Revisional vs. primary Roux-en-Y gastric bypass--a case-matched analysis: less weight loss in revisions

One thousand consecutive mini-gastric bypass: short- and long-term outcome

There is growing evidence that mini-gastric bypass (MGB) is a safe and effective procedure. Operative outcome and long-term follow-up of a consecutive cohort of patients who underwent MGB are reported. The data on 1,000 patients who underwent MGB from November 2005 to January 2011 at an academic institution were reviewed. Mean age was 33.15 ± 10.17 years (range, 14-72), preoperative BMI was 42.5 ± 6.3 kg/m(2) (range, 26-75), mean preoperative weight was 121.6 ± 23.8 kg (range, 71-240), and 663 were women. Operative time and length of stay for primary vs. revisional MGB were 89 ± 12.8 min vs. 144 ± 15 min (p < 0.01) and l.85 ± 0.8 day vs. 2.35 ± 1.89 day (p < 0.01). No deaths occurred within 30 days of surgery. Short-term complications occurred in 2.7% for primary vs. 11.6% for revisionnal MGB (p < 0.01). Five (0.5%) patients presented with leakage from the gastric tube but none had anastomotic leakage. Four (0.4%) patients, all with revisional MGB, presented with severe bile reflux and were cured by stapling the afferent loop and by a latero-lateral jejunojejunostomy. Excessive weight loss occurred in four patients; two were reversed and two were converted to sleeve gastrectomy. Maximal percent excess weight loss (EWL) of 72.5% occurred at 18 months. Weight regain subsequently occurred with a mean variation of -3.9% EWL at 60 months. The 50% EWL was achieved for 95% of patients at 18 months and for 89.8% at 60 months. MGB is an effective, relatively low-risk, and low-failure bariatric procedure. In addition, it can be easily revised, converted, or reversed.

C-reactive protein 2 days after laparoscopic gastric bypass surgery reliably indicates leaks and moderately predicts morbidity

BACKGROUND

The aim of the present study was to evaluate whether serum C-reactive protein (CRP) is a useful predictor of early post-operative complications, particularly of intestinal leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery.

METHODS

The present study was a retrospective analysis of a prospectively maintained database with 809 patients who underwent LRYGB from 2002 until 2011. For 410 of these patients, at least one CRP measurement within the first seven post-operative days was available. The diagnostic value was determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve.

RESULTS

Forty-nine of 410 patients (12.0 %; 95 % confidence intervals [95 % CI], 9.2-15.5 %) developed surgery-related complications. Leaks occurred in 17 patients (4.1 %; 95 % CI, 2.6-6.5 %) at a median of 5 days after surgery. CRP levels 2 days after surgery showed the highest diagnostic value for post-operative complications (AUC, 0.74; 95 % CI, 0.60-0.89). Sensitivity was 0.53 (95 % CI, 0.31-0.74) and specificity was 0.91 (95 % CI, 0.79-0.96) on day 2 (cutoff level, 229 mg/l). The sensitivity for intestinal leaks was 1.00 (95 % CI, 0.51-1.00).

CONCLUSION

CRP on post-operative day 2 is a valuable predictor of post-operative complications, in particular intestinal leaks. Radiological imaging studies for intestinal leaks could be restricted to patients with CRP values exceeding 229 mg/l.

Effect of primary versus revisional Roux-en-Y gastric bypass: inferior weight loss of revisional surgery after gastric banding

BACKGROUND

Laparoscopic adjustable gastric banding is a popular and effective restrictive bariatric procedure. However, with longer follow-up, it has become clear that a considerable number of patients require revisional surgery, of which Roux-en-Y gastric bypass (RYGB) is the most commonly performed procedure. Studies that compared the outcomes of primary RYGB and revisional RYGB have not been conclusive. Our objective was to determine whether significant differences exist in the 1-year outcomes between primary RYGB (prim-RYGB) and revisional RYGB after laparoscopic adjustable gastric banding (rev-RYGB) at a major training hospital in The Netherlands.

METHODS

All prim-RYGB and rev-RYGB procedures performed from 2007 to 2009 were analyzed. Data were collected regarding weight loss, hospitalization, operative time, postoperative complications, and co-morbidities.

RESULTS

A total of 292 RYGB procedures were performed: 66 rev-RYGB and 226 prim-RYGB procedures. The operative time was significantly shorter in the prim-RYGB group (136.6±37.5 versus 167.5±40.6 min; P<.0001). No significant differences were found in hospitalization time (4.4±1.7 versus 4.9±2.4 d; P= .063) or complication rate (14.7% versus 15.2%; P=.962). No deaths occurred in either group. The number of patients with resolved diabetes and hypertension did not differ between the 2 groups (50.1% versus 23.1%; P=.116; and 40.7% versus 25.0%; P=.384, respectively). Weight loss was significantly greater in the prim-RYGB group in terms of excess weight loss (71.6%±20.8% versus 48.4%±26.8%; P<.0001), body mass index reduction (13.0±3.8 versus 10.2±5.6 kg/m(2); P<.0001), absolute weight loss (37.4±11.5 versus 29.3±17.2 kg; P=.001), and percentage of weight loss (29.7%±8% versus 21.7%±11.5%; P<.0001).

CONCLUSION

rev-RYGB is a safe procedure with outcomes similar to those of prim-RYGB in terms of complication rate, hospitalization time, and effect on co-morbidity. Weight loss, however, was significantly less after rev-RYGB than after prim-RYGB.

Indications, safety, and feasibility of conversion of failed bariatric surgery to Roux-en-Y gastric bypass: a retrospective comparative study with primary laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is considered the "gold standard" revision procedure. The purpose of this study was to compare the surgical outcome of primary laparoscopic RYGB (pLRYGB) to revisional open or laparoscopic Roux-en-Y gastric bypass surgery (rRYGB).

METHODS

A retrospective analysis of all patients who underwent pLRYGB or rRYGB from January 2003 to December 2009 has been performed. Demographics, indications for revision, and complications have been reviewed. The rRYGB and pLRYGB patients have been compared.

RESULTS

Seventy-two patients underwent rRYGB, and 652 patients underwent pLRYGB. Mean follow-up was 35 and 45 months, respectively. Fifty-six rRYGB procedures were performed laparoscopically. The primary operations had consisted of laparoscopic gastric banding (n = 28), laparoscopic vertical banded gastroplasty (n = 19), laparoscopic sleeve gastrectomy (n = 6), laparoscopic RYGB (n = 3), and biliopancreatic diversion with duodenal switch (n = 16). Indications included weight regain (n = 29), malabsorption (n = 16), gastrogastric fistula (n = 5), band-associated problems (n = 3), and refractory stomal ulceration (n = 1). There was no significant difference in early or late postoperative complications when comparing rRYGB to pLRYGBP patients (11.1% vs. 5.52%, P = 0.069 and 19.4% vs. 24.2%, P = 0.465 respectively). Five rRYGB patients (7.04%) required reintervention (3 internal hernias, 1 ventral hernia, 1 laparoscopic exploration) compared with 101 pLRYGB patients (15.71%; P = 0.051). None of the patients died. Mean hospital stay was not significantly longer in the rRYGB group (5.38 vs. 4.95 days, P = 0.058).

CONCLUSIONS

In our series, hospital stay, morbidity, and mortality of rRYGB were not significantly higher compared with pLRYGB. Furthermore, we believe that this type of revisional bariatric surgery should be performed in high-volume bariatric centers.

Revisional bariatric surgery

With the increase in bariatric surgical procedures, an increase in revision operations is expected. A thorough preoperative work-up is essential to formulate an appropriate revision strategy. Outcomes vary according to the primary operation and chosen approach to revision. Recent studies have shown acceptably low complication rates and good weight loss with the associated health benefits. Although there is no direct evidence in the form of randomized studies indicating which patients with inadequate weight loss or weight regain will benefit most from revision, or to support one particular revision approach rather than another, it is possible to develop general, effective strategies.

Band revision versus Roux-en-Y gastric bypass conversion as salvage operation after laparoscopic adjustable gastric banding

BACKGROUND

With the increasing popularity of laparoscopic adjustable banding (LAGB), reoperations to treat band complications have become increasingly more common. Few studies, however, have documented the outcomes of such revisional procedures. The purpose of the present study was to compare the different reoperative approaches after LAGB placement. The present study was conducted at a tertiary referral academic medical center in the United States.

METHODS

We reviewed our bariatric database to identify patients who had undergone LAGB from 2004 to 2007 and had undergone either revision of their original band or conversion to Roux-en-Y gastric bypass.

RESULTS

Of the 66 patients who met our inclusion criteria, 47 (71.2%) had undergone revision and 19 (28.8%) conversion. The patient demographics were similar between the 2 groups. The interval to revision or conversion was 22 and 28 months, respectively. Band slippage was the most common surgical indication in the revision group, and inadequate weight loss was the most common in the conversion group. Although patients in the revision group had experienced good weight loss before their reoperation, the conversion group had not. However, the conversion group experienced good weight loss after their reoperation, with an average excess body weight loss of 48%.

CONCLUSION

Patients who have experienced successful weight loss with LAGB and experience band complications will have satisfactory outcomes with band revision, maintaining their excess body weight loss. These data suggest that patients with inadequate weight loss after LAGB can do well after conversion to Roux-en-Y gastric bypass.