Laparoscopic Conversion of Vertical Banded Gastroplasty (Mason MacLean) into Roux-en-Y Gastric Bypass

Short-Term (30-Day) Morbidity of Biliopancreatic Diversion Compared to Roux-en-Y Gastric Bypass as Revisional Procedures for Failed Vertical Banded Gastroplasty

BACKGROUND

Silastic ring vertical gastroplasty (SRVG) and vertical banded gastroplasty (VBG) are associated with a high failure rate due to weight regain and complications at long-term follow-up. Consequently, surgical correction for such procedures is warranted. Controversy exists as to which surgical procedure is the ideal choice for such correction. Our aim is to compare short-term outcome of Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) repair for failed VBG/SRVG bariatric procedures.

METHODS

The medical records of patients with failed SRVG who underwent corrective procedures at our institute between 2004 and 2018 were retrospectively reviewed. Patients characteristics, surgical approaches, and intraoperative and post-operative complications were examined and compared.

RESULTS

Sixty patients in total underwent a surgical corrective procedure for failed SRVG. Thirty-one patients underwent RYGB, and 29 patients underwent BPD. Major complications were seen more in the RYGB group (35% = 11) compared to the BPD (6.9% = 2). Even though anastomotic leak rates were not statistically significant (p = 0.053), an apparent tendency for such a complication was noted in the RYGB group. RYGB procedure had an increased 30-day complication rate (p = 0.055) compared to RYGB. Laparoscopic approach had statistically fewer complications than open approach. No mortality was observed in either group.

CONCLUSION

Our study showed that BPD is a safe option with less complication rates than RYGB in the short-term period for surgical correction of failed VBG/SRVG procedures.

Primary Roux-en-Y Gastric Bypass Results in Greater Weight Loss at 15-Year Follow-Up Compared with Secondary Roux-en-Y Gastric Bypass After Failure of Gastric Band or Mason McLean Vertical Gastroplasty

PURPOSE

The aim of the study is to compare the outcomes of patients treated with secondary Roux-en-Y gastric bypass (RYGB) after adjustable gastric banding (AGB) or vertical banded gastroplasty (VBG) with those of patients having primary RYGB.

MATERIALS AND METHODS

Patients undergoing secondary RYGB after AGB or VBG between 1997 and 2004 with a minimal follow-up of 15 years were matched using a propensity score (according to gender, age, BMI, duration of follow-up) with comparable patients who underwent primary RYGB.

RESULTS

The mean follow-up was 16.50 years in the secondary RYGB group (N = 32) versus 16.33 years in the primary RYGB group (N = 32). Early postoperative complications rate was 6.25% in the secondary RYGBs versus 9.38% in the primary RYGBs (P = 1). Late postoperative complications and additional surgical procedures were 56.25% and 37.5% in the secondary and primary RYGB group, respectively (P = 0.21). Long-term (at 16-20 years) %TWL and %EWL were significantly lower (P < 0.01 and P = 0.013, respectively) after secondary RYGB (%TWL = 7.56%; %EWL = 17.15%) than after primary RYGB (%TWL = 24.51%; %EWL = 55.61%). Remission of obesity-related comorbidities was comparable (P > 0.05). Gastroesophageal reflux was more frequent after secondary RGYB-43.75% versus 25%, P < 0.05. Quality of life-Morehead-Ardelt II score (0.02 in secondary RYGB versus 0.69 in primary RYGB, P = 0.13), general self-assessment of health status and weight satisfaction were comparable.

CONCLUSION

Secondary RYGB after AGB or VBG is less efficient at weight loss, GERD remission and energy expenditure at 15 years after conversion. However, it is as effective for improvement/resolution of obesity-related comorbidities and is associated with similar QoL scores.

Roux-en-Y gastric bypass as revisional surgery

The Roux-en-Y gastric bypass (RYGB) is a worldwide-performed procedure as primary surgery, and as conversional procedure after complications and/or failure of other bariatric procedures. RYGB can be performed as revisional surgery after adjustable gastric banding, vertical banded gastroplasty, sleeve gastrectomy and one anastomosis gastric bypass. Each of these revisional procedures may be technically challenging, and accurate preoperative work-up and operative planning is required. If correctly performed, RYGB as revisional procedure is associated with satisfying outcomes and is indicated in the treatment of insufficient weight loss and postoperative complications of a primary bariatric procedure - such as chronic leak or gastroesophageal reflux after sleeve gastrectomy. The present article analyzes the most important indications, technical points and tips and tricks to safely perform RYGB as a secondary procedure.

Enhanced Recovery After Revisional Bariatric Surgery: a Retrospective Study of 321 Patients with Laparoscopic Conversion of Failed Gastric Banding or Failed Mason Gastroplasty to Roux-en-Y Gastric Bypass

PURPOSE

With the rising incidence of failed bariatric procedures, the importance of revisional surgery has been increasing. These revisional procedures come with a higher risk of complications leading to longer hospital stays. We believe though that enhanced recovery after revisional bariatric surgery is possible and needs to be advocated.

MATERIALS AND METHODS

We retrospectively analyzed our laparoscopic conversions of failed gastric banding and failed Mason gastroplasty to Roux-en-Y gastric bypass. A total of 321 patients was included in the study, from February 2010 until December 2019. The primary endpoints were length of stay (LoS), in-hospital complication rate, and early readmission rate (< 30 days). Logistic regression was used to investigate the impact of several independent variables on complication and readmission rates.

RESULTS

Fifty-four patients were male and 267 female. The mean age was 44.2 years and mean BMI at the time of conversion was 37.9 kg/m². We converted 273 failed adjustable gastric bandings (85,0%) and 48 failed Mason gastroplasties (15.0%). The main reason for conversion was the recurrence of obesity. A mean LoS of 2.10 days was calculated. We had an overall in-hospital complication rate of 3.73% and the overall early readmission rate was 3.43%. The odds ratio for LoS on early readmission is 1.52 (p=0.0079; CI 95% [1.12-2.07]).

CONCLUSION

The above data imply that the implementation of advanced ERAS principles for revisional surgery in our center is safe and does not lead to a higher risk of early readmission.

Revision of Mason's procedure (vertical banded gastroplasty) to Roux-en-Y gastric bypass: role of an associated fundectomy in weight loss outcomes

BACKGROUND

Vertical banded gastroplasty (VBG) presents a significant rate of long-term complications, and revisions are often necessary. Conversion to Roux-en-Y gastric bypass (RYGB) seems to be preferred, but literature data remain limited.

OBJECTIVES

To analyze the indications, safety, results of conversions from VBG to RYGB, and to identify predictive factors of success or failure.

SETTING

Two specialized centers of bariatric surgery.

METHODS

This bicentric retrospective study included all the patients who benefited from a conversion from VBG to RYGB between 2008 and January 2020. Demographic characteristics, indications, preoperative workups, intraoperative data, complications, and weight loss results were analyzed.

RESULTS

During the study period, 85 patients underwent a conversion to RYGB. The mean body mass index (BMI_ before conversion was 40.6 kg/m². 82.3% of the patients were converted because of weight loss failure and 17.6% because of a complication of their VBG. The global rate of complications was 25%. After an average follow-up of 35 months and a rate of loss to follow-up of 33%, the mean BMI was 33.5 kg/m. The weight loss success rate according to Reinhold's criteria was 64.7%, and resolution of complications was obtained in 89.1%. The association of a fundectomy was a predictive factor of weight loss (odds ratio, .27; P = .04), whereas primary failure of the VBG was a predictive factor of failure.

CONCLUSION

Conversion from VBG to RYGB remains the procedure of choice to achieve satisfying weight loss and resolution of functional complications. The addition of a fundectomy appeared to have a significant positive impact on weight loss outcomes.

Roux-en-Y Gastric Bypass Versus One Anastomosis Gastric Bypass as a Preferred Revisional Bariatric Surgery After a Failed Silastic Ring Vertical Gastroplasty

BACKGROUND

Over the years, the silastic ring vertical gastroplasty (SRVG) has shown poor long-term outcomes with both weight regain and complications. Therefore, most bariatric surgeons have been presented with the need to perform a successful and safe conversion procedure. Yet the preferred and recommended conversion surgery regarding weight loss, comorbidity improvement, and postoperative complications remains under debate.

OBJECTIVE

The aim of this study is to compare the outcomes of conversion from SRVG with either Roux-en-Y gastric bypass (RYGBP) or one anastomosis gastric bypass (OAGB).

MATERIALS AND METHODS

A retrospective study was conducted from our bariatric surgery units' database. We reviewed the files of patients who underwent either a RYGBP or OAGB after a previous SRVG. Demographics, obesity-related comorbidities, BMI before and after the procedure, postoperative complications, and length of hospital stay were analyzed.

RESULTS

Between May 2008 and August 2018, fifty-four patients underwent conversion from a failed SRVG. Twenty-one patients underwent conversion to OAGB (39%), and thirty-three patients underwent conversion to RYGBP (61%). Major complications were reported in 9.5% of the OAGB group and 15.1% of the RYGBP group. At a mean follow-up of 28 months, the OAGB group achieved a 78.5% excess BMI loss compared with 57.6% in the RYGBP group (p = 0.137). One patient (4.7%) of the OGBP group and 5 (15.1%) of the RYGBP group needed reoperations due to complications (p = 0.224).

CONCLUSION

The OGBP is gaining popularity and evidence as an effective and safe procedure. Here we show the successful utilization of the OGBP, when compared with RYGBP, as a revisional procedure after SRVG.

Bariatric revisional surgery: What are the challenges for the patient and the practitioner?

Bariatric revisional surgery represents an important new issue for obese patients because of the considerable rate of failure and complications following bariatric surgery. As the frequency of bariatric procedures increases, so too does the incidence of revisional surgery, which has become becoming increasingly important. The surgeon must know the indications and the results of the various revisional procedures in order to best guide the therapeutic decision. The current challenge is to correctly select the patients for revisional surgery and to choose the appropriate procedure in each case. Multidisciplinary management is essential to patient re-assessment and to prepare the patient for a re- intervention. The objective of this update, based on data from all the most recent studies concerning revisional surgery, is to guide the surgeon in the choice of the revisional procedure, depending on patient characteristics, co-morbidities, the previously performed procedure, the type of failure or complication observed, but also on the surgeon's own habits and the center's expertise. The collected results show that revisional surgery is difficult, with higher complication rates and weight-loss results that are often lower than those of first-intent surgery. For these reasons, patient selection must be rigorous and multidisciplinary and the management in expert centers of these difficult situations must be encouraged.

Laparoscopic Roux-en-Y Gastric Bypass for Failed Vertical Banded Gastroplasty

BACKGROUND

Although the vertical banded gastroplasty (VBG) is effective in achieving weight loss without metabolic side effects during the first few years, late failures cause weight regain in about 20% of the patients. The laparoscopic Roux-en-Y gastric bypass (LRYGB) is the procedure of choice to convert a failed VBG.

MATERIALS AND METHODS

Between August 2014 and June 2016, 37 patients (23 females and 14 males) underwent revisional LRYGBs after failed VBGs. Thirty-four patients had open VBGs and two patients had laparoscopic butterfly gastroplasties. These patients completed follow-ups of at least 1 year.

RESULTS

The median operating time was 164 min (range 132-246), and the mean length of the hospital stay was 2.4 days (range 2-7). The mean body mass index (BMI) of the study group was 42.5 kg/m², while the mean BMI and the percentage of excess body weight loss (%EBWL) for the patients 6 months after the operation were 31.7 kg/m² and 52.1%, respectively. The mean BMI and %EBWL for the patients 1 year after the operation were 29.5 kg/m² and 67.7%, respectively. There were neither intraoperative complications nor postoperative mortalities, but the overall complication rate was 22% (eight patients).

CONCLUSION

An LRYGB following a VBG is technically challenging, but safe, with low morbidity and mortality rates. Moreover, a revisional LRYGB provides excellent weight loss results.

Laparoscopic Revision of Failed Bariatric Procedures

Background:

The main indications for revision of bariatric surgery are inadequate weight loss, weight regain, or complications. The objective of revision is to restore the restrictive component and/or add a malabsorptive component.

Objectives:

To evaluate the effectiveness of revisional laparoscopic bariatric surgery for loss of weight and assess the risks and benefits associated with these technically demanding procedures.

Methods:

Revision cases performed between 2001 and 2013 were identified and grouped according to the primary procedure and type of revision. A retrospective analysis was carried out for weight loss as well as perioperative morbidity and mortality.

Results:

The total of 271 patients underwent revisional laparoscopic surgery during the study period and were categorized into four groups. Group 1 (n = 67) had an adjustable gastric band converted to gastric bypass (GBP). Group 2 (n = 128) had a dilated gastric pouch after GBP and underwent pouch reduction. Group 3 (n = 57) had a GBP and underwent pouch reduction and elongation of the biliopancreatic limb. Group 4 (n = 19) had a vertical banded gastroplasty converted to a GBP. The mean total body weight loss for Groups 1 to 4 was 35.3%, 22.9%, 39.4%, and 33.2%, respectively. The average operative times were 185, 75, 142, and 205 minutes; and the average hospitalization was 1.5, 1.0, 2.0, and 2.5 days, respectively. All cases were completed laparoscopically. Concomitant procedures were liver biopsy, cholecystectomy, partial gastrectomy, hiatal, ventral, and internal hernia repairs. Complication rates were 2.9%, 0%, 3.5%, and 5.2% for each of the groups and there were no mortalities.

Conclusion:

Results of revisional bariatric surgery vary depending on the original procedure and the reasons for revision. In particular, if the main reason for reoperation is inadequate weight loss, then the burden is to demonstrate a surgically correctable deficiency. Revisional procedures incorporating malabsorption result in greater weight loss than gastric restriction alone.

The history of metabolic and bariatric surgery: Development of standards for patient safety and efficacy

Weight loss surgery, also referred to as bariatric surgery, has been in existence since the 1950's. Over the decades, it has been demonstrated to successfully achieve meaningful and sustainable weight loss in a large number of patients who undergo these procedures. Additionally, the benefits observed across a number of metabolic disorders such as type 2 diabetes mellitus and hyperlipidemia, are often to a degree, independent of the weight loss, thus the term "metabolic bariatric surgery (MBS)" has become a better descriptor. Throughout its long history, MBS has evolved from an era of high morbidity and mortality to one of laudable safety despite the high-risk nature of the patients undergoing these major gastrointestinal procedures. This article will describe the historic evolution of MBS and concentrate on those events that were instrumental in reducing the morbidity of these operations.

Revisional Bariatric Surgery

Revisional bariatric procedures are increasingly common. With more primary procedures being performed to manage severe obesity and its complications, 5% to 8% of these procedures will fail, requiring revisional operation. Reasons for revisional bariatric surgery are either primary inadequate weight loss, defined as less than 25% excess body weight loss, or weight recidivism, defined as a gain of more than 10 kg based on the nadir weight; however, each procedure also has inherit specific complications that can also be indications for revision. This article reviews the history of each primary bariatric procedure, indications for revision, surgical options, and subsequent outcomes.

Long-term results after revisions of failed primary vertical banded gastroplasty

AIM: To compare the results after revision of primary vertical banded gastroplasty (Re-VBG) and conversion to sleeve gastrectomy (cSG) or gastric bypass (cRYGB).

METHODS: In this retrospective single-center study, all patients with a failed VBG who underwent revisional surgery were included. Medical charts were reviewed and additional postal questionnaires were sent to update follow-up. Weight loss, postoperative complications and long-term outcome were assessed.

RESULTS: A total 152 patients were included in this study, of which 21 underwent Re-VBG, 16 underwent cSG and 115 patients underwent cRYGB. Sixteen patients necessitated a second revisional procedure. No patients were lost-to-follow-up. Two patients deceased during the follow-up period, 23 patients did not return the questionnaire. Main reasons for revision were dysphagia/vomiting, weight regain and insufficient weight loss. Excess weight loss (%EWL) after Re-VBG, cSG and cRYGB was, respectively, 45%, 57% and 72%. Eighteen patients (11.8%) reported postoperative complications and 27% reported long-term complaints.

CONCLUSION: In terms of additional weight loss, postoperative complaints and reintervention rate, Roux-en-Y gastric bypass seems feasible as a revision for a failed VBG.

Treatment of weight regain following roux-en-Y gastric bypass: revision of pouch, creation of new gastrojejunostomy and placement of proximal pericardial patch ring

In the literature, weight regain or failure of weight loss has been reported in up to 35% of patients after Roux-en-Y gastric bypass (RYGB). Several revisional procedures have been suggested to reinitiate further weight loss in this group of patients, and placing a silastic ring around the pouch proximal to the gastrojejunostomy is one among those procedures. The aim of our study is to evaluate and compare the safety and efficacy of salvage banding using a pericardial patch after RYGB for further weight loss. Between December 2009 and April 2013, a total of 46 patients underwent revision with pericardial patch ring after RYGB for weight regain/failure of weight loss. A retrospective review of a prospectively collected database was performed, noting the outcomes and complications of the procedure. The mean body mass index at the time of revision was 40.1 ± 6.8 kg/m2. Mean percentage of excess weight loss was 23.4 ± 15.7%, 39.0 ± 27.4%, and 18.9 ± 20.5% at 6, 12 and 24 months after revision, respectively. Eight (17.4%) patients required a total of 11 readmissions due to nausea, vomiting, dysphagia and abdominal pain. Six (13.0%) patients underwent a total of six reoperations, including four patients with laparoscopic removal of the pericardial patch and another revision of RYGB, and two patients with repair of perforated ulcers. Revision with pericardial patch ring after gastric bypass for weight regain or failure of weight loss may not be feasible, safe and effective.

Worthy or not? Six-year experience of revisional bariatric surgery from an Asian center of excellence

BACKGROUND

Revisional bariatric surgery (RBS) is increasing. The various primary operations with their distinctive complications make this group of patients quite heterogeneous, and treatment has to be individualized. There are concerns regarding the safety profile and efficacy of these procedures. The objective of the present study was to analyze the indications, safety, and efficacy of RBS at a high-volume Asian center and provide insight into the different treatment options.

METHODS

Of a total of 1578 bariatric surgeries from July 2006 to June 2012, 52 patients underwent revisional bariatric procedures. The primary operations included 6 different procedures. The indications for surgery were grouped into weight loss failure (n = 21) or complications related to the primary operation (n = 31). The revisional operations performed were conversion to another procedure (n = 22), revision of existing anatomy (n = 29), or reversal to normal anatomy (n = 1).

RESULTS

96% of revisional surgeries were performed laparoscopically. The median operating time was 72 minutes (25-240 min), and the median duration of hospital stay was 4 days (3-25 d). The mean body mass index for weight loss failure decreased significantly from 36.3 to 29.6 kg/m(2) after 1 year of revisional surgery (P<.01). However, revision of RYGB was only associated with a body mass index loss of 3.2 kg/m(2) and percentage of excess weight loss of 31.8%. More than 90% of the patients with complications had complete resolution of their preoperative symptoms. There were 3 major complications with an overall morbidity rate of 5.8%. There was no mortality.

CONCLUSIONS

RBS is well-tolerated, with satisfactory early outcomes, in high-volume centers. However, larger studies with longer follow-up periods are needed to determine the long-term efficacy of these procedures.

Robotically assisted revision of bariatric surgeries is safe and effective to achieve further weight loss

BACKGROUND

As more bariatric operations are being performed in the USA every year, the number of revisions has increased. These operations are challenging and have a higher morbidity than the initial operation. We have reviewed our series of robotically assisted revisions.

METHODS

At the University of Texas Medical School at Houston, we reviewed robotic revision cases from 2004 through 2011 and found 99 bariatric revisions using robotic assistance. Selected endpoints included body mass index (BMI) at follow-up, percent excess weight loss (%EWL), complications, intubation time, operative time, and length of hospital stay.

RESULTS

The average BMI at the time of revision was 44.8 kg/m(2) and fell to 29 kg/m(2) after 3 years. BMI was significantly lower at all time intervals (3, 12, 24, and 36 months) compared to initial BMI (p < 0.001). The %EWL was also significant at 1, 3, 12, 24, and 36 months post-revision (p < 0.001). There was a 24 % (13/55) 90-day readmission rate. The overall complication rate was 17 %, with each individual complication rate between 2 and 4 %. There were no deaths. The average operative time was 204 min, and the average length of hospital stay was 2.3 days.

CONCLUSIONS

Revising previous bariatric operations to gastric bypass is difficult and time consuming. Although robotically assisted revision can be done safely and can result in effective further weight loss, the high postoperative complication rate is an issue that warrants further attention.

Revisional versus primary Roux-en-Y gastric bypass: a case-matched analysis

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) has been a widely performed bariatric procedure. Unfortunately, revisional surgery is required in 20-30% of cases. Data comparing revisional and primary gastric bypass procedures are scarce. This study compared revisional malabsorptive laparoscopic very very long limb (VVLL) Roux-en-Y gastric bypass (RYGB) with primary VVLL RYGB and tested the hypothesis that one-stage revisional laparoscopic VVLL RYGB is an effective procedure after failed LAGB.

METHODS

In this study, 48 revisional VVLL RYGBs were matched one-to-one with 48 primary VVLL RYGBs. The outcome measures were operating time, conversion to open surgery, excess weight loss (EWL), and early and late morbidity.

RESULTS

Surgical and medical morbidities did not differ significantly. No conversions occurred. The revisional group showed an EWL of 41.8% after 12 months of follow-up evaluation and 45.1% after 24 months based on the pre-revisional weight. The total EWL based on the weight before the LAGB was calculated to be 54.3% after 12 months and 57.2% after 24 months. The EWL in the primary RYGB group was significantly higher for both types of calculation: 41.8%/54.3% versus 64.1 % (p < 0.001 and <0.01) after 12 months and 45.1%/57.2% versus 70.4% (p < 0.001 and <0.002) after 24 months.

CONCLUSIONS

Revisional laproscopic VVLL RYGB can be performed as a one-stage procedure by experienced bariatric surgeons but shows less effective EWL than primary RYGB procedures.

Short- and long-term outcomes of vertical banded gastroplasty converted to Roux-en-Y gastric bypass

BACKGROUND

Vertical banded gastroplasty (VBG) often necessitates revisional surgery for weight regain or symptoms related to gastric outlet obstruction. Roux-en-Y gastric bypass (RYGB) is considered as the revisional procedure of choice. However, revisional bariatric surgery is associated with relatively higher rates of complications. The aim of the current study is to analyse our single-centre experience with patients requiring revisional RYGB following primary VBG.

METHODS

Retrospective review of the prospectively collected database identified 153 patients who underwent RYGB as a revisional procedure after VBG from Feb 2004-Feb 2011. Early and late complications, weight data and resolution of symptoms related to gastric outlet obstruction were analysed.

RESULTS

One hundred twenty-three females and 30 males underwent revisional RYGB post VBG. Mean age was 44.4 (15-74) years with a mean pre-operative body mass index (BMI) of 34.2 (23.5-65.5) kg/m(2). Mean hospital stay was 4.3 days. Early complication rate was 3.9 % with a 30-day re-operation rate of 1.3 %. Mortality and leak rate were zero. After a mean follow-up of 48 months, the mean BMI decreased significantly to 28.8 kg/m(2) and a complete resolution of the obstructive symptoms was achieved in nearly all patients. Late complications developed in 11 (7.7 %) of the patients of which seven (4.9 %) required surgery.

CONCLUSIONS

Revisional RYGB following VBG is technically challenging but safe with low rates of morbidity and mortality, comparable to primary RYGB. It produces a significant reduction in body weight and in symptoms resolution. We recommend RYGB as the procedure of choice in patients requiring revisional surgery following VBG.

Laparoscopic Roux-en-Y Gastric bypass after failed vertical banded gastroplasty: a multicenter experience with 203 patients

BACKGROUND

Vertical banded gastroplasty (VBG) has long been the main restrictive procedure for morbid obesity but has many long-term complications for which conversion to Roux-en-Y gastric bypass (RYGBP) is often considered the best option.

METHODS

This series regroups patients operated on by three different surgeons in four different centers. All data were collected prospectively, then pooled and analyzed retrospectively.

RESULTS

Out of 2,522 RYGBP performed between 1998 and 2010, 538 were reoperations, including 203 laparoscopic RYGBP after VBG. There were 175 women and 28 men. The mean BMI before VBG was 43.2 ± 6.3, and the mean BMI before reoperation was 37.4 ± 8.3. Most patients had more than one indication for reoperation and/or had regained significant weight. There was no conversion to open surgery. A total of 24 patients (11.8 %) developed complications, including nine (4.5 %) who required reoperation and one death. With a follow-up of 88.9 % after 8 years, the mean BMI after 1, 3, 5, 7, and 9 years was 29.1, 28.8, 28.7, 29.9, and 28.8, respectively.

CONCLUSIONS

On the basis of this experience, the largest with laparoscopic reoperative RYGBP after failed VBG, we conclude that this procedure can safely be performed in experienced hands, with weight loss results similar to those observed after primary RYGBP. In patients with too difficult an anatomy below the cardia, dividing the esophagus just above the esophago-gastric junction and performing an esophagojejunostomy may be a safe alternative to converting to a Scopinaro-type BPD, obviating the additional long-term risks associated with malabsorption.

Case-matched analysis comparing outcomes of revisional versus primary laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common approaches used to revise post-bariatric patients with inadequate weight loss or significant weight regain. Previous studies have analyzed the outcomes of open revisional RYGB versus primary RYGB, but no case-control matched analysis comparing revisional LRYGB versus primary LRYGB has been performed.

METHODS

Our cohort includes 37 consecutive patients who underwent revisional LRYGB because of unsatisfactory weight loss or weight regain matched in a 1:2 ratio with 74 control patients who underwent primary LRYGB. Matching included the following parameters: age, gender, preoperative body mass index and comorbidities (diabetes, obstructive sleep apnea, and hypertension).

RESULTS

The revisional group had longer length of stay compared with the primary group (3.8 vs. 2.4 days, P = 0.02) and a higher conversion to laparotomy rate (10.8 vs. 0 %, P = 0.01). The revisional group had a higher 30-day morbidity compared with the primary group (27 vs. 8.1 %, P = 0.02). There were no deaths in both groups. The two groups had similar 30-day readmission and 30 day reoperation rates. At 3, 6, and 12 months of follow-up, the revisional LRYGB group had significantly lower percent of excess weight loss (EWL) than the primary LRYGB group (3 months, 30 vs. 38.4, P = 0.001; 6 months, 36.3 vs. 52.9, P = 0.001; 12 months, 46.5 vs. 68.2, P = 0.001).

CONCLUSIONS

Revisional LRYGB is characterized by lower EWL and higher morbidity than primary LRYGB. However, our data suggest that revisional LRYGB is still capable of providing significant weight loss in these high-risk patients.

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.

Revisional surgery for failed vertical-banded gastroplasty

Vertical-banded gastroplasty (VBG) was once a common bariatric procedure. It has fallen out of favor due to the emergence of the adjustable gastric band and late complications including band erosion and stenosis. Options for revision include conversion to a Roux-en-Y gastric bypass (RYGB) or VBG reversal via gastrogastrostomy. Patients undergoing revision of a previous VBG were identified. VBG reversal was performed laparoscopically. Conversion to RYGB was performed by both laparotomy and laparoscopy. Perioperative outcomes and long-term weight loss were evaluated. A total of 34 patients with a previous open VBG underwent revision over a nearly 8-year period (January 2003 to September 2010). Conversion to RYGB was performed in 25 (four laparoscopically) and VBG reversal in nine patients. Mean age for all patients was 56.3 years (range 36-70), and VBG had been performed 23 years previously (range 16-30). Patients to undergo VBG reversal were more likely to be male and less likely to be morbidly obese at the time of revision. Operative time and length of stay were shorter for laparoscopic procedures. Complication rates did not differ based on technique or procedure. Patients with a previous VBG may present with complications and obesity decades after the primary procedure. Revisional surgery can be accomplished laparoscopically. Following VBG reversal, most patients gain weight and many become morbidly obese again. Conversion to RYGB is associated with weight loss and resolution of morbid obesity in most patients. When feasible, laparoscopic conversion to RYGB may offer the best outcomes.

The history and evolution of bariatric surgical procedures

The search for the ideal weight loss operation began more than 50 years ago. Surgical pioneers developed innovative procedures that initially created malabsorption, then restricted volume intake, and eventually combined both techniques. Variations, alterations, and modifications of these original procedures, combined with intense efforts to follow and document outcomes, have led to the evolution of modern bariatric surgery. More recent research has focused on the hormonal and metabolic effects of these procedures. These discoveries at the cellular level will help develop possible mechanisms of weight loss and comorbidity reduction beyond the traditional explanation of reduced food consumption and malabsorption.

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

With the increase in bariatric procedures performed, revisional surgery is now required more frequently. Roux-en-Y gastric bypass (RYGB) is considered to be the gold standard revision procedure. However, data comparing revisional vs. primary RYGB is scarce, and no study has compared non-resectional primary and revisional RYGB in a matched control setting. Analysis of 61 revisional RYGB that were matched one to one with 61 primary RYGB was done. Matching criteria were preoperative body mass index, age, gender, comorbidities and choice of technique (laparoscopic vs. open). After matching, the groups did not differ significantly. Previous bariatric procedures were 13 gastric bands, 36 vertical banded gastroplasties, 10 RYGB and two sleeve gastrectomies. The indication for revisional surgery was insufficient weight loss in 55 and reflux in 6. Intraoperative and surgical morbidity was not different, but medical morbidity was significantly higher in revisional procedures (9.8% vs. 0%, p = 0.031). Patients undergoing revisional RYGB lost less weight in the first two postoperative years compared with patients with primary RYGB (1 month, 14.9% vs. 29.7%, p = 0.004; 3 months, 27.4% vs. 51.9%, p = 0.002; 6 months, 39.4 vs. 70.4%, p < 0.001; 12 months, 58.5% vs. 85.9%, p < 0.001; 24 months, 60.7% vs. 90.0%, p = 0.003). Although revisional RYGB is safe and effective, excess weight loss after revisional RYGB is significantly less than following primary RYGB surgery. Weight loss plateaus after 12 months follow-up.

Revisional surgery after restrictive procedures for morbid obesity

Bariatric surgery has become more common due to the worldwide obesity epidemic. A shift from open to laparoscopic surgery has occurred in the last 2 decades, because of its advantages. Revisional surgery after bariatric procedures is becoming an important issue, and restrictive procedures account for a large proportion of these interventions. Three restrictive procedures are currently in use: laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy and vertical banded gastroplasty. The first two procedures are more commonly used, and the third is losing favor with surgeons. All three have proven effective, but less than malabsortive or combined procedures. The reasons to reoperate upon a patient and convert a previous bariatric procedure to a different one are failure of the operation, due to insufficient weight loss, or weight regain (secondary obesity); or complications like penetration, infection, bleeding, obstruction, dysphagia, and gastroesophageal reflux, among others. This review will describe the complications or failures leading to the a second operation; the conditions present after the first procedure and the presence of failure or complications; the technical steps required to be taken; and the outcomes and what can be expected afterwards.

Revision laparoscopic gastric bypass: an effective approach following failure of primary bariatric procedures

BACKGROUND

The laparoscopic approach plays an important role in the primary surgical management of morbid obesity. This study evaluated the potential role of the laparoscopic approach to revision Roux-en-Y gastric bypass (LRYGB) in the management of selected patients who fail to lose adequate weight or regain weight after primary bariatric surgery.

METHODS

Revision LRYGB was carried out to remedy early or delayed failure of primary bariatric procedures. Patients who underwent laparoscopic revision surgery to re-establish a functioning gastric band were not included in this report. The results are presented as mean (SD).

RESULTS

Between April 2002 and March 2009, 21 patients underwent 21 laparoscopic revision procedures. The initial bariatric operations were laparoscopic gastric band (n = 10), open vertical banded gastroplasty (n = 6), open Magenstrasse and Mill (n = 2), open gastric bypass with pouch dilatation (n = 2), and open gastric band (n = 1). All revision procedures were completed laparoscopically and included conversion to LRYGB (n = 19), and others (n = 2). The postoperative hospital stay was 2.0 (1.3) days. The anastomotic leak, morbidity, and mortality rates were 0%, 4.8%, and 0% respectively. At a follow-up of 12.9 (7.9) months, the prerevision body mass index has decreased significantly from 43.9 (7.4) to 32.7 (6.6) kg/m(2) (p < 0.001) with a percentage excess weight loss of 61.1 (21.2).

CONCLUSIONS

The laparoscopic approach to revision Roux-en-Y gastric bypass is safe and effective even in patients with previous open bariatric surgery and is associated with rapid recovery and short hospital stay.

Endocrine and nutritional management of the post-bariatric surgery patient: an Endocrine Society Clinical Practice Guideline

OBJECTIVE

We sought to provide guidelines for the nutritional and endocrine management of adults after bariatric surgery, including those with diabetes mellitus. The focus is on the immediate postoperative period and long-term management to prevent complications, weight regain, and progression of obesity-associated comorbidities. The treatment of specific disorders is only summarized.

PARTICIPANTS

The Task Force was composed of a chair, five additional experts, a methodologist, and a medical writer. It received no corporate funding or remuneration.

CONCLUSIONS

Bariatric surgery is not a guarantee of successful weight loss and maintenance. Increasingly, patients regain weight, especially those undergoing restrictive surgeries such as laparoscopic banding rather than malabsorptive surgeries such as Roux-en-Y bypass. Active nutritional patient education and clinical management to prevent and detect nutritional deficiencies are recommended for all patients undergoing bariatric surgery. Management of potential nutritional deficiencies is particularly important for patients undergoing malabsorptive procedures, and strategies should be employed to compensate for food intolerance in patients who have had a malabsorptive procedure to reduce the risk for clinically important nutritional deficiencies. To enhance the transition to life after bariatric surgery and to prevent weight regain and nutritional complications, all patients should receive care from a multidisciplinary team including an experienced primary care physician, endocrinologist, or gastroenterologist and consider enrolling postoperatively in a comprehensive program for nutrition and lifestyle management. Future research should address the effectiveness of intensive postoperative nutritional and endocrine care in reducing morbidity and mortality from obesity-associated chronic diseases.

Sleeve gastrectomy as revisional procedure for failed gastric banding or gastroplasty

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is considered an effective multipurpose operation for morbid obesity, although long-term results are still lacking. Also, the best procedure to be offered in the case of failed restrictive procedures is still debated. We here reported our results of LSG as a revisional procedure for inadequate weight loss and/or complications after adjustable gastric banding or gastroplasty.

METHODS

Since April 2005, 57 patients (20 men and 37 women), with a mean age of 49.9 +/- 11.9 years, underwent revisional LSG, 52 after laparoscopic adjustable gastric banding/adjustable gastric banding and 5 after vertical banded gastroplasty at our institution. The mean interval from the primary procedure to LSG was 7.54 +/- 4.8 years. The LSG was created using a 34F bougie with an endostapler, after removing the laparoscopic adjustable gastric band or the anterior portion of the band in those who had undergone vertical banded gastroplasty. An upper gastrointestinal contrast study was performed within 3 days after surgery and, if the findings were negative, a soft diet was promptly started.

RESULTS

A total of 41 patients had undergone concurrent band removal and LSG and 16 had undergone band removal followed by an interval LSG. Three cases required conversion to open surgery because of a large incisional hernia. The mean operative time was 120 minutes (range 90-180). One patient died of multiple organ failure from septic shock. Three patients (5.7%) developed a perigastric hematoma, 3 (5.7%) had leaks, and 1 had mid-gastric short stenosis. The median hospital stay was 5 days. The mean body mass index at revisional LSG was 45.7 +/- 10.8 kg/m(2) and had decreased to 39 +/- 8.5 kg/m(2) after 2 years, with a mean percentage of the estimated excess body mass index lost of 41.6% +/- 24.4%. Two patients required a duodenal switch for insufficient weight loss.

CONCLUSION

LSG seems to be effective as revisional procedure for failed LAGB/vertical banded gastroplasty, although with greater complication rates than the primary procedures. Larger series and longer follow-up are needed to confirm these promising results.

Bariatric Revisionary Surgery for Failed or Complicated Vertical Banded Gastroplasty (VBG): Comparison of VBG Reoperation (re-VBG) versus Roux-en-Y Gastric Bypass-on-VBG (RYGB-on-VBG)

Background. Revision of failed bariatric procedures is a significant challenge for bariatric surgeons, because of the increasing number of recurring morbid obesity or complications, especially in patients with a previous Vertical Banded Gastroplasty (VBG). Methods. Since November 1998, 109 patients with failed or complicated VBG were followed in a retrospective study. 49 patients underwent re-VBG and, since 2004, 60 underwent Roux-en-Y Gastric Bypass-on-Vertical Banded Gastroplasty (RYGB-on-VBG). Results. At 3 years follow-up, mean BMI decreased from 37.4 to 31.2 Kg/m(2) in the first group, and from 35.0 to 28.4 Kg/m(2) in the second. Early complications were 7 (14.3%) in the first group and 4 (6.5%) in the second; late complications were 33 (59.1%) and 11 (18.3%), respectively. Conclusion. Although both operations seem to be effective as bariatric revision procedures in terms of BMI, the mid-term outcomes of RYGB-on-VBG demonstrate the lowest rate of complications and better quality of life.

Laparoscopic gastric banding as revisional procedure to failed vertical gastroplasty

BACKGROUND

Vertical gastroplasty (VG) was worldwide and until recently a very popular restrictive bariatric procedure. Unfortunately, many patients required revisional surgery for failure of this technique. The present study aimed to evaluate retrospectively the feasibility, safety, and efficiency of conversion of failed VGs to laparoscopic adjustable gastric banding (LAGB).

METHODS

Forty patients underwent LAGB as revisional surgery between August 2001 and June 2008. Preceding VGs were performed either by open procedure {silastic ring vertical gastroplasty (SRVG, n = 21) and vertical-banded gastroplasty (VBG, n = 10)} or by laparoscopy {laparoscopic silastic ring vertical gastroplasty (L-SRVG, n = 9)}. The delay between initial and revisional surgery was significantly shorter for SRVG (5.5 +/- 1.7 years; p < 0.001) as compared to VBG and L-SRVG (9.2 +/- 2.3 and 9.4 +/- 1.8 years, respectively). The reasons for failure of the VG were: disruption of the staple line (n = 23), excessive enlargement of the gastric pouch (n = 15) and inefficient stoma (n = 2). Patients were qualified for revisional surgery in case of uncontrolled weight regain with or without frequent vomiting.

RESULTS

There were three conversions from laparoscopy to laparotomy (7.5%). There was no mortality. Minor morbidity was 12.5%. There were two major complications (5%); one incarcerated port-site hernia requiring small bowel resection, and one band erosion necessitating band removal. The mean BMI dropped from 38.9 kg/m(2) before revision to 30.7 kg/m(2) after conversion to LAGB (follow-up 6-88 months).

CONCLUSIONS

Conversion of failed VGs to gastric banding is safe and efficient. The morbidity rate is acceptable. Gastric banding to correct failing VG is a reasonable option when performed in selected patients.

Laparoscopic sleeve gastrectomy as revisional procedure for failed gastric banding and vertical banded gastroplasty

BACKGROUND

The problem of revision of failed gastric banding (GB) and vertical banded gastroplasty (VBG) procedures has become a common situation in bariatric surgery. Laparoscopic sleeve gastrectomy (LSG) has been recently used to revise failed restrictive procedures. The objective of this study is to evaluate the results of LSG as revisional procedure for failed GB and VBG.

METHODS

A prospective held database was questioned regarding patients' demographic, indication for revision, conversion to open surgery, morbidity, percentage of excess weight loss (%EWL), evolution of comorbidities, and need for a second procedure after LSG.

RESULTS

Forty-one patients, 34 women and seven men with a mean age of 42 years (range 19 to 63 years) and a mean body mass index at 49.9 kg/m(2) (range 35.9-63 kg/m(2)), underwent laparoscopic conversion of GB (36 patients) and VBG (five patients) into LSG. Indication for revisional surgery was insufficient weight loss in all the cases. All procedures were completed laparoscopically. There was no mortality and five patients (12.2%) developed complications (high leak, one patient; intra-abdominal abscess, three patients; and complicated incisional hernia, one patient). At a mean follow-up of 13.4 months, %EWL is on average 42.7% (range 4-76.1%). Six patients had a second procedure (four had laparoscopic duodenal switch, one had laparoscopic Roux-en-Y gastric bypass, and one had laparoscopic biliopancreatic diversion).

CONCLUSION

Conversion of GB and VBG into LSG is feasible and safe. LSG is effective in the short term with a mean %EWL of 42.7% at 13.4 months. Long-term results of LSG as revisional procedure are awaited to establish its efficacy in the long term.

Lap banding as a redo surgery: "restriction over restriction" may be a relevant bariatric strategy

BACKGROUND

The redo issue is a growing and debated issue in bariatric surgery. From the experience of failed vertical banded gastroplasty (VBG), we suggest that adjustable gastric band is a relevant method in many cases.

METHODS

Ninety-eight patients have been operated on in a 13-year period (07/1995-07/2008). The cause of VBG failure has been staple disruption in 58% of cases and an outlet enlargement in 37% of cases. In the meantime, two gastric bypasses have been performed. Mean body mass index has been 38 (28-48) and was less than 35 in 37% of the cases.

RESULTS

Postoperative complications occurred in seven cases, and the band had to be removed in five cases. Mean excess weight loss has been 52% at 8 years, yet 22% of the patients have been lost for follow-up. Slippage occurred in two patients and erosion in one. A final removal of the band has been necessary in two patients.

CONCLUSIONS

VBG failures are highly common in the long run. Lap banding represents an interesting option for redo in a majority of cases, providing good long-term results and demonstrating that "restriction over restriction" can be a relevant strategy. The initial response to VBG has been a key information: if it has been successful in terms of weight loss and food tolerance, then lap banding was a valuable option. VBG has represented an interesting model because it has historical value and could be a procedure for the future if performed through endoscopic channels.

[Reintervention for failed vertical banded gastroplasty: the adjustable lapband offers a useful technique to further restrict a restrictive procedure]

BACKGROUND

Reintervention for failed bariatric procedures is a subject of much debate. Our experience in remediating failed vertical banded gastroplasty (VBG) suggests that the placement of an adjustable lapband may be a useful technique.

PATIENTS AND METHODS

Over a 13-year period, 98 patients with failed VBG underwent remedial placement of an adjustable lapband. Unsatisfactory results of VBG were due to disruption of the staple line in 58% of cases and to outlet enlargement in 37% of patients. Mean BMI was 38 (range: 28-48); BMI was less than 35 in 37% of cases.

RESULTS

Seven postoperative complications (7%) were noted and required the removal of the lapband in five cases. The average loss of excess weight was 52% at 8 years. Twenty-two percent of patients were lost to follow-up.

CONCLUSION

Placement of an adjustable lapband has proved to be a useful remedial approach in the majority of cases and demonstrates that further restriction of a previous restrictive procedure is useful in patients who initially responded well to VBG.

Feasibility of sleeve gastrectomy as a revision operation for failed silastic ring vertical gastroplasty

BACKGROUND

Restrictive bariatric operations are efficient with low morbidity but entail high rate of failure on follow up of several years. We present our experience in laparoscopic revision of patients who previously underwent silastic ring vertical gastroplasty (SRVG) into laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (LRYGB).

METHODS

Data on 12 patients who underwent revisional operations after SRVG was prospectively collected. Six patients underwent LRYGB and six patients underwent LSG. The pathogeneses for failures of SRVG were disruption of staple line, enlargement of gastric pouch, and opening of the ring.

RESULTS

The average age and body mass index (BMI) were 39 and 43, respectively, in the LSG group versus average age and BMI of 39 and 45, respectively, in the LRYGP group (p = 0.45 and p = 0.35, respectively). The average operative time were 206 and 368 min in the LSG and LRYGB groups, respectively (p < 0.01). There were five postoperative complications among LSG group versus two complications in LRYGB group (p < 0.01). Patients who underwent LSG suffered from the following complications: staple line leak in two patients, intra-abdominal hematoma in one patient, intra-abdominal collection in one patient, and gastric outlet obstruction in one patient. Anastomotic leak and wound infection were the complications seen among patients underwent LRYGB. All complications were treated conservatively without necessitating immediate reoperations. Follow-up has shown adequate reduction of body weight and improved quality of life in both groups of patients.

CONCLUSIONS

Revisional bariatric operation is a challenging laparoscopic procedure with higher morbidity compared to primary bariatric operations. Morbidity of LSG compared to LRYGB as a revisional procedure for SRVG is significantly higher.