The Efficacy of Conversional One Anastomoses Gastric Bypass post Sleeve Gastrectomy and Gastric Band: A Large Single Cohort Series

The Efficacy of Conversional One Anastomoses Gastric Bypass post Sleeve Gastrectomy and Gastric Band: A Large Single Cohort Series | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Efficacy of Conversional One Anastomoses Gastric Bypass post Sleeve Gastrectomy and Gastric Band: A Large Single Cohort Series Aaron Lerch, Mokshitha Katneni, Ian Martin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4603959/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Conversional bariatric procedures are increasing, particularly conversional one-anastomosis gastric bypasses (cOAGB). This study reports long-term and patient-reported outcomes for cOAGB after laparoscopic adjustable gastric banding (LAGB) and sleeve gastrectomy (SG). Methods This retrospective single-cohort review of a prospective database examined all cOAGB cases (2016-2023). Perioperative morbidity, long-term surgical or endoscopic interventions, and patient-reported outcomes were analysed. Results Within the largest published cohort of 261 consecutive cOAGB patients, 60.9% had prior-LAGB and 39.1% had prior-SG. Within 30 days, three severe and 13 low-grade complications occurred without mortality, with 98.9% of patients home the following day. Twenty-four longer-term surgical interventions were performed for reflux, port-site hernia, perforated ulcer or adhesions. 14 cases of anastomotic ulcer and one reflux oesophagitis were managed conservatively. 60.9% of patients responded to the survey (35.7 months post-cOAGB). 37.1% reported heartburn and 23.9% reported regurgitation. 81.8% of patients reported they were happy with the procedure, and 78% reported they would choose it again, both outcomes associated with greater percentage excess weight loss (%EWL) and lower heartburn scores. Higher satisfaction was associated with less regurgitation or prior-LAGB. Mean BMI (41.8 months after conversion) was 31.5kg/m 2 (9.7kg/m 2 less than before conversion), with mean %EWL of 64.6% (significantly higher in female patients) and mean TBWL of 22.5%. Conclusion cOAGB was found to be safe and effective for further weight loss or persistent reflux. Although these issues may not be fully resolved, the relative improvement is reflected in the strong satisfaction scores, supporting the use of this technique in conversional surgery. Conversional bariatric surgery One anastomosis gastric bypass Single anastomosis gastric bypass Reflux GERD GORD Sleeve gastrectomy Gastric band Weight loss Key Points Patients undergoing conversional bariatric surgery are a difficult cohort, however examination of patient-reported outcomes pleasingly reveals a relatively satisfied group. High satisfaction rates are seen after cOAGB, despite some having persistent reflux. The safety of this procedure is supported. cOAGB is extremely safe as evidenced by very low complication rates and short lengths of stay. It is a relatively effective conversional bariatric procedure. Introduction With the increasing incidence of obesity worldwide, bariatric surgery has become an integral part of evidence-based treatment options.[ 1 – 3 ] It has proven efficacy in treating numerous obesity comorbidities, including hypertension, obstructive sleep apnoea, type 2 diabetes, and dyslipidaemia. Despite refining surgical techniques over six decades, a small percentage of patients find long-term efficacy elusive.[ 4 , 5 ] As such, conversional procedures are utilised increasingly to help manage suboptimal weight loss, or complications such as reflux.[ 6 ] A variety of conversional techniques exist after laparoscopic adjustable gastric banding (LAGB) and sleeve gastrectomy (SG). This includes further reduction in gastric pouch size (retrimming), and/or conversion to a Roux-en-Y (RYGB), or one-anastomosis gastric bypass (OAGB). Several randomised controlled trials (RCTs) have confirmed the use of OAGB for primary bariatric surgery, with favourable results in weight loss outcomes and reduced complications.[ 7 ] Nevertheless, controversy remains in the setting of conversional surgery due to the potential risk of clinically relevant reflux, which may lower the quality of life and increase the theoretical risk of malignancy due to the metaplastic action of bile.[ 8 , 9 ] Several retrospective studies have outlined conversional OAGB (cOAGB) as a safe and effective technique,[ 9 – 11 ] albeit with potentially higher reflux rates than that of its counterpart, RYGB.[ 12 – 14 ] These conversions were typically either following removal of a LAGB, which comprised 42.3% of primary bariatric operations worldwide in their peak in 2008,[ 15 ] and conversions of SG, currently the most common bariatric procedure worldwide.[ 16 ] There are few published studies that examine the long-term outcomes of cOAGB after both SG and LAGB, and a paucity of patient-reported outcomes. The largest published study of 254 patients prior to this paper suggested cOAGB was not to be recommended due to high early and late complication rates and reflux.[ 12 ] The present study is the largest published patient cohort to date and aims to report our single-centre experience of cOAGB to document long-term outcomes. Methods Study Design and Patient Cohort A retrospective single-cohort observational review of a prospective database was performed for all conversional bariatric procedures performed by a single surgeon in a private hospital in Brisbane, Australia. The primary bariatric procedures were performed by various surgeons. All conversions were managed by cOAGB from 2016 to 2023 and performed by the same surgeon. All patients over age 18 who originally had a SG and/or LAGB were included. Exclusion criteria were only those patients who could not be contacted. Ethics approval was formally obtained from the Wesley Hospital Human Research Ethics Committee (Number 2023.03.381). Patient records, correspondence from other medical practitioners and operation notes were used to assess the outcomes of operation details, early morbidity ( 30 days) and length of stay. All patients received a survey via SMS, with three reminder messages. The remaining responses were sought with phone follow-up. Reflux was assessed with the validated Gastroesophageal Reflux Disease-Quality of Life (GERD-QOL) questionnaire.[ 17 ] Heartburn and regurgitation symptom scores were added to give total symptom scores, each out of 30, with significant symptoms considered as > 12. Additional questions included reflux onset, duration of medication use, medication burden, difficulty swallowing, other complications experienced, satisfaction with the procedure and whether they would have the procedure again. Finally, patients were invited to add any other comments relating to the procedure and rate their satisfaction with their current health condition out of 10. Survey results were correlated with medical records to confirm complications. A final SMS was sent to collect updated weight information separate from the survey to all the survey respondents. Conversional Surgical Technique cOAGB was performed exclusively in all bariatric conversional cases during this seven-year period due to surgeon preference. No patients underwent any other conversional bariatric procedures such as cRYGB. Preoperative endoscopy or contrast studies were not routinely performed. Revisional gastric pouch trimming after SG (“resleeve”) was not performed in any patients. Under general anaesthesia, five laparoscopic ports were used, all in situ lap-bands were removed with tubing and reservoir during the cOAGB usually with limited or no escharotomy. The lap-band tunnel was formally dissected with sharp dissection to expose the left crus. A hiatal hernia repair was performed if identified and provided the hiatus was not considered hostile after previous hiatal or LAGB surgery. The left hiatal crus was defined with dissection above the fundus, then the gastric tube was constructed dividing the lesser curve 2-3cm below the incisura horizontally with a 60mm 3.5mm laparoscopic stapler progressing vertically loosely about a 34fg Nasogastric Bougie to create the gastric pouch. The excluded fundus was left in situ and not resected. The SG patients were not retrimmed in this cohort with the stomach simply divided 3cm below the incisura. The jejunum was counted down 150-250cm dependant on patients BMI and a handsewn 2.5-3cm transverse end to side gastrojejunal anastomosis was performed using a single-layered continuous 3/0 absorbable suture. 100ml of blue dye and air were then injected down the hollow nasogastric bougie to exclude a leak. No nasogastric tube or drains were used postoperatively. Patients were given oral fluids that evening and went home the following day. Several patients had a radiological contrast gastric swallow if persistent nausea or vomiting occurred. Patients were instructed to avoid smoking and anti-inflammatory medications lifelong and given proton pump inhibitors for the first 90 days postoperatively. Preoperative and Postoperative Care All patients had multidisciplinary team consultations (nurse educator, dietician, surgeon) prior to surgery with exercise/psychological, dietician, and surgical support for at least two years postoperatively. All patients were required to stay in hospital the night of the surgery, with 98.9% going home the following morning. Follow-up reviews occurred at one, three, six, and twelve months. Dietician reviews occurred at six, then twelve weekly periods for two years. Data Review Descriptive analyses were performed using Excel. An ideal BMI of 25kg/m 2 was utilised for percentage excess weight loss (%EWL) calculations.[ 18 ] SPSS was utilised to apply linear regressions for the continuous outcomes and logistic regressions for the categorical outcomes to reveal any associations between the outcomes assessed.[ 19 ] Results Baseline Characteristics Baseline parameters, indications for surgery, prior bariatric procedures and concurrent procedures are shown in Table 1 . cOAGB was performed in 261 patients for either suboptimal weight loss (67.4%) or reflux (52.9%). 28% of patients requested both weight loss and reflux control. Three patients had prior gastric band erosions. Prior bariatric procedures were LAGB (60.9%) and SG (39.1%), with the remaining 5.8% of patients undergoing both procedures. Of the 159 previous LAGB patients, 21% had their bands removed prior to conversional surgery due to earlier complications. Otherwise, all bands were removed as a synchronous procedure during cOAGB. Mean age, sex and other concurrent procedures are depicted in Table 1 . Table 1 Baseline parameters, indications for surgery and procedure details Mean age at procedure, years (SD) 48.6 (10.4) Sex, n males (%), n females (%) 38 (14.6), 223 (85.4) Indications present, n (%) Suboptimal weight loss 176 (67.4) Reflux 138 (52.9) Other (including band complications, dysphagia) 20 (7.7) Previous bariatric procedure, n (%) LAGB 159 (60.9) SG 87 (39.1) Both (LAGB converted to SG) 15 (5.8) Concurrent procedures, n (% total) Band removal 125 (47.9) Cholecystectomy 15 (5.7) Hiatal hernia repair 40 (15.3) Inguinal or ventral hernia repair 6 (2.3) Perioperative Morbidity – Within 30 Days Three patients (1.1%) had early complications above Clavien-Dindo grade 3a. One required escharotomy at the previous band removal site, performed on day one postoperatively for persistent vomiting, and discharged on day two. One patient required reoperation for delayed perforation at the site of an unrecognised lap band erosion on day two, with conversion to a RYGB. The third patient on anticoagulants required endoscopic clipping of a bleeding gastroenteric anastomotic ulcer 24 days postoperatively. There were no staple line or anastomotic leaks. The remaining low-grade complications were managed medically, including nine minor port-site infections, three patients with below normal haemoglobin levels (one of which required a 2-unit blood transfusion), and one 2.5cm peri-anastomotic haematoma detected on day seven as an outpatient managed conservatively. Late Interventions – After 30 Days Six patients (2.6%) had non-reflux-related late reinterventions above Clavien-Dindo grade 3a. Three of which were port-site hernia repairs at the site of prior lap band reservoirs (mean 418.3 days after cOAGB), and two were operations for perforated stomal ulcer; one RYGB and the other laparoscopic patch repair. One case of adhesive small bowel obstruction was managed surgically. Eighteen patients (6.9%) had surgery for symptomatic acid or bile reflux (above Clavien-Dindo grade 3a). Two underwent RYGB. The remaining 16 patients underwent laparoscopic enteroenterostomy (Braun loop) at a mean 21.1 months, 14 of which (78%) had concurrent hiatal hernia repair [ 20 ]. The mean satisfaction score post-enteroenterostomy was 6.5, all reported being happy with the procedure and would undergo the cOAGB again. Regarding low-grade late interventions, endoscopy revealed 14 cases of gastroenteric anastomotic ulcer and one reflux oesophagitis (mean 474 days after cOAGB), all resolving with medical management. Survey Outcomes Of the 261 patients contacted to complete the survey, there was a 60.9% response rate (Table 2 ). The mean follow-up time for survey completion was 35.7 months (SD 19.6 months). Fifty-nine patients (37.1%) had significant heartburn, with 47.2% completely free of any heartburn symptoms. The mean total severity score was 9 (out of 30). Significant heartburn was a continuation of pre-existing in 40.6% of patients, 55.9% were de novo cases, and the remaining two patients were unsure. Thirty-eight patients (23.9%) had significant regurgitation, with 65.4% completely free of any regurgitation symptoms and 31 patients (19.5%) reported bringing up bile or yellow food at least once a week. The mean total severity score was 5.7 (out of 30). Significant regurgitation was a continuation of pre-existing in 23.7% of patients, 71% were de novo cases, and the remaining two patients were unsure. 94 (59.1%) patients were on reflux medication, 58.5% of which started after the cOAGB. The average effect of taking these medications on quality of life was 1.9 (0 was no change and 5 was a significant change). Eleven patients (6.9%) reported rare occasions of difficulty swallowing. Across the entire cohort, the average satisfaction score was 6.6 (out of 10), with 81.8% of patients reporting they were happy overall with the procedure (7.5% undecided) and 78% reporting they would have chosen it again (10.1% undecided). Table 2 Survey Outcomes Stratified by Timeframes Follow-up Period Completed Survey, n (%) On reflux medication, n (%) Impact of reflux medication (0–5) GERD-QOL score significant (> 12) for heartburn, n (%) GERD-QOL score significant (> 12) for regurgitation, n (%) Average Satisfaction (0–10) Would get this procedure again, n (%) < 1 year 76 (52.1) 48 (63.2) 2.2 30 (39.5) 21 (27.6) 6.0 48 (63.2) 1 year 50 (69.4) 31 (62) 1.8 23 (46) 14 (28) 6.6 37 (74) 2 years 22 (88) 9 (40.9) 1.7 4 (18.2) 2 (9.1) 8.0 18 (81.8) ≥ 3 years 11 (61.1) 4 (36.4) 1.0 2 (18.2) 1 (9.1) 8.1 9 (81.8) Total Weight Loss Outcomes %EWL at an average of 41.8 months (SD 20.3 months) after the procedure was 64.6% and TBWL was 22.5%, both well within optimal clinical response criteria. It must be noted that 3.8% of respondents did not provide a weight, so these weights were taken from the most recent follow-up from the clinic. Three patients with indications only of reflux had a pre-operative weight below their ideal weight, so they were excluded from the %EWL calculations. The mean BMI at follow-up was 31.50kg/m 2 (SD 6.48kg/m 2 ), which on average was 9.67kg/m 2 (SD 6.43kg/m 2 ) less than the BMI recorded before surgery. Weight loss outcomes for all patients over time are shown in Table 3 A, and the group requesting weight loss as a conversional indication are shown in Table 3 B. Table 3 A: Weight Loss Outcomes Stratified by Timeframes Follow-up Period Patients returning for follow-up, n Mean BMI, kg/m 2 (SD) Mean change in BMI, kg/m 2 (SD) Mean % TBWL, % (SD) Mean %EWL (SD) < 1 year 9 36.3 (10.1) 8.9 (3.4) 18.9 (7.1) 41.0 (16.2) 1 year 23 31.4 (7.3) 8.7 (7.3) 20.7 (15.3) 58.2 (41.7) 2 years 32 29.5 (6.3) 10.2 (5.3) 25.1 (12.0) 80.0 (45.6) 3 years 37 31.0 (6.3) 9.3 (5.8) 22.1 (11.2) 68.6 (42.7) 4 years 25 31.3 (4.3) 12.2 (7.5) 26.3 (12.9) 62.9 (29.0) ≥ 5 years 33 32.9 (6.2) 8.6 (5.3) 19.8 (12.6) 56.6 (33.5) Table 3 B: Weight Loss Outcomes Subgroup; Conversional Indication was for Suboptimal Weight Loss Follow-up Period Patients returning for follow-up, n Mean BMI, kg/m 2 (SD) Mean change in BMI, kg/m 2 (SD) Mean % TBWL, % (SD) Mean %EWL (SD) < 1 year 9 38.8 (5.6) 6.4 (4.4) 18.9 (17.3) 67.3 (5.7) 1 year 16 34.9 (6.2) 7.1 (3.2) 21.6 (16.1) 70.7 (6.2) 2 years 24 31.1 (6.1) 9.3 (4.9) 25.0 (12.9) 69.4 (6.0) 3 years 26 32.3 (8.0) 9.3 (5.5) 22.6 (10.8) 69.7 (6.6) 4 years 14 32.2 (3.1) 10.1 (5.9) 23.3 (15.0) 66.1 (6.2) ≥ 5 years 17 32.3 (5.3) 10.8 (5.2) 21.8 (12.1) 68.2 (7.9) Reflux Subset: Reflux as an Indication for Conversion Eighty-seven patients completed the survey with reflux as an indication for cOAGB, 41% of whom had ongoing significant heartburn (mean 38.5 months later, mean total severity of 16.6 out 30), and 35.6% were completely free of any heartburn symptoms. Within the subset, 27.6% reported significant regurgitation (mean severity 16.4 out of 30), and 63.2% were completely free of regurgitation symptoms. Sixty-two patients remain on reflux medication. Overall satisfaction was 6.6 out of 10, 88.5% were happy they received the procedure and 82.8% would do it again. After two years, a trend towards less heartburn and regurgitation, less use of antacids, and improved satisfaction was noted. Interestingly, similar outcomes were noted between LAGB and SG for the reflux cohort (Table 4 ). Table 4 Selected Outcomes Stratified by Primary Procedure Primary Procedure Total n GERD-QOL score significant (> 12) for heartburn, n (%) GERD-QOL score significant (> 12) for regurgitation, n (%) Average Satisfaction (0–10) LAGB 54 (62.1) 22 (40.7) 13 (24.1) 7.5 SG 33 (37.9) 14 (42.4) 11 (33.3) 5.2 Of these 87 patients, one had a perforated stomal ulcer requiring conversion to RYGB, and seven patients underwent hiatal repair with enteroenterostomies (mean 19 months after cOAGB). There were five delayed endoscopically detected ulcers managed medically. Suboptimal Weight Loss Subset: Suboptimal Weight Loss as Indication for Conversion Of the 176 patients with suboptimal weight loss concerns as an indication for their cOAGB (Table 3 B), the average BMI was 33.2kg/m 2 at appointment follow-up (mean 11.9 months after cOAGB). Compared with an average BMI before cOAGB of 42kg/m 2 , the mean percentage of total weight lost was 20.28%. One hundred and six of these patients went on to complete the survey; the average satisfaction was 6.3 out of 10, 76.4% were happy they received the procedure, and 73.6% would do it again. Statistical Analyses Table 5 Statistical Analyses Summary of Linear Regressions for Continuous Outcomes and Logistic Regressions for Categorical Outcomes[ 19 ] Dependent Variable: Predictor: Higher %EWL • Female sex (P = 0.033) Reports being happy they had the procedure • Higher %EWL (P = 0.003) • Had enteroenterostomy (P < 0.001) • Lower total heartburn score (P = 0.014) Reports would have the procedure again under the same circumstances • Higher %EWL (P = 0.01) • Had enteroenterostomy (P < 0.001) • Lower total heartburn score (P = 0.008) Higher Satisfaction score • Primary procedure was LAGB (P < 0.001) • Lower total regurgitation score (P = 0.025) Experience heartburn or regurgitation • Not significantly associated with any factor Discussion This paper presents a unique analysis of patient-reported symptoms and satisfaction scores after cOAGB. It contributes the largest cohort of patient-reported cOAGB outcomes to the literature (n = 261), representing a single-centre, single-surgeon experience utilising OAGB exclusively as the conversional operation following SG or LAGB. The comparatively low morbidity rates, short hospital stay of 1.02 days, and high patient satisfaction scores in this conversional OAGB series illustrate the potential safety and tolerance for this procedure. cOAGB Safety There were no related deaths, anastomotic leaks, or reoperations for bleeding. An early operation for escharotomy was technical, the other early reoperation was for gastric band erosion in the posterior body of stomach declaring itself postoperatively. Early complications ( 30d) were comparatively low at 6.1% (n = 16) and 14.9% (n = 39) respectively. There were three early (1.1%) and twenty-three late complications above Clavien-Dindo grade 3a (total 10.3%), thus most were low severity and manageable medically. In contrast, Maurice et al. (cOAGB n = 254) found 44.1% of patients experienced a complication higher than Clavien-Dindo class 3a postoperatively, Carandina et al. (cOAGB n = 185) noted a similar value of 10.3%, albeit mixed with primary OAGB procedures, and Bruzzi et al. (cOAGB n = 30) noted 6.6% of severe morbidity in patients.[ 8 , 12 , 21 ] This also compares favourably to cRYGB, with Poublon et al. and Liagre et al. finding significantly increased rates of surgical complications after cRYGB compared to cOAGB.[ 22 , 23 ] The average hospital stay was the lowest published at 1.02 days. This compares favourably with 4.7 days reported by Seyit & Alis following conversional bariatric surgery[ 24 ], 2.6 days reported by Meydan et al.[ 25 ] and Ghosh et al.[ 26 ] for cOAGB, and 1.45 days reported by Karim et al.[ 27 ]. Perhaps a clinical pathway and surgeon reassurance was responsible for early discharge. Reflux Gastroesophageal reflux is a prominent symptom preceding and following conversional bariatric surgery, reflected in our validated GERD-QOL questionnaire.[ 28 ] Over half the respondents remained on reflux medication for a mean of 35.7 months after cOAGB, albeit with minimal effect on quality of life. Potential rationales for this trend include pre-existing reflux, associated obesity, surgical factors (such as pouch size or anastomotic narrowing), selection bias for answering the survey, and performance bias whereby symptoms become more prominent upon questioning.[ 12 , 29 ] Patient-reported reflux symptoms and the use of proton pump inhibitors without objective evidence may be questioned. Poor correlation has been noted late after anti-reflux surgery in patients complaining of reflux taking proton pump inhibitors with only 24% of patients actually demonstrating abnormal pH studies.[ 12 , 30 ] Objective data with pH, impedance monitoring and routine endoscopy would have helped clarify. Persistent reflux after cOAGB is noted in the literature. Maurice et al. similarly found over half their patients (52%) remained on reflux medication at 36.6 months postoperatively.[ 12 ] Dayan et al. reported GERD resolution and PPI cessation in 77.4% of patients following cOAGB, however, this is in comparison to 91.5% of patients following cRYGB, 32.4 months postoperatively.[ 31 ] Similarly, Rayman et al. found that the incidence of GERD was significantly higher in patients who underwent cOAGB compared to cRYGB (17.4% vs 7.6%, p = 0.018) at one year following surgery.[ 32 ] Reflux should be noted as a potential ongoing issue postoperatively in all conversional bariatric procedures.[ 12 , 13 ] Many patients reported these symptoms to arise de novo after the conversion occurred. This is unique to conversions, as multiple reviews have suggested no difference between primary OAGB and RYGB, with very low reflux rates in the primary procedures.[ 7 , 33 ] Therefore, it has been argued that the prior restrictive procedures may promote progressive oesophageal weakening of the musculature and sphincter due to chronic high intragastric pressure from the outflow resistance of the band (LAGB) or pylorus (SG).[ 13 ] Similarly, hiatal laxity worsens with age and time after any bariatric procedure, particularly with the high concurrence of hiatal hernia as observed in this study, which is likely to have contributed to the de novo cases observed.[ 29 ] Weight Loss Outcomes The mean percentage total weight loss (%TWL) at one year was found to be 20.7% (SD 15.3%); this is in comparison to Debs et al. (25%), Kermansaravi et al. (26.6%), Maurice et al. (27.3%) and Poghosyan et al. (29%)[ 12 , 34 – 36 ]. Similarly, the mean %EWL at one year was 58.2% (SD 41.7%), peaking at two years (80.0% EWL) which is remarkably high for a conversional procedure. Comparatively, an excellent result reported by Maurice et al. was 76.7%.[ 12 ] Moreover, the favourable results of these parameters continued longitudinally, with bariatric outcomes retaining comparable rates beyond the 5-year mark indicative of long-term success for weight control with conversion. No patients had a ‘resleeve” of the gastric pouch during cOAGB in this series and perhaps more weight loss could have been expected with the addition of this. Follow-up at one year postoperatively found the mean BMI to be 31.4kg/m2. This, however, is in keeping with the literature, and the stratified postoperative BMIs (Table 3 A) are similar to those reported by Debs et al. (BMI 29.8kg/m2), Maurice et al. (BMI 31.8kg/m2) and Ghosh et al. (BMI 33.2kg/m2) at 12 months follow up.[ 12 , 26 , 34 ] Nevertheless, these remain favourable in contrast to the mean BMI found by Kermansaravi et al. (BMI 34.5kg/m2) and Poghosyan et al. (BMI 34.6kg/m2).[ 35 , 36 ] Statistically, %EWL was higher in female patients (P = 0.033), which aligns with the identification of male patients to be at higher risk of poor outcomes and complications in bariatric surgery, despite forming a small portion of the patient pool.[ 37 ] Alternative Procedures The most widely accepted alternative to cOAGB is cRYGB. As this was a uniquely unselected cohort of cOAGB, no patients underwent cRYGB. Comparative studies have noted that cOAGB had shorter operative times, reduced early postoperative complications, and greater weight loss, however lower haemoglobin levels after 5 years.[ 11 , 23 , 38 ] The increased occurrence of reflux after cOAGB has long been detrimental to its reputation as a conversional procedure.[ 38 ] A meta-analysis of 739 patients found 12% less remission from reflux in cOAGB patients and 5.8% more de novo reflux than cRYGB patients (neither were statistically significant).[ 39 ] However, the marginal ulcer rates for cRYGB have been reported to reach 13.6%, markedly higher than the < 3% consistently reported for cOAGB.[ 40 – 43 ] Future direction should involve a prospective RCT comparing cOAGB to cRYGB cohort to similarly examine weight loss, reflux, and marginal ulcer rates. Intractable reflux was revised with laparoscopic Braun enteroenterostomy conversion. It was noted to significantly increase rates of patients being happy with the cOAGB (P < 0.001) and those who would have the cOAGB again (P < 0.001). Enteroenterostomy is well-validated for use in symptomatic reflux, with supporting evidence for persistent reflux after cOAGB.[ 44 ] In 68.8% of patients, this reduced reflux completely or below significant levels. This procedure has also been found to be comparable with RYGB in terms of postoperative complications, including reflux per the GORD-QOL scores.[ 45 ] Given its simplicity and efficacy, as demonstrated in this paper, enteroenterostomy is a suitable and safe re-conversion option for intractable reflux post-cOAGB; however, converting to RYGB is another valid alternative and lends itself to a future RCT comparing these procedures. Subgroups For patients with suboptimal weight loss as indications for conversion, continuation of this suboptimal clinical response remained an issue that persisted beyond cOAGB. This was reflected with slightly lower satisfaction scores than the whole cohort, with those happy with the procedure and those willing to repeat it 5.4 and 4.4 percentage points lower, respectively. No association with other morbidity was noted. The authors acknowledge that retrimming a dilated stomach at the time of cOAGB may well have contributed to more weight loss, at least in the medium term.[ 46 ] Similarly, reflux remained an issue for patients with reflux as an indication for conversion. Whilst this subset was only 54.7% of respondents (n = 87), it comprised 66.7% and 58.2% of all patients experiencing heartburn and regurgitation, respectively, with higher severity rates. Nevertheless, this suggests 30–40% of patients with persisting reflux had symptom resolution with cOAGB, which accounts for the substantially higher satisfaction proportions. Those happy with the procedure and those willing to repeat it were 6.7 and 4.8 percentage points higher than the whole cohort, respectively. Patient Satisfaction Nevertheless, patient satisfaction remained surprisingly high despite the high reflux rates consistent with the literature and the relatively high mean BMI after cOAGB. This is likely due to fulfilling patient expectations, as illustrated in the subgroup analysis, alongside severity reductions of reflux symptoms and excess BMI. This is exemplified as both lower total heartburn score and a higher %EWL were significantly associated with an increased proportion of patients happy with the procedure and would undergo it again (Table 5 ). Similarly, a higher satisfaction score was linked to a lower regurgitation score, but interestingly also the primary procedure being a LAGB. This trend may result from the higher incidence of complications from the LAGB, e.g. dysphagia, which resolve upon conversion and thus positively reflect on the cOAGB. Furthermore, proportions satisfied with (81.8%) and would have undergone the procedure again (78%) are greater in the conversional cohort presented in this paper than that noted for fulfilled expectations (69.4%), sufficiently satisfied (59.8%), and glad to have had the procedure (75.3–84%) in a variety of primary bariatric procedures from the literature.[ 47 – 49 ] This again is important, as conversional bariatric surgery has been associated with reduced satisfaction compared to primary procedures.[ 49 ] Finally, satisfaction increased substantially in the long-term (Table 2 ), again favourable of cOAGB outcomes. Limitations and Future Directions The retrospective single-cohort observational nature of this study is subject to several limitations. As patients undergo conversional surgery on a case-by-case basis, with both patient motivation and surgeon preference in consideration, the study is inevitably affected by selection bias. Additionally, this study only included patients from a single private hospital. This limits the patient demographic to those who can afford private surgery and may have led to better post-cOAGB outcomes. This cohort’s demographic is substantially skewed towards females (85.4%), with a mean age of 48.6 years. Therefore, the results of this study are most applicable to patients with these characteristics, limiting external validity without utilising different surgeons on a wider demographic range of patients. Furthermore, the survey response rate was 60.9%, further limiting the range of responses received as patients experiencing complications may be more likely to respond. Despite this apparent low response rate, a study noted an average of 31.3–46.5% response rate in North America one year after bariatric surgery, suggesting this value is reasonable within this patient cohort.[ 50 ] Conclusion Patients wishing for conversional surgery after SG or LAGB are difficult to cure with respect to further significant weight loss or reflux control. Therefore, the conversional procedure must be safe, of low morbidity, and have high patient-reported satisfaction scores. We present the largest series of cOAGB, adding weight to the literature to justify this as a safe option for patients troubled with weight or reflux after a primary bariatric procedure. Whilst reflux and suboptimal weight loss may persist, patient satisfaction was high, which is as important as the quantitative parameters generally examined by surgeons. Additionally, the reported bariatric and reflux parameters compared favourably to those in the conversional literature, with improvement of these parameters correlating to improved survey responses. Finally, for those patients that did not improve, enteroenterostomy was utilised for significant reflux, with a 100% conversion to being happy with the original procedure, highlighting its potential for resolving such intractable cases. Declarations Author Contribution Authors AL and IM conceived the design of the study. AL completed data extraction, clarifying any uncertainties with IM. AL prepared the manuscript, IM and MK revised and contributed. MK and AL contributed to the statistical analyses. All authors have approved the final version of the manuscript. All procedures performed in studies involving human participants were in accordance with the ethical standards of the Wesley Hospital research committee (Number 2023.03.381) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The authors declare that they have no conflict of interest. No funding was received for this project. Acknowledgement The authors thank Queensland Cyber Infrastructure Foundation (QCIF) for statistical consultation. References Caballero B. Humans against Obesity: Who Will Win? Advances in Nutrition. 2019;10(suppl_1):S4-S9. doi: 10.1093/advances/nmy055 . Arterburn DE, Telem DA, Kushner RF, Courcoulas AP. Benefits and Risks of Bariatric Surgery in Adults: A Review. JAMA. 2020;324(9):879–87. doi: 10.1001/jama.2020.12567 . Jakobsen GS, Småstuen MC, Sandbu R, Nordstrand N, Hofsø D, Lindberg M, et al. 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PubMed PMID: 23670991; PubMed Central PMCID: PMC3744630. IBM Corp. IBM SPSS Statistics for Windows. Version 28.0 ed. Armonk, NY: IBM Corp; 2021. Hosseini SV, Haghighat N, Kamran H, Arianpour H, Vahidi A, Hesameddini I, et al. Braun Anastomosis: A Technique for Bile Reflux Improvement After Single Anastomosis Sleeve Ileal (SASI) Bypass; a Pilot Study. Surg Innov. 2023;30(3):297–302. Epub 20230322. doi: 10.1177/15533506231164895. PubMed PMID: 36949026. Carandina S, Soprani A, Zulian V, Cady J. Long-Term Results of One Anastomosis Gastric Bypass: a Single Center Experience with a Minimum Follow-Up of 10 Years. Obesity Surgery. 2021;31(8):3468–75. doi: 10.1007/s11695-021-05455-1 . Poublon N, Chidi I, Bethlehem M, Kuipers E, Gadiot R, Emous M, et al. One anastomosis gastric bypass vs. Roux-en-Y gastric bypass, remedy for insufficient weight loss and weight regain after failed restrictive bariatric surgery. Obesity Surgery. 2020;30(9):3287–94. doi: 10.1007/s11695-020-04536-x . 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Short-term results of single-anastomosis gastric bypass after failed sleeve gastrectomy. The Egyptian Journal of Surgery. 2021;40(1):241–9. doi: 10.4103/ejs.ejs_305_20 . PubMed PMID: 00767571-202140010-00031. Masood M, Low D, Deal SB, Kozarek RA. Gastroesophageal Reflux Disease in Obesity: Bariatric Surgery as Both the Cause and the Cure in the Morbidly Obese Population. Journal of Clinical Medicine. 2023;12(17):5543. PubMed PMID: doi: 10.3390/jcm12175543 . Soprani A, Boullenois H, Zulian V, Nedelcu A, Carandina S. One-Anastomosis Gastric Bypass and Hiatal Hernia: Nissen Fundoplication with the Excluded Stomach to Decrease the Risk of Postoperative Gastroesophageal Reflux. J Clin Med. 2022;11(21). Epub 20221030. doi: 10.3390/jcm11216441 . PubMed PMID: 36362669; PubMed Central PMCID: PMC9655570. Lord RVN, Kaminski A, Öberg S, Bowrey DJ, Hagen JA, DeMeester SR, et al. Absence of Gastroesophageal Reflux Disease in a Majority of Patients Taking Acid Suppression Medications After Nissen Fundoplication. Journal of Gastrointestinal Surgery. 2002;6(1):3–10. doi: https://doi.org/10.1016/S1091-255X(01)00031-2 . Dayan D, Kanani F, Bendayan A, Nizri E, Lahat G, Abu-Abeid A. The Effect of Revisional One Anastomosis Gastric Bypass After Sleeve Gastrectomy on Gastroesophageal Reflux Disease, Compared with Revisional Roux-en-Y Gastric Bypass: Symptoms and Quality of Life Outcomes. Obesity Surgery. 2023;33(7):2125–31. doi: 10.1007/s11695-023-06636-w . Rayman S, Assaf D, Azran C, Sroka G, Assalia A, Beglaibter N, et al. Sleeve Gastrectomy Failure-Revision to Laparoscopic One-Anastomosis Gastric Bypass or Roux-n-Y Gastric Bypass: a Multicenter Study. Obes Surg. 2021;31(7):2927–34. Epub 20210325. doi: 10.1007/s11695-021-05334-9 . PubMed PMID: 33765292. Chevallier JM, Arman GA, Guenzi M, Rau C, Bruzzi M, Beaupel N, et al. One thousand single anastomosis (omega loop) gastric bypasses to treat morbid obesity in a 7-year period: outcomes show few complications and good efficacy. Obes Surg. 2015;25(6):951-8. doi: 10.1007/s11695-014-1552-z . PubMed PMID: 25585612. Debs T, Petrucciani N, Kassir R, Juglard G, Gugenheim J, Iannelli A, et al. Laparoscopic Conversion of Sleeve Gastrectomy to One Anastomosis Gastric Bypass for Weight Loss Failure: Mid-Term Results. Obesity Surgery. 2020;30(6):2259–65. doi: 10.1007/s11695-020-04461-z . Kermansaravi M, Karami R, Valizadeh R, Rokhgireh S, Kabir A, Pakaneh M, et al. Five-year outcomes of one anastomosis gastric bypass as conversional surgery following sleeve gastrectomy for weight loss failure. Scientific Reports. 2022;12(1):10304. doi: 10.1038/s41598-022-14633-9 . Poghosyan T, Alameh A, Bruzzi M, Faul A, Rives-Lange C, Zinzindohoue F, et al. Conversion of Sleeve Gastrectomy to One Anastomosis Gastric Bypass for Weight Loss Failure. Obesity Surgery. 2019;29(8):2436–41. doi: 10.1007/s11695-019-03864-x . Dugan N, Thompson KJ, Barbat S, Prasad T, McKillop IH, Maloney SR, et al. Male gender is an independent risk factor for patients undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass: an MBSAQIP® database analysis. Surg Endosc. 2020;34(8):3574–83. Epub 20200218. doi: 10.1007/s00464-019-07106-0 . PubMed PMID: 32072290; PubMed Central PMCID: PMC7224103. Poublon N, Chidi I, Bethlehem M, Kuipers E, Gadiot R, Emous M, et al. One anastomosis gastric bypass vs. Roux-en-Y gastric bypass, remedy for insufficient weight loss and weight regain after failed restrictive bariatric surgery. Obes Surg. 2020;30(9):3287–94. doi: 10.1007/s11695-020-04536-x . PubMed PMID: 32307669; PubMed Central PMCID: PMC7378100. Vitiello A, Berardi G, Peltrini R, Calabrese P, Pilone V. One-anastomosis gastric bypass (OAGB) versus Roux-en-Y gastric bypass (RYGB) as revisional procedures after failed laparoscopic sleeve gastrectomy (LSG): systematic review and meta-analysis of comparative studies. Langenbecks Arch Surg. 2023;408(1):440. Epub 20231118. doi: 10.1007/s00423-023-03175-x . PubMed PMID: 37980292; PubMed Central PMCID: PMC10657303. Anderson B, Zhan T, Swaszek L, Sanicola C, King N, Pryor A, et al. Increased incidence of marginal ulceration following conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: a multi-institutional experience. Surgical Endoscopy. 2023;37(5):3974–81. doi: 10.1007/s00464-022-09430-4 . Parmar CD, Gan J, Stier C, Dong Z, Chiappetta S, El-Kadre L, et al. One Anastomosis/Mini Gastric Bypass (OAGB-MGB) as revisional bariatric surgery after failed primary adjustable gastric band (LAGB) and sleeve gastrectomy (SG): A systematic review of 1075 patients. Int J Surg. 2020;81:32–8. Epub 20200729. doi: 10.1016/j.ijsu.2020.07.007 . PubMed PMID: 32738545. Musella M, Vitiello A, Susa A, Greco F, De Luca M, Manno E, et al. Revisional Surgery After One Anastomosis/Minigastric Bypass: an Italian Multi-institutional Survey. Obes Surg. 2022;32(2):256–65. Epub 20220101. doi: 10.1007/s11695-021-05779-y . PubMed PMID: 34973123; PubMed Central PMCID: PMC8795019. Mahawar KK, Reed AN, Graham YNH. Marginal ulcers after one anastomosis (mini) gastric bypass: a survey of surgeons. Clin Obes. 2017;7(3):151–6. Epub 20170320. doi: 10.1111/cob.12186 . PubMed PMID: 28320077. Almerie MQ, Darrien JH, Javed S, Kerrigan DD. Braun Procedure Is Effective in Treating Bile Reflux Following One Anastomosis Gastric Bypass: a Case Series. Obes Surg. 2021;31(8):3880–2. Epub 20210429. doi: 10.1007/s11695-021-05443-5 . PubMed PMID: 33928523. Shishegar A, Vahedi M, Kamani F, Kazerouni MF, Pasha MA, Fathi F. Comparison between Roux-en-Y gastrojejunostomy and Billroth-II with Braun anastomosis following partial gastrectomy: A randomized controlled trial. Ann Med Surg (Lond). 2022;76:103544. Epub 20220328. doi: 10.1016/j.amsu.2022.103544 . PubMed PMID: 35495374; PubMed Central PMCID: PMC9052292. Faul A, Chevallier JM, Poghosyan T. Dilated Gastric Pouch Resizing for Weight Loss Failure After One Anastomosis Gastric Bypass. Obes Surg. 2019;29(10):3406–9. doi: 10.1007/s11695-019-03972-8 . PubMed PMID: 31115846. White GE, Courcoulas AP, King WC. Long-term Satisfaction with Roux-en-Y Gastric Bypass Surgery: Results From a Multicenter Prospective Cohort Study. Ann Surg. 2022;276(5):e425-e33. Epub 20201124. doi: 10.1097/sla.0000000000004625. PubMed PMID: 33234799. Lundin Kvalem I, Gabrielsen L, Eribe I, Kristinsson JA, Mala T. Predicting satisfaction with outcome and follow-up care 5 years after bariatric surgery: A prospective evaluation. Obes Sci Pract. 2022;8(5):595–602. Epub 20220209. doi: 10.1002/osp4.594 . PubMed PMID: 36238221; PubMed Central PMCID: PMC9535663. Sakran N, Soued S, Hod K, Buchwald JN, Soifer K, Kessler Y, et al. Long-Term Matched Comparison of Primary and Revisional Laparoscopic Sleeve Gastrectomy. Obesity Surgery. 2023;33(3):695–705. doi: 10.1007/s11695-022-06436-8 . Alvarez R, Stricklen A, Buda CM, Ross R, Bonham AJ, Carlin AM, et al. Factors associated with completion of patient surveys 1 year after bariatric surgery. Surg Obes Relat Dis. 2021;17(3):538–47. Epub 20201102. doi: 10.1016/j.soard.2020.10.028 . PubMed PMID: 33334677; PubMed Central PMCID: PMC7904592. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4603959","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":323780077,"identity":"643ec82c-0d9d-4a94-856c-b6af235da727","order_by":0,"name":"Aaron Lerch","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYNCCAiCWYEh8AKR4+IjTYgDW8hhE8bCRoIXxmQSITVALf/vZh48LDGzy+Wc3p1V+zbGTYWNgfvjoBh4tEmfSjY1nGKRZzrhzLO227LZkoMPYjI1z8FlzII1NmsfgsIGBRE7abcltzEAtPGzS+LTIn38G0vIfqCX/W7HktnrCWgxugG05ANSSkMb4cdthwloMbzxjNuYxSDaQuJGQLM247TgPGzMBv8idT2N8zFNhZ8A/IyHx489t1fb87M0PH+P1PjJg5gGTxCoHAcYfpKgeBaNgFIyCEQMAW6M/WgAfvUQAAAAASUVORK5CYII=","orcid":"","institution":"University of Queensland","correspondingAuthor":true,"prefix":"","firstName":"Aaron","middleName":"","lastName":"Lerch","suffix":""},{"id":323780078,"identity":"cd0ffa4b-cf39-453e-a17f-8d5ab440cddb","order_by":1,"name":"Mokshitha Katneni","email":"","orcid":"","institution":"Bond University","correspondingAuthor":false,"prefix":"","firstName":"Mokshitha","middleName":"","lastName":"Katneni","suffix":""},{"id":323780079,"identity":"770d411f-458b-4cb0-940e-b0389a06e0df","order_by":2,"name":"Ian Martin","email":"","orcid":"","institution":"Wesley Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ian","middleName":"","lastName":"Martin","suffix":""}],"badges":[],"createdAt":"2024-06-19 07:25:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4603959/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4603959/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":75841744,"identity":"842ca011-3b25-4637-8304-ce3d50cecb7d","added_by":"auto","created_at":"2025-02-09 18:01:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1136574,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4603959/v1/681fbca7-9679-4293-9f23-48a422a7f9df.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Efficacy of Conversional One Anastomoses Gastric Bypass post Sleeve Gastrectomy and Gastric Band: A Large Single Cohort Series","fulltext":[{"header":"Key Points","content":"\u003cul\u003e\n \u003cli\u003ePatients undergoing conversional bariatric surgery are a difficult cohort, however examination of patient-reported outcomes pleasingly reveals a relatively satisfied group.\u003c/li\u003e\n \u003cli\u003eHigh satisfaction rates are seen after cOAGB, despite some having persistent reflux.\u003c/li\u003e\n \u003cli\u003eThe safety of this procedure is supported.\u003c/li\u003e\n \u003cli\u003ecOAGB is extremely safe as evidenced by very low complication rates and short lengths of stay. It is a relatively effective conversional bariatric procedure.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eWith the increasing incidence of obesity worldwide, bariatric surgery has become an integral part of evidence-based treatment options.[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] It has proven efficacy in treating numerous obesity comorbidities, including hypertension, obstructive sleep apnoea, type 2 diabetes, and dyslipidaemia. Despite refining surgical techniques over six decades, a small percentage of patients find long-term efficacy elusive.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] As such, conversional procedures are utilised increasingly to help manage suboptimal weight loss, or complications such as reflux.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eA variety of conversional techniques exist after laparoscopic adjustable gastric banding (LAGB) and sleeve gastrectomy (SG). This includes further reduction in gastric pouch size (retrimming), and/or conversion to a Roux-en-Y (RYGB), or one-anastomosis gastric bypass (OAGB). Several randomised controlled trials (RCTs) have confirmed the use of OAGB for primary bariatric surgery, with favourable results in weight loss outcomes and reduced complications.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Nevertheless, controversy remains in the setting of conversional surgery due to the potential risk of clinically relevant reflux, which may lower the quality of life and increase the theoretical risk of malignancy due to the metaplastic action of bile.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eSeveral retrospective studies have outlined conversional OAGB (cOAGB) as a safe and effective technique,[\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] albeit with potentially higher reflux rates than that of its counterpart, RYGB.[\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] These conversions were typically either following removal of a LAGB, which comprised 42.3% of primary bariatric operations worldwide in their peak in 2008,[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and conversions of SG, currently the most common bariatric procedure worldwide.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThere are few published studies that examine the long-term outcomes of cOAGB after both SG and LAGB, and a paucity of patient-reported outcomes. The largest published study of 254 patients prior to this paper suggested cOAGB was not to be recommended due to high early and late complication rates and reflux.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] The present study is the largest published patient cohort to date and aims to report our single-centre experience of cOAGB to document long-term outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\n\u003ch3\u003eStudy Design and Patient Cohort\u003c/h3\u003e\n\u003cp\u003eA retrospective single-cohort observational review of a prospective database was performed for all conversional bariatric procedures performed by a single surgeon in a private hospital in Brisbane, Australia. The primary bariatric procedures were performed by various surgeons.\u003c/p\u003e \u003cp\u003eAll conversions were managed by cOAGB from 2016 to 2023 and performed by the same surgeon. All patients over age 18 who originally had a SG and/or LAGB were included. Exclusion criteria were only those patients who could not be contacted. Ethics approval was formally obtained from the Wesley Hospital Human Research Ethics Committee (Number 2023.03.381).\u003c/p\u003e \u003cp\u003ePatient records, correspondence from other medical practitioners and operation notes were used to assess the outcomes of operation details, early morbidity (\u0026lt;\u0026thinsp;30 days), late interventions (\u0026gt;\u0026thinsp;30 days) and length of stay. All patients received a survey via SMS, with three reminder messages. The remaining responses were sought with phone follow-up. Reflux was assessed with the validated Gastroesophageal Reflux Disease-Quality of Life (GERD-QOL) questionnaire.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Heartburn and regurgitation symptom scores were added to give total symptom scores, each out of 30, with significant symptoms considered as \u0026gt;\u0026thinsp;12. Additional questions included reflux onset, duration of medication use, medication burden, difficulty swallowing, other complications experienced, satisfaction with the procedure and whether they would have the procedure again. Finally, patients were invited to add any other comments relating to the procedure and rate their satisfaction with their current health condition out of 10. Survey results were correlated with medical records to confirm complications. A final SMS was sent to collect updated weight information separate from the survey to all the survey respondents.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eConversional Surgical Technique\u003c/h2\u003e \u003cp\u003ecOAGB was performed exclusively in all bariatric conversional cases during this seven-year period due to surgeon preference. No patients underwent any other conversional bariatric procedures such as cRYGB. Preoperative endoscopy or contrast studies were not routinely performed. Revisional gastric pouch trimming after SG (\u0026ldquo;resleeve\u0026rdquo;) was not performed in any patients.\u003c/p\u003e \u003cp\u003eUnder general anaesthesia, five laparoscopic ports were used, all \u003cem\u003ein situ\u003c/em\u003e lap-bands were removed with tubing and reservoir during the cOAGB usually with limited or no escharotomy. The lap-band tunnel was formally dissected with sharp dissection to expose the left crus.\u003c/p\u003e \u003cp\u003eA hiatal hernia repair was performed if identified and provided the hiatus was not considered hostile after previous hiatal or LAGB surgery. The left hiatal crus was defined with dissection above the fundus, then the gastric tube was constructed dividing the lesser curve 2-3cm below the incisura horizontally with a 60mm 3.5mm laparoscopic stapler progressing vertically loosely about a 34fg Nasogastric Bougie to create the gastric pouch. The excluded fundus was left \u003cem\u003ein situ\u003c/em\u003e and not resected.\u003c/p\u003e \u003cp\u003eThe SG patients were not retrimmed in this cohort with the stomach simply divided 3cm below the incisura. The jejunum was counted down 150-250cm dependant on patients BMI and a handsewn 2.5-3cm transverse end to side gastrojejunal anastomosis was performed using a single-layered continuous 3/0 absorbable suture. 100ml of blue dye and air were then injected down the hollow nasogastric bougie to exclude a leak. No nasogastric tube or drains were used postoperatively.\u003c/p\u003e \u003cp\u003ePatients were given oral fluids that evening and went home the following day. Several patients had a radiological contrast gastric swallow if persistent nausea or vomiting occurred. Patients were instructed to avoid smoking and anti-inflammatory medications lifelong and given proton pump inhibitors for the first 90 days postoperatively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePreoperative and Postoperative Care\u003c/h2\u003e \u003cp\u003eAll patients had multidisciplinary team consultations (nurse educator, dietician, surgeon) prior to surgery with exercise/psychological, dietician, and surgical support for at least two years postoperatively.\u003c/p\u003e \u003cp\u003eAll patients were required to stay in hospital the night of the surgery, with 98.9% going home the following morning. Follow-up reviews occurred at one, three, six, and twelve months. Dietician reviews occurred at six, then twelve weekly periods for two years.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Review\u003c/h2\u003e \u003cp\u003eDescriptive analyses were performed using Excel. An ideal BMI of 25kg/m\u003csup\u003e2\u003c/sup\u003e was utilised for percentage excess weight loss (%EWL) calculations.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] SPSS was utilised to apply linear regressions for the continuous outcomes and logistic regressions for the categorical outcomes to reveal any associations between the outcomes assessed.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eBaseline Characteristics\u003c/h2\u003e \u003cp\u003eBaseline parameters, indications for surgery, prior bariatric procedures and concurrent procedures are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. cOAGB was performed in 261 patients for either suboptimal weight loss (67.4%) or reflux (52.9%). 28% of patients requested both weight loss and reflux control. Three patients had prior gastric band erosions.\u003c/p\u003e \u003cp\u003ePrior bariatric procedures were LAGB (60.9%) and SG (39.1%), with the remaining 5.8% of patients undergoing both procedures. Of the 159 previous LAGB patients, 21% had their bands removed prior to conversional surgery due to earlier complications. Otherwise, all bands were removed as a synchronous procedure during cOAGB. Mean age, sex and other concurrent procedures are depicted in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline parameters, indications for surgery and procedure details\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age at procedure, years (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.6 (10.4)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, n males (%), n females (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38 (14.6), 223 (85.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndications present, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuboptimal weight loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e176 (67.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReflux\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e138 (52.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther (including band complications, dysphagia)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious bariatric procedure, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAGB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e159 (60.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e87 (39.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth (LAGB converted to SG)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (5.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcurrent procedures, n (% total)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBand removal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e125 (47.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCholecystectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (5.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHiatal hernia repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40 (15.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInguinal or ventral hernia repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePerioperative Morbidity \u0026ndash; Within 30 Days\u003c/h2\u003e \u003cp\u003eThree patients (1.1%) had early complications above Clavien-Dindo grade 3a. One required escharotomy at the previous band removal site, performed on day one postoperatively for persistent vomiting, and discharged on day two. One patient required reoperation for delayed perforation at the site of an unrecognised lap band erosion on day two, with conversion to a RYGB. The third patient on anticoagulants required endoscopic clipping of a bleeding gastroenteric anastomotic ulcer 24 days postoperatively. There were no staple line or anastomotic leaks.\u003c/p\u003e \u003cp\u003eThe remaining low-grade complications were managed medically, including nine minor port-site infections, three patients with below normal haemoglobin levels (one of which required a 2-unit blood transfusion), and one 2.5cm peri-anastomotic haematoma detected on day seven as an outpatient managed conservatively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eLate Interventions \u0026ndash; After 30 Days\u003c/h2\u003e \u003cp\u003eSix patients (2.6%) had non-reflux-related late reinterventions above Clavien-Dindo grade 3a. Three of which were port-site hernia repairs at the site of prior lap band reservoirs (mean 418.3 days after cOAGB), and two were operations for perforated stomal ulcer; one RYGB and the other laparoscopic patch repair. One case of adhesive small bowel obstruction was managed surgically.\u003c/p\u003e \u003cp\u003eEighteen patients (6.9%) had surgery for symptomatic acid or bile reflux (above Clavien-Dindo grade 3a). Two underwent RYGB. The remaining 16 patients underwent laparoscopic enteroenterostomy (Braun loop) at a mean 21.1 months, 14 of which (78%) had concurrent hiatal hernia repair [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The mean satisfaction score post-enteroenterostomy was 6.5, all reported being happy with the procedure and would undergo the cOAGB again.\u003c/p\u003e \u003cp\u003eRegarding low-grade late interventions, endoscopy revealed 14 cases of gastroenteric anastomotic ulcer and one reflux oesophagitis (mean 474 days after cOAGB), all resolving with medical management.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurvey Outcomes\u003c/h3\u003e\n\u003cp\u003eOf the 261 patients contacted to complete the survey, there was a 60.9% response rate (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The mean follow-up time for survey completion was 35.7 months (SD 19.6 months).\u003c/p\u003e \u003cp\u003eFifty-nine patients (37.1%) had significant heartburn, with 47.2% completely free of any heartburn symptoms. The mean total severity score was 9 (out of 30). Significant heartburn was a continuation of pre-existing in 40.6% of patients, 55.9% were \u003cem\u003ede novo\u003c/em\u003e cases, and the remaining two patients were unsure.\u003c/p\u003e \u003cp\u003eThirty-eight patients (23.9%) had significant regurgitation, with 65.4% completely free of any regurgitation symptoms and 31 patients (19.5%) reported bringing up bile or yellow food at least once a week. The mean total severity score was 5.7 (out of 30). Significant regurgitation was a continuation of pre-existing in 23.7% of patients, 71% were \u003cem\u003ede novo\u003c/em\u003e cases, and the remaining two patients were unsure.\u003c/p\u003e \u003cp\u003e94 (59.1%) patients were on reflux medication, 58.5% of which started after the cOAGB. The average effect of taking these medications on quality of life was 1.9 (0 was no change and 5 was a significant change). Eleven patients (6.9%) reported rare occasions of difficulty swallowing.\u003c/p\u003e \u003cp\u003eAcross the entire cohort, the average satisfaction score was 6.6 (out of 10), with 81.8% of patients reporting they were happy overall with the procedure (7.5% undecided) and 78% reporting they would have chosen it again (10.1% undecided).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurvey Outcomes Stratified by Timeframes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up Period\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompleted Survey, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOn reflux medication, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImpact of reflux medication (0\u0026ndash;5)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGERD-QOL score significant (\u0026gt;\u0026thinsp;12) for heartburn, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGERD-QOL score significant (\u0026gt;\u0026thinsp;12) for regurgitation, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAverage Satisfaction (0\u0026ndash;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eWould get this procedure again, n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;1 year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (52.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (63.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (39.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21 (27.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e48 (63.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1 year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (69.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e37 (74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (40.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e18 (81.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026ge;\u0026thinsp;3 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (61.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (36.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9 (81.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTotal Weight Loss Outcomes\u003c/h2\u003e \u003cp\u003e%EWL at an average of 41.8 months (SD 20.3 months) after the procedure was 64.6% and TBWL was 22.5%, both well within optimal clinical response criteria. It must be noted that 3.8% of respondents did not provide a weight, so these weights were taken from the most recent follow-up from the clinic. Three patients with indications only of reflux had a pre-operative weight below their ideal weight, so they were excluded from the %EWL calculations. The mean BMI at follow-up was 31.50kg/m\u003csup\u003e2\u003c/sup\u003e (SD 6.48kg/m\u003csup\u003e2\u003c/sup\u003e), which on average was 9.67kg/m\u003csup\u003e2\u003c/sup\u003e (SD 6.43kg/m\u003csup\u003e2\u003c/sup\u003e) less than the BMI recorded before surgery. Weight loss outcomes for all patients over time are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003eA, and the group requesting weight loss as a conversional indication are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003eB.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eA: Weight Loss Outcomes Stratified by Timeframes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up Period\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients returning for follow-up, n\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean BMI, kg/m\u003csup\u003e2\u003c/sup\u003e (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean change in BMI, kg/m\u003csup\u003e2\u003c/sup\u003e (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean % TBWL, % (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean %EWL (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;1 year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.3 (10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.9 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18.9 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e41.0 (16.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1 year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.4 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20.7 (15.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e58.2 (41.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.5 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.2 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25.1 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e80.0 (45.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.0 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.3 (5.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22.1 (11.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e68.6 (42.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.3 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.2 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26.3 (12.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e62.9 (29.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026ge;\u0026thinsp;5 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.9 (6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.6 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19.8 (12.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e56.6 (33.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eB: Weight Loss Outcomes Subgroup; Conversional Indication was for Suboptimal Weight Loss\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up Period\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients returning for follow-up, n\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean BMI, kg/m\u003csup\u003e2\u003c/sup\u003e (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean change in BMI, kg/m\u003csup\u003e2\u003c/sup\u003e (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean % TBWL, % (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean %EWL (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;1 year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.8 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.4 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18.9 (17.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e67.3 (5.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1 year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34.9 (6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.1 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21.6 (16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e70.7 (6.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.1 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.3 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25.0 (12.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e69.4 (6.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.3 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.3 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22.6 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e69.7 (6.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.2 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.1 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23.3 (15.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e66.1 (6.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026ge;\u0026thinsp;5 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.3 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.8 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21.8 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e68.2 (7.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eReflux Subset: Reflux as an Indication for Conversion\u003c/h2\u003e \u003cp\u003eEighty-seven patients completed the survey with reflux as an indication for cOAGB, 41% of whom had ongoing significant heartburn (mean 38.5 months later, mean total severity of 16.6 out 30), and 35.6% were completely free of any heartburn symptoms. Within the subset, 27.6% reported significant regurgitation (mean severity 16.4 out of 30), and 63.2% were completely free of regurgitation symptoms. Sixty-two patients remain on reflux medication. Overall satisfaction was 6.6 out of 10, 88.5% were happy they received the procedure and 82.8% would do it again. After two years, a trend towards less heartburn and regurgitation, less use of antacids, and improved satisfaction was noted.\u003c/p\u003e \u003cp\u003eInterestingly, similar outcomes were noted between LAGB and SG for the reflux cohort (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelected Outcomes Stratified by Primary Procedure\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary Procedure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal n\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGERD-QOL score significant (\u0026gt;\u0026thinsp;12) for heartburn, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGERD-QOL score significant (\u0026gt;\u0026thinsp;12) for regurgitation, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAverage Satisfaction (0\u0026ndash;10)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAGB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54 (62.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (40.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13 (24.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (37.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (42.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOf these 87 patients, one had a perforated stomal ulcer requiring conversion to RYGB, and seven patients underwent hiatal repair with enteroenterostomies (mean 19 months after cOAGB). There were five delayed endoscopically detected ulcers managed medically.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSuboptimal Weight Loss Subset: Suboptimal Weight Loss as Indication for Conversion\u003c/h2\u003e \u003cp\u003eOf the 176 patients with suboptimal weight loss concerns as an indication for their cOAGB (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003eB), the average BMI was 33.2kg/m\u003csup\u003e2\u003c/sup\u003e at appointment follow-up (mean 11.9 months after cOAGB). Compared with an average BMI before cOAGB of 42kg/m\u003csup\u003e2\u003c/sup\u003e, the mean percentage of total weight lost was 20.28%.\u003c/p\u003e \u003cp\u003eOne hundred and six of these patients went on to complete the survey; the average satisfaction was 6.3 out of 10, 76.4% were happy they received the procedure, and 73.6% would do it again.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analyses\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStatistical Analyses Summary of Linear Regressions for Continuous Outcomes and Logistic Regressions for Categorical Outcomes[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDependent Variable:\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePredictor:\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher %EWL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Female sex (P\u0026thinsp;=\u0026thinsp;0.033)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReports being happy they had the procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Higher %EWL (P\u0026thinsp;=\u0026thinsp;0.003)\u003c/p\u003e \u003cp\u003e\u0026bull; Had enteroenterostomy (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003cp\u003e\u0026bull; Lower total heartburn score (P\u0026thinsp;=\u0026thinsp;0.014)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReports would have the procedure again under the same circumstances\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Higher %EWL (P\u0026thinsp;=\u0026thinsp;0.01)\u003c/p\u003e \u003cp\u003e\u0026bull; Had enteroenterostomy (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003cp\u003e\u0026bull; Lower total heartburn score (P\u0026thinsp;=\u0026thinsp;0.008)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher Satisfaction score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Primary procedure was LAGB (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003cp\u003e\u0026bull; Lower total regurgitation score (P\u0026thinsp;=\u0026thinsp;0.025)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperience heartburn or regurgitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Not significantly associated with any factor\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis paper presents a unique analysis of patient-reported symptoms and satisfaction scores after cOAGB. It contributes the largest cohort of patient-reported cOAGB outcomes to the literature (n\u0026thinsp;=\u0026thinsp;261), representing a single-centre, single-surgeon experience utilising OAGB exclusively as the conversional operation following SG or LAGB. The comparatively low morbidity rates, short hospital stay of 1.02 days, and high patient satisfaction scores in this conversional OAGB series illustrate the potential safety and tolerance for this procedure.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ecOAGB Safety\u003c/h2\u003e \u003cp\u003eThere were no related deaths, anastomotic leaks, or reoperations for bleeding. An early operation for escharotomy was technical, the other early reoperation was for gastric band erosion in the posterior body of stomach declaring itself postoperatively. Early complications (\u0026lt;\u0026thinsp;30d) and late interventions (\u0026gt;\u0026thinsp;30d) were comparatively low at 6.1% (n\u0026thinsp;=\u0026thinsp;16) and 14.9% (n\u0026thinsp;=\u0026thinsp;39) respectively. There were three early (1.1%) and twenty-three late complications above Clavien-Dindo grade 3a (total 10.3%), thus most were low severity and manageable medically. In contrast, Maurice et al. (cOAGB n\u0026thinsp;=\u0026thinsp;254) found 44.1% of patients experienced a complication higher than Clavien-Dindo class 3a postoperatively, Carandina et al. (cOAGB n\u0026thinsp;=\u0026thinsp;185) noted a similar value of 10.3%, albeit mixed with primary OAGB procedures, and Bruzzi et al. (cOAGB n\u0026thinsp;=\u0026thinsp;30) noted 6.6% of severe morbidity in patients.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] This also compares favourably to cRYGB, with Poublon et al. and Liagre et al. finding significantly increased rates of surgical complications after cRYGB compared to cOAGB.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe average hospital stay was the lowest published at 1.02 days. This compares favourably with 4.7 days reported by Seyit \u0026amp; Alis following conversional bariatric surgery[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], 2.6 days reported by Meydan et al.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and Ghosh et al.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] for cOAGB, and 1.45 days reported by Karim et al.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Perhaps a clinical pathway and surgeon reassurance was responsible for early discharge.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eReflux\u003c/h2\u003e \u003cp\u003eGastroesophageal reflux is a prominent symptom preceding and following conversional bariatric surgery, reflected in our validated GERD-QOL questionnaire.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] Over half the respondents remained on reflux medication for a mean of 35.7 months after cOAGB, albeit with minimal effect on quality of life. Potential rationales for this trend include pre-existing reflux, associated obesity, surgical factors (such as pouch size or anastomotic narrowing), selection bias for answering the survey, and performance bias whereby symptoms become more prominent upon questioning.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] Patient-reported reflux symptoms and the use of proton pump inhibitors without objective evidence may be questioned. Poor correlation has been noted late after anti-reflux surgery in patients complaining of reflux taking proton pump inhibitors with only 24% of patients actually demonstrating abnormal pH studies.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] Objective data with pH, impedance monitoring and routine endoscopy would have helped clarify.\u003c/p\u003e \u003cp\u003ePersistent reflux after cOAGB is noted in the literature. Maurice et al. similarly found over half their patients (52%) remained on reflux medication at 36.6 months postoperatively.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Dayan et al. reported GERD resolution and PPI cessation in 77.4% of patients following cOAGB, however, this is in comparison to 91.5% of patients following cRYGB, 32.4 months postoperatively.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] Similarly, Rayman et al. found that the incidence of GERD was significantly higher in patients who underwent cOAGB compared to cRYGB (17.4% vs 7.6%, p\u0026thinsp;=\u0026thinsp;0.018) at one year following surgery.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eReflux should be noted as a potential ongoing issue postoperatively in all conversional bariatric procedures.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Many patients reported these symptoms to arise \u003cem\u003ede novo\u003c/em\u003e after the conversion occurred. This is unique to conversions, as multiple reviews have suggested no difference between primary OAGB and RYGB, with very low reflux rates in the primary procedures.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] Therefore, it has been argued that the prior restrictive procedures may promote progressive oesophageal weakening of the musculature and sphincter due to chronic high intragastric pressure from the outflow resistance of the band (LAGB) or pylorus (SG).[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Similarly, hiatal laxity worsens with age and time after any bariatric procedure, particularly with the high concurrence of hiatal hernia as observed in this study, which is likely to have contributed to the \u003cem\u003ede novo\u003c/em\u003e cases observed.[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eWeight Loss Outcomes\u003c/h2\u003e \u003cp\u003eThe mean percentage total weight loss (%TWL) at one year was found to be 20.7% (SD 15.3%); this is in comparison to Debs et al. (25%), Kermansaravi et al. (26.6%), Maurice et al. (27.3%) and Poghosyan et al. (29%)[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Similarly, the mean %EWL at one year was 58.2% (SD 41.7%), peaking at two years (80.0% EWL) which is remarkably high for a conversional procedure. Comparatively, an excellent result reported by Maurice et al. was 76.7%.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Moreover, the favourable results of these parameters continued longitudinally, with bariatric outcomes retaining comparable rates beyond the 5-year mark indicative of long-term success for weight control with conversion. No patients had a \u0026lsquo;resleeve\u0026rdquo; of the gastric pouch during cOAGB in this series and perhaps more weight loss could have been expected with the addition of this.\u003c/p\u003e \u003cp\u003eFollow-up at one year postoperatively found the mean BMI to be 31.4kg/m2. This, however, is in keeping with the literature, and the stratified postoperative BMIs (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003eA) are similar to those reported by Debs et al. (BMI 29.8kg/m2), Maurice et al. (BMI 31.8kg/m2) and Ghosh et al. (BMI 33.2kg/m2) at 12 months follow up.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] Nevertheless, these remain favourable in contrast to the mean BMI found by Kermansaravi et al. (BMI 34.5kg/m2) and Poghosyan et al. (BMI 34.6kg/m2).[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eStatistically, %EWL was higher in female patients (P\u0026thinsp;=\u0026thinsp;0.033), which aligns with the identification of male patients to be at higher risk of poor outcomes and complications in bariatric surgery, despite forming a small portion of the patient pool.[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eAlternative Procedures\u003c/h2\u003e \u003cp\u003eThe most widely accepted alternative to cOAGB is cRYGB. As this was a uniquely unselected cohort of cOAGB, no patients underwent cRYGB. Comparative studies have noted that cOAGB had shorter operative times, reduced early postoperative complications, and greater weight loss, however lower haemoglobin levels after 5 years.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] The increased occurrence of reflux after cOAGB has long been detrimental to its reputation as a conversional procedure.[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] A meta-analysis of 739 patients found 12% less remission from reflux in cOAGB patients and 5.8% more de novo reflux than cRYGB patients (neither were statistically significant).[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] However, the marginal ulcer rates for cRYGB have been reported to reach 13.6%, markedly higher than the \u0026lt;\u0026thinsp;3% consistently reported for cOAGB.[\u003cspan additionalcitationids=\"CR41 CR42\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] Future direction should involve a prospective RCT comparing cOAGB to cRYGB cohort to similarly examine weight loss, reflux, and marginal ulcer rates.\u003c/p\u003e \u003cp\u003eIntractable reflux was revised with laparoscopic Braun enteroenterostomy conversion. It was noted to significantly increase rates of patients being happy with the cOAGB (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and those who would have the cOAGB again (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Enteroenterostomy is well-validated for use in symptomatic reflux, with supporting evidence for persistent reflux after cOAGB.[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] In 68.8% of patients, this reduced reflux completely or below significant levels. This procedure has also been found to be comparable with RYGB in terms of postoperative complications, including reflux per the GORD-QOL scores.[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] Given its simplicity and efficacy, as demonstrated in this paper, enteroenterostomy is a suitable and safe re-conversion option for intractable reflux post-cOAGB; however, converting to RYGB is another valid alternative and lends itself to a future RCT comparing these procedures.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eSubgroups\u003c/h2\u003e \u003cp\u003eFor patients with suboptimal weight loss as indications for conversion, continuation of this suboptimal clinical response remained an issue that persisted beyond cOAGB. This was reflected with slightly lower satisfaction scores than the whole cohort, with those happy with the procedure and those willing to repeat it 5.4 and 4.4 percentage points lower, respectively. No association with other morbidity was noted. The authors acknowledge that retrimming a dilated stomach at the time of cOAGB may well have contributed to more weight loss, at least in the medium term.[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eSimilarly, reflux remained an issue for patients with reflux as an indication for conversion. Whilst this subset was only 54.7% of respondents (n\u0026thinsp;=\u0026thinsp;87), it comprised 66.7% and 58.2% of all patients experiencing heartburn and regurgitation, respectively, with higher severity rates. Nevertheless, this suggests 30\u0026ndash;40% of patients with persisting reflux had symptom resolution with cOAGB, which accounts for the substantially higher satisfaction proportions. Those happy with the procedure and those willing to repeat it were 6.7 and 4.8 percentage points higher than the whole cohort, respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003ePatient Satisfaction\u003c/h2\u003e \u003cp\u003eNevertheless, patient satisfaction remained surprisingly high despite the high reflux rates consistent with the literature and the relatively high mean BMI after cOAGB. This is likely due to fulfilling patient expectations, as illustrated in the subgroup analysis, alongside severity reductions of reflux symptoms and excess BMI. This is exemplified as both lower total heartburn score and a higher %EWL were significantly associated with an increased proportion of patients happy with the procedure and would undergo it again (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Similarly, a higher satisfaction score was linked to a lower regurgitation score, but interestingly also the primary procedure being a LAGB. This trend may result from the higher incidence of complications from the LAGB, e.g. dysphagia, which resolve upon conversion and thus positively reflect on the cOAGB.\u003c/p\u003e \u003cp\u003eFurthermore, proportions satisfied with (81.8%) and would have undergone the procedure again (78%) are greater in the conversional cohort presented in this paper than that noted for fulfilled expectations (69.4%), sufficiently satisfied (59.8%), and glad to have had the procedure (75.3\u0026ndash;84%) in a variety of primary bariatric procedures from the literature.[\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] This again is important, as conversional bariatric surgery has been associated with reduced satisfaction compared to primary procedures.[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] Finally, satisfaction increased substantially in the long-term (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), again favourable of cOAGB outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e \u003cp\u003eThe retrospective single-cohort observational nature of this study is subject to several limitations. As patients undergo conversional surgery on a case-by-case basis, with both patient motivation and surgeon preference in consideration, the study is inevitably affected by selection bias. Additionally, this study only included patients from a single private hospital. This limits the patient demographic to those who can afford private surgery and may have led to better post-cOAGB outcomes. This cohort\u0026rsquo;s demographic is substantially skewed towards females (85.4%), with a mean age of 48.6 years. Therefore, the results of this study are most applicable to patients with these characteristics, limiting external validity without utilising different surgeons on a wider demographic range of patients. Furthermore, the survey response rate was 60.9%, further limiting the range of responses received as patients experiencing complications may be more likely to respond. Despite this apparent low response rate, a study noted an average of 31.3\u0026ndash;46.5% response rate in North America one year after bariatric surgery, suggesting this value is reasonable within this patient cohort.[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePatients wishing for conversional surgery after SG or LAGB are difficult to cure with respect to further significant weight loss or reflux control. Therefore, the conversional procedure must be safe, of low morbidity, and have high patient-reported satisfaction scores. We present the largest series of cOAGB, adding weight to the literature to justify this as a safe option for patients troubled with weight or reflux after a primary bariatric procedure. Whilst reflux and suboptimal weight loss may persist, patient satisfaction was high, which is as important as the quantitative parameters generally examined by surgeons. Additionally, the reported bariatric and reflux parameters compared favourably to those in the conversional literature, with improvement of these parameters correlating to improved survey responses. Finally, for those patients that did not improve, enteroenterostomy was utilised for significant reflux, with a 100% conversion to being happy with the original procedure, highlighting its potential for resolving such intractable cases.\u003c/p\u003e "},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthors AL and IM conceived the design of the study. AL completed data extraction, clarifying any uncertainties with IM. AL prepared the manuscript, IM and MK revised and contributed. MK and AL contributed to the statistical analyses. All authors have approved the final version of the manuscript.\u003c/p\u003e\u003cp\u003e\u003cem\u003eAll procedures performed in studies involving human participants were in accordance with the\u0026nbsp;\u003c/em\u003e\u003cem\u003eethical standards of the Wesley Hospital research committee (Number 2023.03.381) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors declare that they have no conflict of interest. No funding was received for this project.\u003c/em\u003e\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank Queensland Cyber Infrastructure Foundation (QCIF) for statistical consultation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCaballero B. Humans against Obesity: Who Will Win? 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PubMed PMID: 33334677; PubMed Central PMCID: PMC7904592.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Conversional bariatric surgery, One anastomosis gastric bypass, Single anastomosis gastric bypass, Reflux, GERD, GORD, Sleeve gastrectomy, Gastric band, Weight loss","lastPublishedDoi":"10.21203/rs.3.rs-4603959/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4603959/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eIntroduction\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eConversional bariatric procedures are increasing, particularly conversional one-anastomosis gastric bypasses (cOAGB). This study reports long-term and patient-reported outcomes for cOAGB after laparoscopic adjustable gastric banding (LAGB) and sleeve gastrectomy (SG).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMethods\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective single-cohort review of a prospective database examined all cOAGB cases (2016-2023). Perioperative morbidity, long-term surgical or endoscopic interventions, and patient-reported outcomes were analysed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResults\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWithin the largest published cohort of 261 consecutive cOAGB patients, 60.9% had prior-LAGB and 39.1% had prior-SG. Within 30 days, three severe and 13 low-grade complications occurred without mortality, with 98.9% of patients home the following day. Twenty-four longer-term surgical interventions were performed for reflux, port-site hernia, perforated ulcer or adhesions. 14 cases of anastomotic ulcer and one reflux oesophagitis were managed conservatively.\u003c/p\u003e\n\u003cp\u003e60.9% of patients responded to the survey (35.7 months post-cOAGB). 37.1% reported heartburn and 23.9% reported regurgitation. 81.8% of patients reported they were happy with the procedure, and 78% reported they would choose it again, both outcomes associated with greater percentage excess weight loss (%EWL) and lower heartburn scores. Higher satisfaction was associated with less regurgitation or prior-LAGB.\u003c/p\u003e\n\u003cp\u003eMean BMI (41.8 months after conversion) was 31.5kg/m\u003csup\u003e2\u003c/sup\u003e (9.7kg/m\u003csup\u003e2\u003c/sup\u003e less than before conversion), with mean %EWL of 64.6% (significantly higher in female patients) and mean TBWL of 22.5%.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConclusion\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ecOAGB was found to be safe and effective for further weight loss or persistent reflux. Although these issues may not be fully resolved, the relative improvement is reflected in the strong satisfaction scores, supporting the use of this technique in conversional surgery.\u003c/p\u003e","manuscriptTitle":"The Efficacy of Conversional One Anastomoses Gastric Bypass post Sleeve Gastrectomy and Gastric Band: A Large Single Cohort Series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-15 18:14:02","doi":"10.21203/rs.3.rs-4603959/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b47136fd-51f1-4cf4-9992-118c851dfe81","owner":[],"postedDate":"July 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-09T17:53:06+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-15 18:14:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4603959","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4603959","identity":"rs-4603959","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}