Sleeve gastrectomy or gastric bypass as revisional bariatric procedures: retrospective evaluation of outcomes

Nissen Sleeve as a Redo Surgery Post Gastric Banding for Non-responders to Weight Loss and Therapy-Resistant Reflux

Roux-en-Y gastric bypass (LRYGB) would be the procedure of choice for non-responders of weight loss and patients with reflux symptoms (GERD). However, not every patient is a candidate for RYGB, and sometimes, the patient can insist only on alternatives other than malabsorption procedures, as was the case with our patient. We report a case with symptomatic GERD who underwent a successful Nissen sleeve gastrectomy after band removal. To our knowledge, this is the first case using Nissen sleeve as a redo surgery after a previous bariatric procedure.

Roux-en-Y Gastric Bypass after Laparoscopic Sleeve Gastrectomy Failure: Could the Number of Previous Operations Influence the Outcome?

After a failed laparoscopic adjustable gastric band (LAGB), laparoscopic sleeve gastrectomy (LSG) has been proposed as revisional surgery. Those patients that receive a second restrictive procedure fall into a small subgroup of patients with more than one restrictive procedure (MRP). If also the second restrictive procedure fails, the correct surgical strategy is a challenge for the surgeon. Roux-en-Y gastric bypass (RYGB) may be an option but there is no evidence in the literature on whether the procedure is effective in treating failures after MRP. This study aims to evaluate the influence of the previous number of restrictive interventions (MRP vs single LSG) in the results of RYGB as revisional surgery. We have retrospectively analyzed patients who underwent conversion from laparoscopic sleeve gastrectomy (LSG), or from multiple restrictive procedures (MRP), to RYGB for weight regain (WR) or insufficient weight loss (IWL) between 2009 and 2019. The number of patients analyzed was 69 with conversion to RYGB after LSG and 44 after MRP. The reduction of excess weight (%TWL) at 3, 6, 12, 24 RYGB postoperative months was respectively of 11.03%, 16.39%, 21.43%, and 24.22% in the MRP group, and of 10.97%, 16.4%, 21.22%, and 22.71% in the LSG group. No significant difference was found in %TWL terms after RYGB for the MRP group and the LSG group with an overall %TWL, which was 11.00 ± 6.03, 16.40 ± 8.08, 21.30 ± 9.43, and 23.30 ± 9.91 respectively at 3, 6, 12, and 24 months. The linear regression model highlighted a positive relationship between the %EWL post-bypass at 24 months and the time elapsed only between the LSG and RYGB in the MRP group patients (p < 0.001). RYGB has proved to be a reliable technique with good results in terms of weight loss after failed bariatric surgery both in patients who previously underwent MRP and in those who underwent exclusively LSG. RYGB showed better results in patients who experienced WR than in those who had IWL from previous techniques.

Patient Outcomes and Rate of Intensive Care Unit Admissions Following Bariatric Surgery: A Retrospective Cohort Study of 775 Patients

Background The last two decades have seen a significant rise in obesity and its adverse consequences across the globe. Bariatric surgery has emerged as a widely employed therapeutic approach for weight reduction and alleviating the risk of obesity-related chronic diseases such as diabetes, cardiovascular diseases, and cancer. As bariatric procedures are gaining popularity, the complications associated with these procedures can not be ignored. This retrospective study aimed to investigate the incidence of intensive care unit (ICU) admissions following bariatric surgery and ICU-related mortality. Methodology This retrospective study conducted at King Hamad University Hospital, Bahrain evaluated the patient outcomes and the rate of ICU admissions following bariatric surgery between 2018 and 2022. Demographic data of the patients were extracted from electronic health records. The primary endpoint was ICU admission incidence and mortality, while secondary outcomes included risk factors, duration of ICU stay, and complications leading to ICU admission. Results Of the 775 patients included, 66.3% were female. The mean age of the patients was 35.92 ± 21.12 years. Over 91% of the patients had a body mass index above 30 kg/m2. The most common primary procedure was laparoscopic sleeve gastrectomy (75%), followed by gastric bypass (22.6%). In revision bariatric surgery, the majority (91.3%) had a conversion from sleeve gastrectomy to gastric bypass. Overall, 0.77% of patients were admitted to the ICU, with the majority being unplanned ICU admissions (0.52%). The average ICU stay was 21 days (1 to 54 days). The most common reason for ICU admission was sepsis, septic shock, and gastric leakage. Conclusions The results of this study show a relatively lower number of ICU admissions after bariatric surgery compared to previous studies.

Roux-en-Y Gastric Bypass as Conversion Procedure of Failed Gastric Banding: Short-Term Outcomes of 1295 Patients in One Single Center

PURPOSE

Laparoscopic adjustable gastric band (LAGB) has high technical and weight loss failure rates. We evaluate here the 1-year morbidity, mortality, and weight loss of laparoscopic Roux-en-Y-gastric bypass (LRYGB) as a feasible conversion strategy.

METHODS

Patients with a failed primary LAGB who underwent LRYGB from July 2004 to December 2019 were selected from an electronic database at our center. Patients had a conversion to LRYGB at the same time (one-stage approach) or with a minimum of 3 months in between (two-stage approach). Primary outcomes included 30-day morbidity and mortality. Secondary outcomes were body mass index (BMI), percent excess weight loss (%EWL), and percent excess BMI lost (%EBMIL) at 1 year postoperatively.

RESULTS

A total of 1295 patients underwent a conversion from LAGB to LRYGB at our center: 1167 patients (90.1%) in one stage and 128 patients (9.9%) in two stages. There was no mortality. An early (30-day) postoperative complication occurred in 93 patients (7.2%), with no significant difference found between groups. Hemorrhage was the most common complication in 39 patients (3.0%), and the reoperation was required in 19 patients (1.4%). At 1 year postoperatively, the mean BMI was 28.0 kg/m2, the mean %EWL 72.8%, and the mean %EBMIL 87.0%. No statistically significant difference was found between the groups.

CONCLUSION

Conversion to LRYGB can be considered as a safe and effective option with low complication rate and good weight loss outcomes at 1 year. One-stage conversion provides the same early outcome as two-step surgery with a competent surgeon.

Postoperative morbidity and weight loss after revisional bariatric surgery for primary failed restrictive procedure: A systematic review and network meta-analysis

BACKGROUND

revisional bariatric surgery is gaining increasing interest as long term follow-up studies demonstrate an elevated failure rate of primary surgery due to insufficient weight loss, weight regain or complications. This particularly concerns restrictive bariatric surgery which has been widely adopted from the '80s till present through different procedures, notably vertical banded gastroplasty, laparoscopic adjusted gastric banding and sleeve gastrectomy. The aim of this study is to define which revisional bariatric procedure performs the best after failure of primary restrictive surgery.

METHODS

a systematic review and network meta-analysis of 39 studies was conducted following the PRISMA guidelines and the Cochrane protocol.

RESULTS

biliopancreatic diversion with duodenal switch guarantees the best results in terms of weight loss (1 and 3-years %TWL MD: 12.38 and 28.42) followed by single-anastomosis duodenoileal bypass (9.24 and 19.13), one-anastomosis gastric bypass (7.16 and 13.1), and Roux-en-Y gastric bypass (4.68 and 7.3) compared to re-sleeve gastrectomy. Duodenal switch and Roux-en-Y gastric bypass are associated to an increased risk of late major morbidity (OR: 3.07 and 2.11 respectively) compared to re-sleeve gastrectomy while no significant difference was highlighted for the other procedures. Re-sleeve gastrectomy is the revisional intervention most frequently burdened by weight recidivism; compared to it, patients undergoing single-anastomosis duodenoileal bypass have the lowest risk of weight regain (OR: 0.07).

CONCLUSION

considering the analyzed outcomes altogether, single-anastomosis duodenoileal bypass and one-anastomosis gastric bypass are the most performing revisional procedures after failure of restrictive surgery due to satisfying short and mid-term weight loss and low early and late morbidity. Moreover, single-anastomosis duodenoileal bypass has low risk of weight recidivism.

Clinical Outcomes of Sleeve Gastrectomy Versus Roux-En-Y Gastric Bypass After Failed Adjustable Gastric Banding

BACKGROUND

Over recent decades, laparoscopic adjustable gastric banding (LAGB) has been among the most common bariatric surgeries. Nowadays, many patients require revision surgery due to insufficient weight loss and band-related complications. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the two most common revision surgeries for failed LAGB, but the conclusions about their efficacy and safety have been inconsistent. This meta-analysis aimed to review the clinical outcomes of SG and RYGB after failed LAGB.

METHODS

In accordance with the PRISMA guidelines, the PubMed, Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were systematically searched for articles that had studied the efficacy and safety of SG and RYGB. The most appropriate effects model was chosen based on the heterogeneity of the articles included in this meta-analysis. Statistical analysis was conducted using Stata 14.0.

RESULTS

Of 586 articles that were retrieved, 16 articles which examined 2141 SG and 2990 RYGB patients met the inclusion criteria. The patients in RYGB groups showed increased percent excess weight loss (%EWL) at 12 and 24 months after revision surgery but no statistically significant change was found about %EWL after 3, 6, or 36 months. In addition, RYGB was associated with a higher rate of complications, interventions, and readmission in addition to being of more operative time.

CONCLUSIONS

This review suggested that RYGB was more effective at demonstrating weight loss after 12 and 24 months, but comparisons of the long-term efficacy of RYGB with that of SG remain inconclusive. In addition, RYGB was accompanied by a greater number of post-operative complications, interventions, and readmissions. Thus, surgeons should consider the overall status of the patients and their comorbidities as crucial factors when selecting a form of revision surgery. Additional high-quality randomized controlled studies are required to further compare the efficacy and safety of these treatments with longer follow-up times.

Roux-en-Y gastric bypass, sleeve gastrectomy, or one anastomosis gastric bypass as rescue therapy after failed adjustable gastric banding: a multicenter comparative study

BACKGROUND

To date, laparoscopic adjustable gastric banding remains the third most commonly performed surgical procedure for weight loss. Some patients fail to get acceptable outcomes and undergo revisional surgery at rates ranging from 7% to 60%. Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB), and sleeve gastrectomy (SG) are among the most common salvage options for failed laparoscopic adjustable gastric banding.

OBJECTIVE

To compare the outcomes of converting failed laparoscopic adjustable gastric banding to RYGB, OAGB, or SG.

METHODS

Data collected from 7 experienced bariatric centers around the world were retrospectively collected, reviewed, and analyzed. Final body mass index (BMI), change in BMI, percentage excess BMI loss, and major complications with particular attention to leaks, hemorrhage, and mortality were reported.

RESULTS

Of 1219 patients analyzed, 74% underwent RYGB, 16% underwent OAGB, and 10% underwent SG after banding failure. The mean age was 38 years (±10 yr), and 82% of patients were women. The mean follow-up was 33 months. The follow-up rate was 100%, 87%, and 52% at 1, 3, and 5 years, respectively. At the latest follow-up, percentage excess BMI loss >50% was achieved by 75% of RYGB, 85% of OAGB, and 67% of SG patients. Postoperative complications occurred in 13% of patients after RYGB, 5% after OAGB, and 15% after SG.

CONCLUSION

Our data show that it is possible to achieve or maintain significant weight loss with an acceptable complication rate with all 3 surgical options.

Case report of combined surgical oncologic and bariatric procedures

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Morbidly obese patients do get cancer and require laparotomy for resection of the malignancy.

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Sleeve gastrectomy can follow a successful oncologic intervention with minimal increase in morbidity and mortality.

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Doing the oncologic procedure, HIPEC, and then sleeve gastrectomy helps prevent tumor seeding at the gastric staple line.

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Patient satisfaction is high with a favorable prognosis expected from a simultaneous oncologic and bariatric intervention.

Introduction

Morbidly obese patients may require a laparotomy to resect a malignancy. In some patients the cancer resection can be combined with the bariatric procedure to concomitantly treat both diseases.

Presentation of case

A morbidly obese patient with peritoneal metastases from an appendiceal mucinous neoplasm was evaluated and definitively treated with Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC), at the same time the patient was treated for morbid obesity with sleeve gastrectomy and removal of a previous laparoscopic adjustable gastric banding (LAGB).

Discussion

The clinical features and treatments of a cancer patient who underwent a combined surgical oncologic and bariatric procedure is presented. A second-look cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) preceded a sleeve gastrectomy. At the time of surgical exploration the prognosis from an oncologic perspective was acceptable. The near total gastric resection was performed without complications.

Conclusions

With short term follow-up, this patient’s outcome was favorable suggesting that surgical oncologic and bariatric procedures can be combined. Further, clinical investigations are indicated in this common clinical setting.

A comparison of revisional and primary bariatric surgery

BACKGROUND

Revisional surgery is an important component of addressing weight regain and complications following primary bariatric surgery. Owing to provincial need and the complexity of this patient population, a specialized multidisciplinary revision clinic was developed. We sought to characterize patients who undergo revision surgery and compare their outcomes with primary bariatric surgery clinic data.

METHODS

We completed a retrospective chart review of bariatric revision clinic patients compared with primary bariatric surgery patients from December 2009 to June 2014.

RESULTS

We reviewed the charts of 2769 primary bariatric clinic patients, 886 of whom had bariatric surgery, and 534 revision bariatric clinic patients, 83 of whom had revision surgery. Fewer revision clinic patients underwent surgery than primary clinic patients (22% v. 32%). The mean preoperative body mass index (BMI) was 44.7 ± 9.5 in revision patients compared with 45.7 ± 7.6 in primary bariatric surgery patients. Most revision patients had a prior vertical banded gastroplasty (VBG; 48%) or a laparoscopic adjustable gastric band (LAGB; 24%). Bands were removed in 36% of all LAGB patients presenting to clinic. Of the 134 procedures performed in the revision clinic, 83 were bariatric weight loss surgeries, and 51 were band removals. Revision clinic patients experienced a significant decrease in BMI (from 44.7 ± 9.5 to 33.8 ± 7.5, p < 0.001); their BMI at 12-month follow-up was similar to that of primary clinic patients (34.5 ± 7.0, p = 0.7). Complications were significantly more frequent in revision patients than primary patients (41% v. 15%, p < 0.001).

CONCLUSION

A bariatric revision clinic manages a wide variety of complex patients distinct from those seen in a primary clinic. Operative candidates at the revision clinic are chosen based on favourable medical, anatomic and psychosocial factors, keeping in mind the resource constraints of a public health care system.

Revisional metabolic/bariatric surgery: a moral obligation

Revisional metabolic/bariatric surgery is a moral obligation; for not to perform revisional surgery is a denial of the precepts of our discipline and an abandonment of the underprivileged population who has placed its trust and future in our hands.

Laparoscopic sleeve gastrectomy as revisional surgery for adjustable gastric band erosion

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has been increasingly adopted as a revisional surgery for failed gastric banding. However, little information is available regarding the outcome of revisional LSG for band erosion.

MATERIALS AND METHODS

A retrospective database analysis was performed to study LSG as revisional surgery for band erosion. For staged revision, we waited a minimum of 3 months after band removal, and for single-stage revision, the band was removed by gastrotomy, and sleeve gastrectomy was performed at the same time. Main outcome measures were success rates of therapeutic strategies, morbidity, and mortality rates, length of stay, and body mass index (BMI) (percentage excess weight loss [%EWL]) before and after revision.

RESULTS

From March 2011 to February 2013, 9 female patients underwent revisional LSG. Average age was 34.7 years. Six patients underwent a staged procedure, and the other 3 underwent a single-stage revision. Among the 6 staged patients, eroded bands had been removed by laparoscopy in 4 and by endoscopy in 2 without complications. Their LSGs were performed at a median of 4.4 months after band removal. Another 2 patients underwent single-stage revision. In the last patient, band erosion was incidentally found during a revisional LSG for insufficient weight loss. No mortality occurred. There were one stenosis and two proximal leaks. Two patients with leak underwent total gastrectomy and fistulojejunostomy. After a mean follow-up of 19.1 months, all 9 patients exhibited weight loss. The mean (±standard deviation [SD]) pre- and post-LSG BMIs were 34.0±4.4 and 25.6±2.1 kg/m(2), respectively, and their mean (±SD) %EWL from prebanding was 86.8±10.1%. Revisional LSG resulted in a further median %EWL of 28.0% (range, 7.9%-68.9%) versus weight at time of band removal.

CONCLUSIONS

Revisional LSG after band erosion was found to be feasible and effective. However, it is prone to severe complication. In selected cases of band erosion, LSG can be performed at the time of band removal in a single stage.

Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force

BACKGROUND

Reoperative bariatric surgery has become a common practice in many bariatric surgery programs. There is currently little evidence-based guidance regarding specific indications and outcomes for reoperative bariatric surgery. A task force was convened to review the current evidence regarding reoperative bariatric surgery. The aim of the review was to identify procedure-specific indications and outcomes for reoperative procedures.

METHODS

Literature search was conducted to identify studies reporting indications for and outcomes after reoperative bariatric surgery. Specifically, operations to treat complications, failed weight loss, and weight regain were evaluated. Abstract and manuscript reviews were completed by the task force members to identify, grade, and categorize relevant studies.

RESULTS

A total of 819 articles were identified in the initial search. After review for inclusion criteria and data quality, 175 articles were included in the systematic review and analysis. The majority of published studies are single center retrospective reviews. The evidence supporting reoperative surgery for acute and chronic complications is described. The evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. Procedure-specific outcomes are described. Complication rates are generally reported to be higher after reoperative surgery compared to primary surgery.

CONCLUSION

The indications and outcomes for reoperative bariatric surgery are procedure-specific but the current evidence does support additional treatment for persistent obesity, co-morbid disease, and complications.

Laparoscopic sleeve gastrectomy as a revisional procedure for failed laparoscopic gastric banding with a "2-step approach": a multicenter study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has been proposed as an alternative revisional procedure for failed/complicated gastric banding. This is a retrospective cohort study of a prospectively maintained database of revisional LSG after band removal for insufficient weight loss and/or band-related complications, using a 2-step approach. The outcomes were compared with a control group of primary LSG. The study was conducted at a university hospital (Sapienza University of Rome-Polo Pontino, Icot, Latina, Italy) and 2 community general hospitals (Hospital Andosilla Civita Castellana, Viterbo, Italy and Hospital Villa D'Agri, Potenza, Italy).

METHODS

A total of 76 revisional LSG procedures was recorded; a control group of 279 LSG patients was selected. The primary endpoint was to compare the perioperative complication rate between the revisional versus the control group. Secondary endpoints were operative time, conversion rate, postoperative length of stay and percentage excess weight loss (%EWL) at 6, 12, and 24 months.

RESULTS

The indications for band removal were inadequate weight loss (47 patients), slippage (10 patients), erosion (7 patients), and pouch dilation (12 patients). All procedures were completed laparoscopically. The median operative time was 78 minutes for the revision LSG and 65 minutes for the control LSG (P<.05). In the revision group, the overall complication rate was 17.1%, and the median postoperative length of stay was 4 days; in the control group, the overall complication rate was 10.7%, and the median postoperative length of stay was 3. No complications requiring reoperation or readmission occurred in the revision group. In the control group, there were 5 cases of major complications. All the patients completed the follow-up. A total of 56 patients in the revision group and 184 patients in the control group were followed-up for at least 24 months. The %EWL at 6, 12, and 24 months was 46.5%, 66.4%, and 78.5%, respectively, in the revision group, and 49.8%, 78.2%, and 78%, respectively, in the control group.

CONCLUSION

Results confirmed that LSG, performed in 2 steps, is an effective revision procedure for failed or complicated laparoscopic adjustable gastric banding with good perioperative outcomes and 2-year weight loss.