• Hosam Hamed, Mahmoud Ali, and Youssif Elmahdy.
• Gastrointestinal surgical center (GISC), Faculty of Medicine, Mansoura University, Mansoura, Egypt.
• Ann. Surg. 2021 Aug 1; 274 (2): 271280271-280.

ObjectiveComprehensive classification and evaluation of the outcome of limb distalization (LD) for inadequate weight loss after roux-en-y gastric bypass (RYGB).BackgroundLimb distalization is a revisional malabsorptive procedure for the management of inadequate weight loss after RYGB. Multiple studies with small sample sizes reported the outcome of LD. This meta-analysis aims to reach a higher level of evidence regarding the safety and efficacy of the procedure.MethodsA systematic search, including all studies on LD for management of inadequate weight loss after RYGB. The search engines included were PubMed, Embase, Web of Science, Cochrane Library, Scopus, and EBSCOhost.ResultsFourteen studies were included. The pooled estimates of the mid-term percentage of excess weight loss (%EWL), diabetic, and hypertension remission were 50.8%, 69.9%, and 59.8%, respectively. The rate of surgical revision for the management of protein-energy malnutrition (PEM) was 17.1%. The %EWL was significantly higher with older age and good response to index surgery (P = 0.01, 0.04, respectively). Less total alimentary limb length was not associated with better %EWL (P = 0.9), but it was significantly associated with severe PEM (P = 0.01).ConclusionsLD has an encouraging rate of resolution of comorbidities. A judicious patient selection is essential for better weight loss after LD. Type I LD with total alimentary limb length ≥350 cm was associated with less risk of malnutrition. PEM is a life-threatening complication that may require revisional surgery years after LD. Future studies on LD, adopting standardized surgical practice and terminology, will allow a more conclusive assessment of the outcome of the procedure.Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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