4±8 13.7±7.5 15.2±8.5 0.33 
TWL <20% at last follow-up, n (%) 52 (23.5) 39 (21) 13 (33) 0.11 
T2D resolution**, n (%) 42/53 (79) 38/48 (79.2) 4/5 (80) 0.96 
Hypertension resolution**, n (%) 40/55 (72.7) 33/46 (71.7) 7/9 (77.7) 0.71 

TWL, total weight loss; BMI, body mass index; T2D, type 2 diabetes.

*Relates to the revisional group.

**Ratio was calculated from patients with available follow-up.

Fig. 1.

Trends in BMI over time. BMI, body mass index. *Relates to the revisional group.

Fig. 1.

Trends in BMI over time. BMI, body mass index. *Relates to the revisional group.

Close modal

Reoperations

From patients available to follow up, 35/221 (15.8%) patients underwent reoperation during the follow-up. Thirteen (5.9%) patients underwent revision of OAGB – 11 patients from the pOAGB group (6.1%) and 2 patients (5.1%) from the rOAGB group (p = 0.8).

OAGB Revisions

Marginal Ulcers

Five patients (2.3%) underwent revisional surgery due to marginal ulcer perforation, and all patients underwent laparoscopic omental patch fixation, with resolution of symptoms on postoperative follow-up. The time from OAGB to perforation was 5–6 years.

Internal Hernia

Two patients (0.9%) were diagnosed with an internal hernia during the follow-up. The first patient underwent a laparoscopic exploration with a reduction in the herniated bowel and repair of the mesenteric defect. The second patient underwent a conversion to RYGB due to an ischemic bowel.

Malnutrition

Two patients (0.9%) underwent OAGB reversal due to severe protein energy malnutrition.

Others Revisional Surgery

Two patients (0.9%) underwent conversion to RYGB due to gastro-jejunal anastomotic stricture. One patient underwent conversion to RYGB due to severe bile reflux (0.5%). An additional patient underwent laparoscopic exploration due to a small bowel obstruction caused by extensive adhesions.

Additional Surgeries

Twelve patients (5.4%) underwent a cholecystectomy due to cholelithiasis during follow-up. Ten patients (4.5%) had a repair of a ventral hernia, of which 6 were incisional hernia repair (2.7%). Other surgeries included colectomy for colon cancer (n = 3), diaphragmatic hernia repair (n = 2), and appendectomy (n = 1).

Other Chronic Complications

Bile Reflux

During follow-up, 23 patients (10%) were diagnosed with bile reflux, of which one underwent revisional surgery due to severe debilitating symptoms as mentioned above. The other patients were treated in a conservative manner which included a prescription of proton pump inhibitors in a high dose, sucralfate, and lifestyle modifications such as avoiding eating immediately before sleeping, staying upright after eating, and raising the head of the bed before sleeping.

Hypoglycemia

Eight patients (3.6%) were noted to experience hypoglycemic episodes that were treated in conservative manners which included strict dietary changes to a high-protein and low-carbohydrate diet. If despite dietary changes symptoms persisted, patients are prescribed medications which initially include alpha-glucosidase inhibitors and if still symptoms persist, calcium channel blockers (diazoxide) and/or somatostatin analogues are recommended. In cases of severe life-threatening symptoms and failure of conservative measures, we recommend revisional surgery which was not required in any of the patients in the cohort.

Deaths

Two patients (0.9%) died during follow-up. One patient committed suicide, and the other patient had a cerebral aneurysm which caused a severe debilitating condition that eventually led to her death.

In this study, we compared the long-term outcomes of patients undergoing primary OAGB to revisional OAGB. We have found that in a follow-up time of at least 8 years, the weight loss results in addition to the resolution of severe obesity-associated medical conditions are comparable. When comparing weight loss outcomes in relation to the BMI at the time of OAGB, pOAGB showed significantly better results.

We have previously published our first-year outcomes following OAGB [24]. Out of 407 patients that underwent OAGB (254 females, average age 41.8 ± 12.05, BMI = 41.7 ± 5.77 kg/m2), the average excess weight loss (%EWL) 1 year following surgery was 88.9 ± 27.3 and 72.8 ± 43.5% in patients that underwent primary and revision OAGB, respectively. Our complication rate was 1.96% for early minor complications (Clavien-Dindo 1-3a) and 2.45% for early major complications (Clavien-Dindo ≥3b).

In the current study, the mean TWL at the last follow-up was 30.1% and the rate of patients with a poor clinical response of TWL <20% was ≈20%. Patients undergoing pOAGB had a significantly higher rate of TWL and lower mean BMI in the last follow-up (31.3% vs. 24.1%, p = 0.006, and 28.3 vs. 30.7, p = 0.03, respectively). These outcomes were insignificant when analyzing the preoperative weight in the primary procedure in the rOAGB group. In addition, there was a high rate of T2D and hypertension resolution (79%, and 72.7%, respectively) with no significant difference between groups.

Neuberg et al. [17], evaluated 163 patients undergoing OAGB in which for 57.6% it was a revisional procedure. The mean BMI reduction at 5–8 years was 8.8–12.6, and the mean EWL was 62.3–81.8% with significantly higher EWL and lower BMI at the last follow-up in patients undergoing primary OAGB. However, it is important to note that these results relate to the BMI at the time of OAGB for revisional patients, and the results could be comparable if the BMI at primary surgery for the revisional group were analyzed. They also reported excellent outcomes in obesity-associated medical problems improvement or resolution which was 80%. Carandina et al. [26] reported the >10-year outcome of patients undergoing OAGB and compared primary versus revisional OAGB. The TWL was 33.4% and was comparable between groups. In addition, 29% of patients were defined to have a poor clinical response with EWL <50%. T2D and HTN resolution rates were high as well (90% and 85%, respectively). These studies outline that OAGB, both as a primary and as a revisional procedure, is effective in terms of sustained weight loss, as well as resolution of T2D and hypertension in the long term and are in line with our current results.

Comparison of primary and revisional MBS has been reported in the literature. Sakran et al. [27] evaluated the long-term outcomes (12 years) of patients undergoing primary versus revisional SG, and it was shown that mean TWL was comparable between groups (20.9 and 18.3; p = 0.165) and resolution of associated medical conditions was comparable as well. Despite showing these outcomes, more than 50% had insufficient weight loss and the vast majority of patients in both groups had weight regain with a trend toward earlier weight regain in the revisional group (2.6 vs. 3.4 years). Interestingly, they reported that patients undergoing primary SG were significantly more satisfied with the surgery and would likely choose the procedure again. In a propensity-matched analysis by Giannopoulus et al. [28] RYGB and SG were performed as primary or revisional procedures. The TWL was significantly higher in the primary group (32% vs. 21%) at a 2-year follow-up with no significant difference in associated medical condition resolutions and reoperations. In a systematic review and meta-analysis of short- and long-term outcomes of RYGB, Pedziwiatr et al. [29] reported that patients in the revisional group had 20% less EWL than patients undergoing primary RYGB with no difference in resolution of T2D and hypertension. Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S), a relatively innovative procedure [30], has been reported in a systematic review by Esparham et al. [31] In this review, they reported patients demonstrating a decreased BMI with a weighted mean of 37.5% and 37% at a 5- and 10-year follow-up in primary SADI-S, while in revisional SADI-S, it was 17.1% in a 5-year follow-up. It is important to note that in this study, the authors were unable to perform a meta-analysis due to the heterogeneity of the reported studies and it is difficult to draw clear conclusions from their analysis. To our knowledge, there are no long-term studies comparing primary and revisional SADI-S.

The rate of revisional surgery after OAGB varies in the literature. In the multi-institutional survey by Musella et al. [32], the rate of patients undergoing revisional surgery at 62-month follow-up was 2.08% with conversion to RYGB being the most frequent choice. Jedamzik et al. [33] reported 82/1,025 patients undergoing conversion from OAGB to RYGB with most patients converted due to severe biliary reflux (n = 42) followed by marginal ulcers (n = 11), stenosis (n = 10), malnutrition (n = 9), and weight regain (n = 3).

In a review study by Kermensaravi et al. [34], it was noted that 4% of patients will require surgical revision of OAGB. In addition, this study also emphasizes the advantages of OAGB when revision or reversal is required owing to its relative simplicity. The rate of OAGB revision in our study was shown to be 5.9%; however, the total reoperation rate in our study was 15.8%. The reoperation rate may seem high when compared to other studies in the literature; however, we estimate that ≈12% of surgeries are related to OAGB, some procedures were performed concomitantly, and nearly 50% of patients lost to follow-up which may alter the rate. Moreover, it is important to notice that this study evaluated patients undergoing OAGB during our learning curve, and this may explain the relatively high reoperation rate.

Our study has several limitations, it is retrospective in nature with non-randomized groups which were comparable except for preoperative T2D rates and therefore is susceptible to biases such as underreporting and selection bias. It was conducted at a single center which may limit generalizability. The loss to follow-up rate was 48%, which could possibly skew the data. It is important to note that loss to follow-up is a well-known phenomenon in patient follow-up after MBS, and its rate increases with longer follow-ups. We believe that the follow-up rate is reasonable and reflective of most surgeons’ experience. In addition, we think that further comparative long-term studies of larger cohorts would be appropriate to further clarify the long-term outcomes of OAGB both as a primary and a revisional procedure. Moreover, long-term studies comparing OAGB to other MBS as a revisional procedure could aid in defining its safety and efficacy as a revisional aaaaaprocedure.

Despite these limitations, our study has several strengths. It consists of a relatively large cohort of patients (both primary and revisional) from a single center with a standardized approach. The follow-up time is relatively long (8–9 years). The study showed that pOAGB was comparable in terms of weight loss to rOAGB. rOAGB showed satisfactory long-term outcomes, which further highlights the effectiveness of OAGB both as a primary and as a secondary procedure.

In conclusion, OAGB is effective as a primary and as a revisional procedure for severe obesity with good long-term results in terms of weight loss and resolution of obesity-associated medical problems. In addition, the rate of revisional surgery and chronic complications is reasonable. Further large prospective studies and large cohorts are required to clarify these data.

The study was approved by the Tel-Aviv Souraski Medical Center Institutional Review Board, approval number TLV-16-0325/2019, and was performed in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. No vulnerable participant was included in the study, and the need for written informed consent was waived by the Tel Aviv Sourasky Medical Center Ethics Committee.

The authors state that they have no conflict of interest with this publication.

The authors did not receive support from any organization for the submitted work.

Adam Abu-Abeid and Yonatan Lessing: study concept and design, data analysis and compilation, revision of the manuscript, writing of the manuscript, and approval. Anat Bendayan: data acquisition. Jonathan B Yuval: revision of the manuscript, statistical advice, and approval. Shai Meron Eldar and Guy Lahat: revision of the manuscript and approval.

The datasets generated during and/or analyzed during the current study are not publicly available due to their containing information that could compromise the privacy of research participants but are available from the corresponding author [Y.L.] on reasonable request.

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