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

Prevalence, Indications, and Complications of Conversional Surgery After Vertical Banded Gastroplasty: A MBSAQIP Analysis

PURPOSE

Vertical banded gastroplasty (VBG) was once the most popular bariatric procedure in the 1980's, with many patients subsequently requiring conversional surgery. However, knowledge regarding the prevalence and outcomes of these procedures remains limited. This study aims to determine the prevalence, indications, rate of 30-day serious complications, and mortality of conversional surgery after VBG.

MATERIALS AND METHODS

A retrospective analysis of the MBSAQIP database from 2020 to 2022 was conducted. Individuals undergoing conversional or revisional surgery after VBG were included. The primary outcomes were 30-day serious complications and mortality.

RESULTS

Of 716 VBG conversions, the common procedures included 660 (92.1%) Roux-en-Y gastric bypass (RYGB) and 56 (7.9%) sleeve gastrectomy (SG). The main indication for conversion was weight gain for RYGB (31.0%) and for SG (41.0%). RYGB had longer operative times than SG (223.7 vs 130.5 min, p < 0.001). Although not statistically significant, serious complications were higher after RYGB (14.7% vs 8.9%, p = 0.2). Leak rates were higher after SG (5.4 vs 3.5%) but this was not statistically significant (p = 0.4). Mortality was similar between RYGB and SG (1.2 vs 1.8%, p = 0.7). Multivariable regression showed higher body mass index, longer operative time, previous cardiac surgery and black race were independently associated with serious complications. Conversion to RYGB was not predictive of serious complications compared to SG (OR 0.96, 95%CI 0.34-2.67, p = 0.9).

CONCLUSIONS

Conversional surgery after VBG is uncommon, and the rate of complications and mortality remains high. Patients should be thoroughly evaluated and informed about these risks before undergoing conversion from VBG.

Gastric mucocele after conversion of open butterfly gastroplasty to Roux-En-Y gastric bypass - A case report with a review of the literature

INTRODUCTION

There has been a significant increase in the prevalence of morbid obesity across the globe. Various non-surgical weight loss options have shown limited long-term efficacy, leading to the popularity of surgical treatment alternatives with long-term efficacy.

PRESENTATION OF CASE

This case report describes the development of a gastric mucocele in a 51-year-old female patient. The patient initially underwent open butterfly gastroplasty in August 2016. Seven years later, she presented with severe symptoms of gastroesophageal reflux disease (GERD). After further diagnostic evaluations, laparoscopic Roux-en-Y bypass surgery was performed. However, the patient experienced complications including fever, abdominal pain, and fluid collection around the stomach. Conservative management initially helped, but persistent symptoms led to laparoscopic exploration, which revealed a distended remnant stomach forming a gastric mucocele. Severe adhesions hindered attempts to remove the remnant stomach, resulting in the need for gastro-gastric anastomosis. Following the surgery, the patient had no symptoms, could eat solid food, and was discharged in good condition.

DISCUSSION

Although various non-surgical weight loss options such as diet modifications, lifestyle changes, and drug therapy have been used for weight loss, they have demonstrated limited long-term efficacy. Surgical treatment has demonstrated long-term efficacy in such patient groups. In recent years, there has been an increased popularity of Roux-en-Y gastric bypass (RYGBP) due to long-term weight loss. However, in some cases, complications have also been reported.

CONCLUSION

This case emphasizes the challenges in managing complications from open butterfly gastroplasty and Roux-en-Y gastric bypass. Surgeons should be aware of the possibility of gastric mucocele development and consider appropriate management strategies.

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.

Comparison of 5-Year Follow-up Outcomes Between Primary and Revision Roux-en-Y Gastric Bypasses After Open Vertical Banded Gastroplasty: an Inverse Propensity Score-Weighted Analysis

INTRODUCTION

Vertical banded gastroplasty (VBG) is associated with high weight regain; Roux-en-Y gastric bypass (RYGB) is used as a revision procedure in patients with VBG experiencing weight regain. This study compared the 5-year follow-up outcomes of primary (PRYGB) and revision RYGB after VBG (RRYGB).

METHODS

Patients who underwent PRYGB or RRYGB after VBG from 2008 to 2016 were enrolled. Data on weight regain, weight loss (WL), food tolerance (FT), early and late complications, and resolution or improvement in associated medical conditions were analyzed.

RESULTS

PRYGB and RRYGB groups had 558 and 156 patients, respectively, after exclusion of the lost to follow-up patients. PRYGB group showed significantly lower mean body mass index (over the entire follow-up period), early complications, reintervention rates for late complications, and overall reintervention rates than that of the RRYGB group. On the other hand, FT scores, odds of late complications, and improvements (in the fifth year) in associated medical conditions were comparable between the two groups.

CONCLUSION

RRYGB in patients with VBG who regained weight showed comparable safety and resolution of associated diseases to that of PRYGB over the 5-year follow-up period. The WL in the RRYGB group was acceptable despite being less than that of the PRYGB group. FT was better after RRYGB than that of PRYGB in the first year; however, both were comparable at the fifth year follow-up. Patients with VBG undergoing RYGB should receive attentive treatment and evaluation of associated factors.

Re-Do Surgery after Sleeve Gastrectomy: A Single Center Comparison between Roux-en-Y Gastric Bypass and One Anastomosis Gastric Bypass

Introduction: According to the high rate of patients requiring a Re-Do surgery after a primary Sleeve Gastrectomy, due to failure on weight loss, this study proposes a comparison between RYGB and OAGB as a secondary intervention for morbidly obese patients. Methods: A retrospective review of patients who underwent revisional surgery to convert SG to RYGB or OAGB at our institution from November 2011 to November 2019 was performed. Results: A subset of sixty-three patients with previous SG underwent revisional surgery due to failure of the primary intervention. The OAGB group (n = 17) had a mean BMI at the time of the sleeve of 62 kg/m2 and a mean BMI of 50.7 kg/m2, the length of the Omega was 139.35 cm. The RYGB (n = 46) group showed a mean BMI of 47 kg/m2 at the time of the sleeve and a BMI of 34.8 kg/m2 at the time of the revision. The RYGB was performed according to the 70/120 cm standard for all the patients. One patient also had a revision from secondary OAGB to RYGB due to persistent biliary reflux, in this case the biliary branch was settled at 150 cm and the alimentary at 50 cm. Conclusions: The outcomes in the OAGB group showed a 29%WL and a 47%EWL (out of a 17%WL and 28%EWL at the time of the sleeve), on the other side the RYGB group reached a 33%WL and 72%EWL (out of a 25%WL and a 54%EWL at the time of the sleeve). According to our data we assume that RYGB is more effective in terms of weight loss as a revisional surgery after sleeve

Endoscopic revision for weight regain after open vertical-banded gastroplasty

Video 1Technical feasibility, safety, and efficacy of a novel endoscopic approach to treating weight regain after open vertical-banded gastroplasty using an endoscopic suturing device.

One anastomosis gastric bypass vs. Roux-en-Y gastric bypass, remedy for insufficient weight loss and weight regain after failed restrictive bariatric surgery

Background

Failure occurs in up to 60% of the patients that were treated with primary restrictive bariatric operations such as Laparoscopic Adjustable Gastric Banding (LAGB), or restrictive/metabolic operations like Laparoscopic Sleeve Gastrectomy (LSG). Insufficient weight loss and weight regain are the most commonly reported reasons of failure. The aim of this retrospective multicenter study was to compare One Anastomosis Gastric Bypass (OAGB) to Roux-en-Y Gastric Bypass (RYGB) as a revisional procedure in terms of weight loss, procedure time, complication rate and morbidity.

Methods

491 patients operated on between 2012 and 2017 for failed restrictive surgery were included in this study (OAGB (n=185) or RYGB (n=306)). Failure was defined as total weight loss (TWL) less than 25%, excess weight loss (EWL) less than 50% and/or a remaining body mass index (BMI) larger than 40 kg/m2 at two years of follow up. Primary outcome measures were %TWL and % excess BMI loss (EBMIL) at 12, 24 and 36 months of follow-up. Secondary outcomes were procedure time, reduction of comorbidity, early and late complication rate, and mortality.

Results

%TWL was significantly larger in the OAGB group at 12 months (mean 24.1±9.8 vs. 21.9±9.7, p = 0.023) and 24 months (mean 23.9±11.7 vs. 20.5±11.2, p = 0.023) of follow-up. %EBMIL was significantly larger in the OAGB group at 12 months (mean 69.0±44.6 vs. 60.0±30.1, p = 0.014) and 24 months (mean 68.6±51.6 vs. 56.4±35.4, p = 0.025) of follow-up. Intra-abdominal complications (leakage, bleeding, intra-abdominal abscess and perforation) occurred less frequently after revisional OAGB (1.1% vs. 4.9%, p = 0.025). Surgical intervention for biliary reflux (5.4% vs. 0.3%, p < 0.001) was more prevalent in the OAGB group. Surgical intervention for internal herniation (0.0% vs. 4.9%, p = 0.002) was more prevalent in the RYGB group.

Conclusions

This study suggests that OAGB is superior to RYGB as a remedy for insufficient weight loss and weight regain after failed restrictive surgery with more weight loss and a lower early complication rate. To substantiate these findings, further research from prospective randomized controlled trials is needed.

Laparoscopic Roux-en-Y Gastric Bypass After Failed Vertical Banded Gastroplasty: 2-Year Follow-up of 102 Patients

BACKGROUND

Vertical banded gastroplasty (VBG) is now discarded from being a restrictive procedure for morbid obesity due to its many drawbacks, doubtful efficacy, and lots of post-operative complications. Roux-en-Y gastric bypass (RYGB) is the most commonly performed procedure for VBG revision. So we aimed at reporting our experience in conversional RYGB for a failed VBG.

MATERIAL AND METHODS

Analyzing follow-up records of 102 patients who underwent revisional RYGB after failed VBG in the period from April 2014 to January 2018.

RESULTS

A total of 102 laparoscopic revisions of failed VBGs to RYGB were performed. The mean operating time was 161.9 min ±29.2 and the mean length of the hospital stay was 1.5 days ±1.2. Fourteen patients (13%) developed early post-operative complications (gastrojejunostomy leak 5; bleeding 9). Four patients (4.7%) developed late complications (Port site hernia 2; internal hernia 1; Stomal ulcer 1). The mean BMI pre-RYGB was 46.6 ± 5.9 kg/m², and the mean %EBWL (percent excess body weight lost) of the patients at 12 and 24 months post-revision were 56.2% and 64.3%, respectively. Our patients had immediate post-revision resolution of VBG-related complications like dysphagia and vomiting. We also report improvement in all obesity-related health problems with (75.7%) complete remission rate and (24.3%) partial remission or improvement rate of diabetes mellitus.

CONCLUSION

Conversion of VBG to RYGB is a feasible procedure and is associated with acceptable early morbidity rates and reduced lengths of hospitalization also it provides acceptable weight loss and improvement in obesity-related health problems. Graphical Abstract.

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.

Treatment Options for Poor Responders to Bariatric Surgery

PURPOSE OF REVIEW

This review aims to evaluate the latest evidence on the treatment options for perceived poor responders to bariatric surgery and provide practitioners with a guide on when to consider revisional surgery and when to consider alternatives.

RECENT FINDINGS

The use of adjuvant pharmacotherapy has been increasingly described in the literature as an adjunct to primary bariatric surgery, in order to attain more weight loss or better control of obesity-related complications. The newer anti-obesity and anti-diabetes drugs also have cardiorenal benefits, which are shown in recent cardiovascular outcome trials. Revisional bariatric surgery has emerged as a distinctive entity and can be broadly organized into three categories: corrective, conversion, and reversal surgeries. Careful patient selection and preoperative optimization are needed to ensure long-term favorable outcomes. Newer treatment modalities involving the use of anti-obesity medications and endoscopic bariatric interventions provide patients and healthcare providers with more options, when faced with the challenge of poor response after bariatric surgery.

Twelve-Year Experience with Roux-en-Y Gastric Bypass as a Conversional Procedure for Vertical Banded Gastroplasty: Are We on the Right Track?

BACKGROUND

Vertical banded gastroplasty (VBG) has high rates of long-term complications. Conversion to Roux-en-Y gastric bypass (RYGB) is considered optimal; however, there are limited data on the late results of these conversions. We aimed to analyze our single-center long-term outcomes of patients requiring conversional RYGB for a failed VBG.

METHODS

The records of patients who underwent RYGB as a conversional procedure after VBG from November 2004 to December 2016 were reviewed. Follow-up data were obtained by direct telephone calls with patients, electronic files, and general practitioner reports. Characteristics, indications of conversion, long-term (> 30 days) morbidities, weight records, obesity-related comorbidities, and overall patient satisfaction were analyzed.

RESULTS

Overall, 305 VBG patients (82% female) underwent conversional RYGB during the study period. The mean pre-RYGB body mass index (BMI) was 35.6 (23-66) kg/m². Conversions were indicated in 61% of patients because of simultaneous VBG complications and weight regain. After a median follow-up of 74.3 (5-151) months, 225 (73.8%) patients agreed to participate. The mean BMI and percentage of total weight loss (%TWL) were 28.6 (18-45) kg/m² and 17.4%, respectively. Nearly all conversion indications were addressed effectively. Surgical reintervention was mandatory in 28 of 225 patients (12.4%) due to complications. Approximately 85% of patients reported complete remission of obesity-related comorbidities, and four-fifths were fully satisfied.

CONCLUSION

RYGB resolves VBG complications, improves quality of life, and results in prolonged stable weight loss. It has a key role in the management of obesity-related comorbidities and in expert hands is the preferred conversional procedure for patients with failed VBG.

Conversion of both Versions of Vertical Banded Gastroplasty to Laparoscopic Roux-en-Y Gastric Bypass: Analysis of Short-term Outcomes

BACKGROUND

Conversional bariatric surgery has relatively high rates of complications. We aimed to analyze our single-center experience with patients requiring conversional laparoscopic Roux-en-Y gastric bypass (LRYGB) following a failed primary open or laparoscopic vertical banded gastroplasty (OVBG or LVBG, respectively).

METHODS

The records of patients who underwent LRYGB as a conversional procedure after VBG between November 2004 and December 2017 were reviewed. Characteristics, body mass index (BMI), operation time, intraoperative problems, length of hospitalization, and early (< 30 days) morbidity and mortality were analyzed. Data were expressed as mean ± standard deviation or frequency.

RESULTS

A total of 329 patients (81.76% females) who underwent conversional RYGB were included. For the LVBG group (224 patients) and OVBG group (105 patients), respectively, BMI was 34.15 ± 6.38 and 37.79 ± 6.31 kg/m2 (p < 0.05), the operation time was 96.00 ± 31.40 and 123.15 ± 40.26 min (p < 0.05), hospitalization duration was 2.96 ± 1.13 and 3.20 ± 1.20 days (p = 0.08), the early complication rate was 7.14 and 11.43% (p = 0.19), and the reoperation rate was 2.23 and 2.86% (p = 0.73). There were no major intraoperative problems. Three patients with OVBG were converted to open RYGB (2.86%). There was no mortality.

CONCLUSION

The conversion of OVBG and LVBG to laparoscopic RYGB is technically feasible and provides comparably low early morbidity rates and length of hospitalization. However, compared to LVBG, conversional laparoscopic RYGB following OVBG is technically more challenging and time-consuming, with a slightly higher risk of conversion to open surgery. We support the use of such conversional bariatric surgery in specialized, high-volume bariatric centers.

Reoperations After Bariatric Surgery in 26 Years of Follow-up of the Swedish Obese Subjects Study

Importance

Bariatric surgery is an established treatment for obesity, but knowledge on the long-term incidence of revisional surgery is scarce.

Objective

To determine the incidence and type of revisional surgery after bariatric surgery in 26 years of follow-up of participants in the Swedish Obese Subjects (SOS) study.

Design, Setting, and Participants

The SOS study is a prospective nonrandomized controlled study comparing bariatric surgery (banding, vertical banded gastroplasty [VBG], and gastric bypass [GBP]) with usual care. The bariatric surgeries in the SOS study were conducted at 25 public surgical departments in Sweden. Men with body mass index values of 34 or higher and women with body mass indexes of 38 or higher were recruited to the surgery group of the SOS study between September 1, 1987, and January 31, 2001, and follow-up continued until December 31, 2014. Data analysis occurred from November 2016 to April 2018.

Interventions

Banding, VBG, or GBP.

Main Outcomes and Measures

Revisional surgeries, analyzed using data from questionnaires, hospital records, and the Swedish National Patient register through December 31, 2014.

Results

A total of 2010 participants underwent surgery. The age range was 37 to 60 years. A total of 376 participants underwent banding (18.7%), while 1365 had VBG (67.9%) and 266 had GBP (13.2%). During a median follow-up of 19 years, 559 participants (27.8%) underwent first-time revisional surgery, including 354 conversions to other bariatric procedures (17.6%), 114 corrective surgeries (5.6%), and 91 reversals to normal anatomy (4.5%). Revisional surgeries (conversions, corrective surgery, and reversals) were common after banding (153 of 376 [40.7%]) and VBG (386 of 1365 [28.3%]) but relatively rare after GBP (20 of 266 [7.5%]). Patients who had banding and VBG primarily underwent conversions to GBP or reversals. Incidence of reversals was 5 times higher after banding than after VBG (40.7% vs 7.5%; unadjusted hazard ratio, 5.19 [95% CI, 3.43-7.87]; P < .001). Corrective surgeries were equally common irrespective of the index surgery (72 of 1365 patients who had VBG [5.3%]; 23 of 376 patients who had banding [6.1%]; 19 of 266 patients who had GBP [7.1%]). Revisional surgery indications, including inadequate weight loss, band-associated complications (migration, stenosis, and slippage), staple-line disruptions, and postsurgical morbidity, varied depending on index surgery subgroup. Most corrections occurred within the first 10 years, whereas conversions and reversals occurred over the entire follow-up period.

Conclusions and Relevance

Corrective surgeries occur mainly within the first 10 years and with similar incidences across all 3 surgical subgroups, but indications varied. Conversions (mainly to GBP) and reversals occurred after many years and were most frequent after banding and VBG, reflecting a higher overall revisional surgery demand after these operations.

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.

Revisional Gastric Bypass for Failed Restrictive Procedures: Comparison of Single-Anastomosis (Mini-) and Roux-en-Y Gastric Bypass

BACKGROUND

Ten to 50% of patients who received restrictive bariatric operations may require reoperation for unsatisfactory weight loss or weight regain. Failed restrictive procedures are usually managed with conversion to another bariatric procedure with a favor of conversion to laparoscopic gastric bypass. Our aim is to evaluate two different bypass techniques, laparoscopic RY gastric bypass (RYGB) versus single-anastomosis (mini-) gastric bypass (SAGB) as a revision option (R-RYGB and R-SAGB) for failed restrictive bariatric operations.

MATERIAL AND METHODS

From May 2001 to December 2015, a total of 116 patients with failed restrictive bariatric operations underwent laparoscopic revisional bypass surgery (81 R-SAGB and 35 R-RYGB). Among them, 81 were failed after vertical banded gastroplasty (VBG) and 35 were after adjustable gastric band (AGB). The demographic data, surgical parameters, and outcomes were studied.

RESULTS

The average age at revision surgery was 35.7 years (range 22-56), and the average body mass index (BMI) before reoperation was 37.2 kg/m² (29.0-51.8). Revision surgery was performed after 58.8 months from the primary surgery on average (14-180 months). The main reasons for the revisions were weight regain (50.9%), inadequate weight loss (31%), and intolerance (18.1%). All of the procedures were completed laparoscopically as one-stage procedure. R-RYGB had significantly longer operative times than R-SAGB. Major complication occurred in 12 (10%) patients without significant difference between R-SAGB group and R-RYGB group. At 1 year follow-up, weight loss was better in R-SAGB than R-RYGB (76.8 vs. 32.9% EWL; p = 0.001). At 5 year follow-up, a significantly lower hemoglobin level was found in R-SAGB group (p = 0.03).

CONCLUSION

Both SAGB and RYGB are acceptable options for revising a restrictive type of bariatric procedures with equal safety profile. R-SAGB was shown to be a simpler procedure with better weight reduction than R-RYGB but anemia is a considerable complication at long-term follow-up.

Indications and Operative Outcomes of Gastric Bypass Reversal

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is one of the best-known and most commonly performed bariatric procedures. However, this procedure carries infrequent but serious long-term complications, which may require revisional procedures. This study reports the indications and outcomes of gastric bypass reversal that have not been described well in the literature.

METHODS

A multicenter retrospective study of 50 patients who underwent reversal of RYGB conducted between 2006 and 2015 was reviewed to describe the usual indications and outcomes of gastric bypass reversal surgeries.

RESULTS

Of 50 patients, 7 (14 %) were males and 43 (86 %) were females. The mean age of the patient population was 40.4 ± 11.6 years (range 19-66). Reasons for reversal included anastomotic ulcers (n = 27), anastomotic complications (n = 9), malnutrition (n = 2), and functional disorder (n = 12). The mean BMI before the reversal was 29 ± 9.4 kg/m(2) (range 16-60). The mean time between the primary procedure and reversal was 60 ± 65.5 months (range 2-300). Fourteen of the reversals were done via laparotomy. Mean hospital stay was 8.4 ± 7.3 days (range 3-34 days). There was no peri-operative death 30 days after reversal. Following gastric bypass reversal, 92.6 % (n = 25) of the patient population had resolution from ulcers, 77.8 % (n = 7) of the patient population had resolution from anatomic complications, 100 % (n = 2) of the patient population had resolution from malnutrition, and 66.7 % (n = 8) of the patient population had resolution from functional disorders.

CONCLUSIONS

Gastric bypass reversal is a reasonable and safe treatment for complications arising from the GBP surgery. A laparoscopic approach is feasible in select patients.

[Conversional and endoscopic procedures following bariatric surgery]

The Roux-en-Y gastric bypass (RYGB) is the therapy of choice in bariatric surgery. Sleeve gastrectomy and gastric banding are showing higher rates of treatment failure, reducing obesity-associated morbidity and body weight insufficiently. Moreover, gastroesophageal reflux disease (GERD) can occur refractory to medication. Therefore, a laparoscopic conversion to RYGB can be reasonable as long as specific conditions are fulfilled.Endoscopic procedures are currently being applied to revise bariatric procedures. Therapy failure following RYGB occurs in up to 20 % of cases. Transoral outlet reduction is the minimally invasive method of choice to reduce gastrojejunal anastomosis of the alimentary limb. The diameter of a gastric sleeve can be unwantedly enlarged as well; that can be reduced by placement of a longitudinal full-thickness suture.Severe hypoglycemic episodes can be present in patients following RYGB. Hypoglycemic episodes have to be diagnosed first and can be treated conventionally. Alternatively, a laparoscopic approach according to Branco-Zorron can be used for non-responders. Hypoglycemic episodes can thus be prevented and body weight reduction can be assured.Conversional and endoscopic procedures can be used in patients with treatment failure following bariatric surgery. Note that non-invasive approaches should have been applied intensively before a revisional procedure is performed.

Laparoscopic Conversion of Vertical Banded Gastroplasty into Roux-en-Y Gastric Bypass

Laparoscopic conversion of vertical banded gastroplasty (VBG) into Roux-en-Y gastric bypass is a technically demanding procedure. This article demonstrates the feasibility of conversion of failed VBG to Roux-en-Y gastric bypass (RYGBP).We have a series of 15 patients who underwent conversion from VBG to RYGBP, and the results were satisfactory regarding the percent excess weight loss and the resolution of the comorbidities, without a significant increase in the complications. In patients with a difficult anatomy below the cardia, dividing the esophagus just above the esophagogastric junction and performing an esophagojejunostomy may be a safe alternative to converting to a Scopinaro-BPD. Laparoscopic conversion of failed VBG to RYGBP is safe and feasible.

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.

FROM COMPLEX EVOLVING TO SIMPLE: CURRENT REVISIONAL AND ENDOSCOPIC PROCEDURES FOLLOWING BARIATRIC SURGERY

Background

Roux-en-Y gastric bypass (RYGB) is a standard therapy in bariatric surgery. Sleeve gastrectomy and gastric banding, although with good results in the literature, are showing higher rates of treatment failure to reduce obesity-associated morbidity and body weight. Other problems after bariatric may occur, as band erosion, gastroesophageal reflux disease and might be refractory to medication. Therefore, a laparoscopic conversion to a RYGB can be an effective alternative, as long as specific indications for revision are fulfilled.

Objective

The objective of this study was to analyse own and literature data on revisional bariatric procedures to evaluate best alternatives to current practice.

Methods

Institutional experience and systematic review from the literature on revisional bariatric surgery.

Results

Endoscopic procedures are recently applied to ameliorate failure and complications of bariatric procedures. Therapy failure following RYGB occurs in up to 20%. Transoral outlet reduction is currently an alternative method to reduce the gastrojejunal anastomosis. The diameter and volume of sleeve gastrectomy can enlarge as well, which can be reduced by endoscopic full-thickness sutures longitudinally. Dumping syndrome and severe hypoglycemic episodes (neuroglycopenia) can be present in patients following RYGB. The hypoglycemic episodes have to be evaluated and usually can be treated conventionally. To avoid partial pancreatectomy or conversion to normal anatomy, a new laparoscopic approach with remnant gastric resection and jejunal interposition can be applied in non-responders alternatively. Hypoglycemic episodes are ameliorated while weight loss is sustained.

Conclusion

Revisional and endoscopic procedures following bariatric surgery in patients with collateral symptomatic or treatment failure can be applied. Conventional non-surgical approaches should have been applied intensively before a revisional surgery will be indicated. Former complex surgical revisional procedures are evolving to less complicated endoscopic solutions.

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.

Conversion of Vertical Banded Gastroplasty to Laparoscopic Gastric Bypass: a Step-By-Step Teaching Video

PURPOSE

Vertical banded gastroplasty (VBG) has been demonstrated to be disappointing for long-term weight loss and quality of life (Br J Surg 100:222–230, 2013). Laparoscopic revisional gastric bypass has been found to be feasible, but this procedure in case of prior VBG is deemed both challenging and difficult and should be performed by experienced surgeons (Obes Surg 22:1554–1561, 2012; Surg Endosc 27:558–564, 2013).

MATERIALS AND METHODS

We present the case of a 56-year-old man with a body mass index (BMI) of 39.6 kg/m2 who had undergone open VBG, 11 years ago (initial BMI 39.2 kg/m2). He was referred to our tertiary care center for weight regain and daily vomiting.

RESULTS

In this high definition multimedia video, we present a step-by-step laparoscopic conversion of VBG to gastric bypass. After careful adhesiolysis, key points of such procedure are resizing of the small gastric pouch and resection of the enlarged gastric pouch with the band and the upper portion of the remnant fundus, in order to avoid leakage or blind stomach pouch. No adverse outcomes occurred during the postoperative period.

CONCLUSION

Laparoscopic conversion of previous open VBG to gastric bypass is a challenging procedure. Learning the key points of such procedure is mandatory to limit postoperative complications.

Laparoscopic conversion of failed silastic ring vertical gastroplasty (SRVG) and vertical banded gastroplasty (VBG) into biliopancreatic diversion (BPD)

BACKGROUND

The Silastic ring vertical gastroplasty (SRVG), a newer modification of Mason's vertical banded gastroplasty (VBG), was the restrictive procedure of choice for many bariatric surgeons before the advent of the laparoscopic adjustable gastric banding. However, a high rate of reoperations for failure and severe complications was reported in long-term studies. Around 50% of the patients underwent conversion to other bariatric procedures.

OBJECTIVES

The aim of this study is to report our experience in laparoscopic conversion of failed VBG and SRVG to biliopancreatic diversion (BPD).

SETTINGS

The setting of the study was at the University hospital.

METHODS

Between March 2010 and July 2013, 12 patients underwent laparoscopic conversion of VBG and SRVG to BPD. Using a prospectively collected database, we analyzed their data and outcomes.

RESULTS

Eighty-six percent of the conversions were successfully completed laparoscopically. The mean operative time was 220 min. There was no mortality. Perioperative complications occurred in four patients (33%). One (9%) late complication, an adhesional small bowel obstruction, was encountered later than 30 days postoperatively. The follow-up rate was 100%, but only three patients reached 3 years at the time of this writing. At a mean follow-up of 19 (3-40) months, the mean body mass index (BMI) decreased from 45.3 to 27.8 kg/m2. Percent excess weight loss (EWL) was 65.7, and 86.3% at 1 and 3 years, respectively.

CONCLUSION

Laparoscopic conversion of failed VBG to BPD is feasible and effective in further reducing weight in morbidly obese patients. Weight loss continues beyond the first postoperative year. However, the complication rate is much higher than in the primary procedure.

Rejecting the demise of vertical-banded gastroplasty: a long-term single-institute experience

Surgical interventions have proven to be more effective than other measures in the treatment of morbid obesity. The short-term outcomes of the various surgical interventions have been well documented in the literature, with fewer reports on long-term outcomes. The reported long-term outcome of the vertical-banded gastroplasty (VBG) is conflicting. The aim of the present study was to evaluate our long-term experience with VBG. A retrospective review of a prospectively maintained database was conducted. Records of patients who underwent VBG five or more years ago were retrieved. An analysis of the long-term weight changes and reported complications was conducted. The study included 150 patients: 43 males (29%) and 107 females (71%). Their mean age was 30 years old (12-53), and the mean body mass index (BMI) was 47 ± 8.4 kg/m2. Patients were followed up for an average of 8 years (5-11). More than 60 % of patients had good long-term weight loss (EWL > 50%). A significant negative correlation was found between the excess weight loss percent (EWL%) and the pre-operative BMI (p < 0.05). The differences in EWL% between males and females were not significant (p = 0.061). Nevertheless, the change in EWL% over time for both males and females was significant (p = 0.004). Revision surgery was required in seven patients (4.7%). Five patients had conversion of VBG to gastric bypass (3.3%), while two patients (1.3%) had reversal of the procedure. Late complications included mesh erosion in three cases, staple line dehiscence in two patients, and stomal stenosis in six patients. VBG could be a long-term effective intervention for the treatment of morbid obesity. Good selection is the cornerstone for long-term success. Late complication rate is acceptable after VBG. VBG is a specifically useful tool under stringent financial circumstances.

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.

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.