Is a one-step sleeve gastrectomy indicated as a revision procedure after gastric banding? Data analysis from a quality assurance study of the surgical treatment of obesity in Germany

Challenges of Revisional Metabolic and Bariatric Surgery: A Comprehensive Guide to Unraveling the Complexities and Solutions of Revisional Bariatric Procedures

Revisional metabolic and bariatric surgery (RMBS) presents unique challenges in addressing weight loss failure or complications arising from initial bariatric procedures. This review aims to explore the complexities and solutions associated with revisional bariatric procedures comprehensively, offering insights into the evolving terrain of metabolic and bariatric surgery. A literature review is conducted to identify pertinent studies and expert opinions regarding RMBS. Methodological approaches, patient selection criteria, surgical techniques, preoperative assessments, and postoperative management strategies are synthesized to provide a comprehensive overview of current practices and advancements in the field, including institutional protocols. This review synthesizes key findings regarding the challenges encountered in RMBS, including the underlying causes of primary procedure failure, anatomical complexities, technical considerations, and assessments of surgical outcomes. Additionally, patient outcomes, complication rates, and long-term success are presented, along with institutional approaches to patient assessment and procedure selection. This review provides valuable insights for clinicians grappling with the complexities of RMBS. A comprehensive understanding of patient selection, surgical techniques, preoperative management, and postoperative care is crucial for enhancing outcomes and ensuring patient satisfaction in the field of metabolic bariatric surgery.

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

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

Bariatric Surgery and Femoral Vein Diameter in Morbidly Obese Patients: a Cohort Study in Iran

INTRODUCTION

Considering the importance of health, the effect of obesity on the quality of life, the person's self-image, and the effect of obesity on various organs, especially the vessels, and the absence or presence of a study in Iran that investigated the effect of gastric bariatric surgery on the diameter of the femoral vein, in the present study, we investigated the effect of bariatric surgery on femoral vein diameter in morbidly obese patients referred to Imam Hossein hospital.

MATERIALS AND METHODS

The present study was a prospective cohort study on morbidly obese patients referred to the center in 2022-2023. In this study, 31 morbidly obese patients with BMI above 30 kg/m2 who were candidates for bariatric surgery were examined. Demographic data were collected using a demographic profile checklist. BMI, the diameter of common femoral veins, and the great saphenous vein were measured and recorded before and 6 months after surgery. Ultimately, the data was collected and analyzed using SPSS V.24 software.

RESULTS

In the current study, 31 patients (62 extremities) were examined. The mean age of the patients was 34.45, with a standard deviation of 8.86. Fourteen patients (45.2%) were male, and 17 (54.8%) were female. The mean diameter of the common femoral vein in the 6 months after surgery was significantly less than before surgery (11.58 (1.64) compared to 12.95 (1.84), P = 0.0001). The mean diameter of the great saphenous vein in the 6 months after surgery was significantly less than before surgery (7.30 (1.45) compared to 7.75 (1.45), P = 0.0001).

CONCLUSION

It seems that bariatric surgery causes a significant decrease in the diameter of lower limb veins (common femoral vein and great saphenous vein) compared to before surgery. However, further studies in this field are recommended.

One- versus two-stage conversions of adjustable gastric bands: an analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database

BACKGROUND

Laparoscopic adjustable gastric bands (AGB) are converted at high rates to secondary bariatric procedures. The available literature on the safety of converting in 1- versus 2-stage processes has not included large databases.

OBJECTIVE

To evaluate the safety of a 1- versus 2-stage conversion of AGB.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), United States.

METHODS

The MBSAQIP database for the years 2020 and 2021 was evaluated. One-stage AGB conversions were identified using Current Procedural Terminology codes and database variables. Multivariable analysis was performed to determine whether 1- or 2-stage conversions were associated with 30-day serious complications.

RESULTS

There were 12,085 patients who underwent conversion from previous AGB to sleeve gastrectomy (SG) (63.0%) or Roux-en-Y gastric bypass (RYGB) (37.0%), of whom 41.0% underwent conversion in 1 stage and 59.0% in 2 stages. Patients who underwent 2-stage conversions had higher body mass indexes. Rates of serious complications were higher for patients undergoing RYGB compared with SG (5.2% versus 3.3%, P < .001) but were similar between 1-stage and 2-stage conversions in both cohorts. In both cohorts, there were similar rates of anastomotic leaks, postoperative bleeding, reoperation, and readmissions. Mortality was rare and similar between conversion groups.

CONCLUSIONS

There was no difference in outcomes or complications in 30 days between 1- and 2-stage conversions of AGB to RYGB or SG. Conversions to RYGB have higher complication and mortality rates than to SG, but there was no statistically significant difference between staged procedures. One- and 2-stage conversions from AGB are equivalent in safety.

A Comparison of One- and Two-Stage Laparoscopic Sleeve Gastrectomy Following Failed Laparoscopic Adjustable Gastric Banding Using the BAROS Score

INTRODUCTION

Revision of a failed band can be done by laparoscopic sleeve gastrectomy (LSG). It can be performed synchronously with band removal or during two separate procedures.

AIM

Comparing single- and two-staged LSG following a failed LAGB in terms of short- and mid-term outcomes, with an emphasis on postoperative quality of life.

METHODS

A retrospective cohort study comparing revisional LSG's safety and efficacy after failed LAGB removal. Data included patients' medical files, as telephone interviews. We compared demographics, weight loss, complications, long-term outcomes, and quality-of-life measures, including the Bariatric Analysis and Reporting Outcome System (BAROS).

RESULTS

Ninety-three patients were enrolled, of which 68 (73.1%) underwent a single-stage revisional LSG. Of these, 40 were males (35.1%) with a mean age of 44.9 years (± 12.9). The two-staged group were older. The reasons for band removal differed between the groups: whereas in the two-stage surgery, the common causes were slippage (29.2%) or band intolerance (25%); in the single-stage group, it was weight gain (51%). There were no differences in short- and mid-term complications, weight loss, and quality of life.

CONCLUSION

In selected cases, laparoscopic sleeve gastrectomy as a revision of failed gastric banding in one stage is as safe as a two-stage procedure in terms of short- and mid-term complications, weight loss, and quality of life. We believe that there is little benefit in performing elective surgery in two stages unless there are clinical indications. Exceptions for two-stage revision should include cases of band erosion and acute slippage with patient preference for band removal.

Revisional One Anastomosis Gastric Bypass with a 150-cm Biliopancreatic Limb After Failure of Adjustable Gastric Banding: Mid-Term Outcomes and Comparison Between One- and Two-Stage Approaches

PURPOSE

Laparoscopic adjustable gastric banding (LAGB) was a common procedure worldwide but associated with a high rate of long-term failure. This study aims to evaluate the safety and effectiveness of conversion to one anastomosis gastric bypass (OAGB) after failed LAGB.

MATERIALS AND METHODS

We undertook a retrospective analysis of a prospectively maintained database in a tertiary referral center for bariatric surgery. All cases of revisional OAGB with a biliopancreatic limb (BPL) of 150 cm after failed LAGB performed between 2010 and 2016 were analyzed.

RESULTS

Overall, 215 patients underwent conversion from LAGB to OAGB. Indication for surgery was primary weight loss (WL) failure in 30.7% of cases and long-term complications in the remaining patients, with or without associated weight regain. At the time of OAGB, the mean age was 43.2 ± 10.5 years and the mean BMI was 42 ± 6.9. Overall postoperative morbidity was 13.5%. The postoperative abscess ± leak rate was 5.9% in the overall population. Two years after OAGB, 9.7% of patients were lost to follow-up, % excess weight loss (EWL) was 88.2 ± 23.9, and % total weight loss (TWL) was 38.7 ± 9.3. At 5 years, 16.6% of patients were lost to follow-up, %EWL was 82.4 ± 25, and %TWL was 36.1 ± 10. There was no statistical difference in complication rates or WL results between the one-stage and two-stage approaches.

CONCLUSION

OAGB with a 150-cm BPL represents a safe and effective option after failed LAGB. Both synchronous OAGB and two-step revisional OAGB guarantee satisfying results in terms of postoperative morbidity and WL outcomes.

Feasibility and Short-Term Outcomes of One-Step and Two-Step Sleeve Gastrectomy as Revision Procedures for Failed Adjustable Gastric Banding Compared With Those After Primary Sleeve Gastrectomy

Background: The practice of bariatric surgery was studied using the German Bariatric Surgery Registry (GBSR). The focus of the study was to evaluate whether revision surgery One-Step (OS) or Two-Step (TS) sleeve gastrectomy (SG) has a large benefit in terms of perioperative risk in patients after failed Adjustable Gastric Banding (AGB). Methods: The data collection includes patients who underwent One-Step SG (OS-SG) or Two-Step SG (TS-SG) as revision surgery after AGB and primary SG (P-SG) between 2005 and 2019. Outcome criteria were perioperative complications, comorbidities, 30-day mortality, and operating time. Results: The study analyzed data from 27,346 patients after P-SG, 320 after OS-SG, and 168 after TS-SG. Regarding the intraoperative complication, there was a significant difference in favor of P-SG and TS-SG compared to OS-SG (p < 0.001). The incidence of pulmonary complications was significantly higher in the OS-SG (p < 0.001). There was also a significant difference in occurrence of staple line stenosis in favor of TS-SG (p = 0.005) and the occurrence of sepsis (p = 0.008). The mean operating time was statistically longer in the TS-SG group than in the OS-SG group (p < 0.001). The 30-day mortality was not significantly different between the three groups (p = 0.727). Conclusion: In general, our study shows that converting a gastric band to a SG is safe and feasible. However, lower complications were obtained with TS-SG compared to OS-SG. Despite acceptable complication and mortality rates of both procedures, we cannot recommend any surgical method as a standard procedure. Proper patient selection is crucial to avoid possible adverse effects.

Safety and effectiveness of 1-stage conversion of adjustable gastric band-to-sleeve gastrectomy: a single-institution case-control study

BACKGROUND

Patients are increasingly referred for conversion of laparoscopic adjustable gastric band (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (SG). The safety of a 1- versus 2-stage approach to this revision is debated.

OBJECTIVES

We examined the safety and efficacy of 1-stage conversion of LAGB to SG at our institution.

SETTING

University hospital.

METHODS

An institutional database was used to retrospectively identify patients who underwent single-stage LAGB-to-SG conversion between 2010 and 2018. Patients were matched 1:1 for age, sex, and body mass index with primary SG patients during this same period. Primary endpoints were operative time, complication rate, length of hospital say, and weight loss 12 months from surgery.

RESULTS

Two-hundred and twenty-nine patients undergoing conversion of LAGB to SG were identified. Median postoperative length of hospital stay was 2 days. Two patients (.8%) developed surgical site infection. One patient (.4%) developed a postoperative myocardial infarction. There were 4 total readmissions (1.7%) and 1 reoperation within 30 days (.4%). There were no statistically significant differences in 30-day complication rates between groups. Weight loss at 12 months was significantly different: Median body mass index loss for conversion patients was 5.1 kg/m² compared with 8.85 kg/m² for patients in the primary SG group (P < .0001).

CONCLUSION

Single-stage conversion of LAGB to SG is safe and effective. Patients may not experience the same extent of weight loss as those with primary SG. Our findings represent the largest single-institutional experience to date and support a 1-stage approach whenever feasible.

Laparoscopic Sleeve Gastrectomy Following Failed Laparoscopic Adjustable Gastric Banding-a Comparison Between One- and two-Stage Procedures, an Israeli National Database Study

PURPOSE

The optimal revisional bariatric surgery procedure following a previous failed gastric band surgery is yet to be determined. The aim of our study was to compare single- and two-stage laparoscopic sleeve gastrectomy (LSG) following laparoscopic adjustable gastric banding (LAGB) in terms of short- and mid-term outcomes.

MATERIALS AND METHODS

Patients who underwent LSG after a failed LAGB in Israel during 2014-2017 were included. Data were obtained from the Israeli National Bariatric Surgery Registry. Data analyzed included comorbidities, postoperative complications, and anthropometric outcomes.

RESULTS

Of 595 patients included in the data analysis, 381 (64%) underwent one-stage and 214 (36%) had two-stage LSG. No differences were observed between the groups in complication rates (5.0 vs. 5.1%, p=0.93). Percent of total weight loss was lower following one-stage than two-stage procedure at both 6 months (19.3±9.3 vs. 21.5±8.1%; p=0.02) and 1 year postoperative (24.9±10.4 vs. 27.8±9.9%; p=0.02). No difference was observed in the percent excess weight loss (51 vs. 56%; p=0.34 and 66 vs. 72%; p=0.38, at 6 months and 12 months postoperative, respectively). In a regression analysis, percent excess weight loss was greater in the two-stage procedure (p=0.02), with no difference in the complication rates (p=0.98).

CONCLUSION

Single-step LSG had a similar safety profile as two-stage LSG following a failed LAGB. Better weight loss was seen following two-stage LSG. Further prospective studies should investigate long-term follow-up after one- and two-stage procedure.

Safety of Revision Sleeve Gastrectomy Compared to Roux-Y Gastric Bypass After Failed Gastric Banding: Analysis of the MBSAQIP

OBJECTIVE

The aim of this study was to assess the safety of revisional surgery to laparoscopic sleeve gastrectomy (LSG) compared to laparoscopic Roux-Y gastric bypass (LRYGB) after failed laparoscopic adjustable gastric banding (LAGB).

BACKGROUND

The number of reoperations after failed gastric banding rapidly increased in the United States during the last several years. A common approach is band removal with conversion to another weight loss procedure such as gastric bypass or sleeve gastrectomy in a single procedure. The safety profile of those procedures remains controversial.

METHODS

Preoperative characteristics and 30-day outcomes from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Files 2015 were selected for all patients who underwent a 1-stage conversion of LAGB to LSG (conv-LSG) or LRYGB (conv-LRYGB). Conv-LSG cases were matched (1:1) with conv-LRYGB patients by age (±1 year), body mass index (±1 kg/m(2)), sex, and comorbidities including diabetes, hypertension, hyperlipidemia, venous stasis, and sleep apnea.

RESULTS

A total of 2708 patients (1354 matched pairs) were included in the study. The groups were closely matched as intended. The mean operative time in conv-LRYGB was significantly longer in comparison to conv-LSG patients (151 ± 58 vs 113 ± 45 minutes, P < 0.001). No mortality was observed in either group. Patients after conv-LRYGB had a clinically increased anastomotic leakage rate (2.07% vs 1.18%, P = 0.070) and significantly increased bleed rate (2.66% vs 0.44%, P < 0.001). Thirty-day readmission rate was significantly higher in conv-LRYGB patients (7.46% vs 3.69%, P < 0.001), as was 30-day reoperation rate (3.25% vs 1.26%, P < 0.001). The length of hospital stay was longer in conv-LRYGB.

CONCLUSIONS

A single-stage conversion of failed LAGB leads to greater morbidity and higher complication rates when converted to LRYGB versus LSG in the first 30 days postoperatively. These differences are particularly notable with regards to bleed events, 30-day reoperation, 30-day readmission, operative time, and hospital stay.

Conversion to laparoscopic sleeve gastrectomy after failure of laparoscopic gastric band: A systematic review of the literature and cost considerations

No universal consensus has been achieved as to whether the laparoscopic adjustable gastric band to laparoscopic sleeve gastrectomy conversion should be performed in one or two steps. To determine the differences in operative outcomes and cost, a systematic, comprehensive review of the literature was conducted using the PubMed database from the National Institutes of Health. Nine studies were included with 809 patients. Weighted averages were calculated to compare operative outcomes, and cost analyses were conducted with these averages. Results indicate a longer operative time for the one-step approach than the two-step approach, but studies included in the meta-analysis found no statistical difference between the two. The two-step approach was found to have a longer length of hospital stay, but this finding refuted included studies that indicate no significant difference. Complication rates were higher for the one-step approach than the two-step approach, and costs associated with complications average $806 more for one-step patients than two-step patients. This suggests that the two-step approach could prove better for patient safety and cost outcomes, but both approaches are comparable in operating time and length of stay.

Bariatric Surgery Registries: Can They Contribute to Improved Outcomes?

PURPOSE OF REVIEW

Clinical registries systematically collect prospective information about patients with a particular medical condition, who have had a medical device implanted or who have undergone a particular procedure. When these variables are collected with pre-defined quality indices included, the benched-marked risk-adjusted data may be a valuable resource for providing feedback on outcomes, including performance, to practitioners, patients, health services and device manufacturers.

RECENT FINDINGS

There are examples of feedback from clinical registries positively influencing patient care. The Australian National Joint Registry identified a poorly performing hip prosthesis which was ultimately withdrawn from the market. Feedback from the Victorian State Prostate Cancer Registry has contributed to improved patient care and fewer positive surgical margins noted over a 5-year reporting period. There are several national and regional registries collecting information on patients undergoing bariatric surgery, however, few currently focus on quality outcome measures. Whilst, current bariatric registries have contributed to improved understanding of some of the clinical situations relating to bariatric surgery, as well as developing composite risk scores and measuring quality cultures, they have not as yet demonstrably directly influenced patient care. This may reflect the fact that many of the registries do not hold data that are mature enough for proper analysis, but may also reflect problems with systematic data collection, bias from missing results and lack of appropriate funding. It will be important in the future that bariatric surgery registries actively seek to measure and validate their contribution to patient outcomes.

Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy as Revisional Procedures after Adjustable Gastric Band: 5-Year Outcomes

INTRODUCTION

In 2013, a worldwide bariatric surgery survey showed that laparoscopic adjustable gastric banding (LAGB) has been abandoned in favor of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-y gastric bypass (LRYGBP).

PURPOSE

The aim of this study was to compare results of LRYGBP and LSG performed as a revisional procedure after LAGB.

MATERIALS AND METHODS

All patients converted from LAGB to LSG or to LRYGBP from January 2007 to December 2011 were included in the study. Clinical data collected were age, gender, indications for revision, complications, body mass index (BMI), and body weight at revisional procedures. Weight loss was calculated at 1, 3, and 5 years after conversion.

RESULTS

Fifty-one patients were included in this study, 43 females and 8 males. Twenty-four patients were converted to LRYGBP (LRYGBP group) and 27 to LSG (LSG group). Indication for conversion was weight loss failure in 34 (67%) patients and band complications in 17 (33%) patients. No significant difference in age, BMI, and body weight in the two groups was found at the time of revision. One patient converted to LRYGBP had an internal hernia; one patient initially scheduled for LSG was intraoperatively converted to LRYGBP due to staple line leak. No other major perioperative complication was observed. Follow-up rate at 5 years was 84.3% (43 patients out of 51 patients) Delta-BMI and percentage of excess weight loss (%EWL) were not significantly different in the two groups at 1, 3, and 5 years (p > 0.05).

CONCLUSION

LRYGBP or LSG are feasible and effective surgical options after LAGB. Satisfactory weight loss was achieved after both procedures.

Gastric Band Removal in Revisional Bariatric Surgery, One-Step Versus Two-Step: a Systematic Review and Meta-analysis

We aimed to systematically review the literature comparing the safety of one-step versus two-step revisional bariatric surgery from laparoscopic adjustable gastric banding (LAGB) to Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). There is debate on the safety of removing the gastric band and performing revisional surgery immediately or in a delayed, two-step fashion due to potential higher complications in one-step revisions. A systematic and comprehensive search of the literature was conducted. Included studies directly compared one-step and two-step revisional surgery. Eleven studies were included with 1370 patients. Meta-analysis found comparable rates of complications, morbidity, and mortality between one-step and two-step revisions for both RYGB and SG groups. This suggests that immediate or delayed revisional bariatric surgeries are both safe options for LAGB revisions.

A one-step conversion from gastric banding to laparoscopic Roux-en-Y gastric bypass is as safe as a two-step conversion: A comparative analysis of 885 patients

AIMS

To achieve additional weight loss or to resolve band-related problems, a laparoscopic adjustable gastric banding (LAGB) can be converted to a laparoscopic Roux-en-Y gastric bypass (RYGB). There is limited data on the feasibility and safety of routinely performing a single-step conversion. We assessed the efficacy of this revisional approach in a large cohort of patients operated in a high-volume bariatric institution.

METHODS

Between October 2004 and December 2015, a total of 885 patients who underwent LAGB removal with RYGB were identified from a prospectively collected database. In all cases, a single-stage conversion procedure was planned. The feasibility of this approach and peri-operative outcomes of these patients were evaluated and analyzed.

RESULTS

A single-step approach was successfully achieved in 738 (83.4%) of the 885 patients. During the study period, there was a significant increase in performing the conversion from LAGB to RYGB single-staged. No mortality or anastomotic leakage was observed in both groups. Only 45 patients (5.1%) had a 30-d complication: most commonly hemorrhage (N = 20/45), with no significant difference between the groups.

CONCLUSION

Converting a LAGB to RYGB can be performed with a very low morbidity and zero-mortality in a high-volume revisional bariatric center. With increasing experience and full standardization of the conversion, the vast majority of operations can be performed as a single-stage procedure. Only a migrated band remains a formal contraindication for a one-step approach.

Analysis of Morbidity Data of 308 Cases of Laparoscopic Sleeve Gastrectomy--the Soroka Experience

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) became a prevalent bariatric procedure in Israel, while laparoscopic adjustable gastric banding (LAGB) was losing ground, due to high failure rates (40 % at 10 years). Many patients after LAGB failure choose LSG as a further bariatric surgery (secondary LSG). However, LAGB often impairs upper stomach anatomy and physiology, which may contribute to complications increased risk after secondary LSG, in comparison to surgery-naive obese patients choosing LSG (primary LSG).

METHODS

A retrospective cohort study was conducted on a prospective database, looking at morbidly obese patients for LSG surgery. All procedures were done by a single surgeon at the Soroka Medical Center between January 2008 and March 2013. Data were collected from hospitalization charts on demographics, biometric and bariatric status, medical and bariatric surgical history, post-LSG morbidity, and mortality.

RESULTS

Three hundred eight patients underwent LSG during the study period, 181 (58.8 %) had a primary LSG while 127 (41.2 %) had a secondary LSG. No mortality occurred in both groups. Odds ratio for major complication (leak, stenosis) was 3.12 [CI 0.90-10.75] among the secondary LSG group, compared to the primary LSG (p = 0.071). The risk for major complication was doubled (OR = 2, 95 % CI [1.36-3.06]) for each one of previous bariatric procedure underwent (p = 0.001). Significant differences were found between the two groups regarding number and length of readmissions and number of imaging tests (p value = 0.027, 0.022, and 0.049, respectively).

CONCLUSIONS

Primary LSG is a safe and efficient bariatric procedure. After failed LAGB, secondary LSG should be carefully considered, because of a potentially higher risk of complications.

[Revisional surgery and reoperations in obesity and metabolic surgery : Data analysis of the German bariatric surgery registry 2005-2012]

BACKGROUND

Increasing numbers of interventions for obesity and metabolic surgery have led to an increase of primary bariatric operations as well as redo operations and revisional surgery after various primary bariatric procedures. Evidence-based guidelines for indications and choice of procedure for revisional surgery do not currently exist.

AIM

The spectrum of various revisional and redo operations following standard operative procedures for obesity and metabolic surgery is presented based on current data from the German bariatric surgery registry (GBSR, German nationwide survey on quality assurance in bariatric surgery) and a literature search.

MATERIAL AND METHODS

Since 1 January 2005, the current situation of bariatric surgery has been examined using the GBSR. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University Magdeburg. Since 2005 a total of 24,070 primary bariatric procedures, 2070 revisional procedures and 1124 redo operations were analyzed. The study evaluated 1021 revisional and 491 redo operations after gastric banding (GB), 443 redo operations after sleeve gastrectomy (SG) and 306 revisional procedures and 10 redo operations after a Roux-en-Y gastric bypass (RYGBP).

RESULTS

Reoperations of GB to SG were performed in 240 cases. The complication rate for GB removal and SG showed a significantly higher leakage rate for one step operations than for two step procedures of 3.3% vs. 0.0%. Conversion of GB to RYGBP was performed in 402 operations without any significant differences between one and two step approaches (1.9% vs. 2.2%). The specific complication rate in the 443 interventions in patients for conversion from SG to RYGBP was 10.8% which is higher than for primary SG (4.9%) and RYGBP (5.3%).

CONCLUSION

Compared with the primary surgical procedures redo operations and revisional procedures have significantly higher complication rates. The data evaluated show that strong and differentiated indications are necessary for revisional and redo operations particularly in cases of therapy or metabolic failure.

[Anastomosis and suture insufficiency after interventions for bariatric and metabolic surgery]

BACKROUND

Metabolic surgery is internationally well-established for the treatment of obesity and its comorbidities. The numbers of procedures performed is steadily increasing. The results of surgery are superior in comparison to conservative treatment options regarding weight loss and resolution of comorbidities. The insufficiency of suture lines is a well-known and feared complication in the stapling procedures and is associated with an increased morbidity as well as mortality, especially in super obese patients.

MATERIAL AND METHODS

The current literature was reviewed and the results are reported within the context of own experience.

RESULTS

The most severe complications are staple line leakage after sleeve gastrectomy, leakage of anastomoses after bypass procedures and duodenal stump insufficiency. For the treatment of sleeve leakage various endoscopic procedures, such as over the scope (OTS) clips, stents and endoluminal vacuum therapy are available. Surgical revision, such as oversuturing, drainage and redo surgery are well-established. The management of all other complications is mainly by surgical intervention. Intraoperative standardization of procedures and knowledge of the physical foundations are essential for the prevention of leakage. Several preventive methods are available but randomized controlled trials are missing.

CONCLUSION

The therapy of leakages in the field of bariatric surgery is an interdisciplinary approach and dependent on the available resources in the treating hospital. The data reported show good results but the different reports published are inconsistent. Leakages often do not occur in the immediate postoperative period but in the sense of a long-term complication; therefore standardization of procedures and follow-up as well as complication management is mandatory. Randomized controlled studies must be promoted.

Revisions after failed gastric band: sleeve gastrectomy and Roux-en-Y gastric bypass

INTRODUCTION

Laparoscopic gastric band is an appealing bariatric operation due to its simplicity and good short-term outcomes; however, it is associated with complications (slippage, erosion, prolapse) and failure in reaching target weight loss. This study describes our experience with failed gastric bands that required a revisional procedure.

MATERIALS AND METHODS

This single-center retrospective analysis includes all consecutive patients who underwent a gastric band removal and revisional surgery in our hospital from January 2008 to June 2014. A total of 81 patients were identified and divided in three groups: Group one included patients who just had the gastric band removed (43), group two consisted of patients who underwent a conversion to sleeve gastrectomy (SG) (26), and group three included patients who required a conversion to Roux-en Y gastric bypass (RYGB) (12). Patient demographics, date of gastric band placement, indications for revision, postoperative morbidity and mortality, operating time, blood loss, length of stay, and % excess weight loss (%EWL) were recorded. Perioperative and clinical outcomes were compared between conversions to SG and RYGB.

RESULTS

In group two (n = 26), 21 conversions to SG were performed in concurrence with the band removal as a one-stage operation, while five procedures were performed in two-stages. There were no complications and no case was converted to open. Patients who underwent a one-stage procedure had a longer operative time, although it did not reach statistical significance. In group three, 12 patients underwent a conversion to RYGB as a revisional operation; 11 were performed as a one-stage procedure and only one patient underwent a two-stage procedure.

CONCLUSIONS

SG and RYGB are safe options to revise a failed gastric band. Both groups who received either a SG or RYGB had a low complication rate and acceptable %EWL with no statistical difference between the two.

[Redo intervention and complication management in bariatric surgery]

Morbid obesity and the associated comorbidities are rapidly increasing worldwide. Bariatric surgery has proven to be an effective treatment option. In 2011 more then 340,000 bariatric procedures were performed worldwide which is accompanied by a growing demand for revision bariatric procedures due to complications or failure, such as insufficient weight loss or weight regain.Redo operation procedures as well as the management of complications require a profound preoperative medical history and diagnostic investigation in combination with an exact knowledge of the anatomical changes made in the primary procedure.

Single-stage versus 2-stage sleeve gastrectomy as a conversion after failed adjustable gastric banding: 30-day outcomes

BACKGROUND

Sleeve gastrectomy (SG) is being performed as a conversion after adjustable gastric banding (AGB), often in a single stage. However, some argue that it should be performed in 2 stages to improve safety. Few studies compare complications between 1-stage and 2-stage procedures. Our aim is to compare the 30-day complication rates among these two groups.

METHODS

We retrospectively reviewed patients converted from AGB to SG between 8/2008 and 10/2013 and compared patients undergoing 1-stage and 2-stage techniques. Primary outcome was overall 30-day adverse event rate (postoperative complication, readmission, or reoperation). Secondary outcomes included operating room (OR) time, length of stay (LOS), leak, infection, and bleeding rates, as well as mortality.

RESULTS

A total of 83 patients underwent SG after band removal; three were excluded due to short follow-up, leaving 60 1-stage and 20 2-stage. Mean time from band removal to SG for 2-stage was 438 days. Demographics, intraoperative technique (bougie size, staple reinforcement, oversewing staple line, and leak test), and mean follow-up were not statistically different. Mean OR time (132.1 min 1-stage vs. 127.8 min 2-stage, p = 0.702) and LOS (3.1 vs. 2.4 days, p = 0.676) were similar. Overall 30-day adverse event rate was 12 % for 1-stage versus 15 % for 2-stage procedures (p = 0.705). Differences in 30-day readmission (8 vs. 5 %) and reoperation (5 vs. 0 %) were not statistically significant (p = 0.999 and 0.569, respectively). Leak (3 vs. 0 %, p = 0.999), abscess (2 vs. 5 %, p = 0.440), and bleeding rates (2 vs. 0 %, p = 0.999) were not different. There were no deaths.

CONCLUSIONS

SG performed as a conversion after AGB is safe and feasible. Our findings indicate no statistical difference in 30-day outcomes when performed in 1 or 2 stages. Future studies with larger sample sizes are necessary to further investigate these differences.

A histologic evaluation of the laparoscopic adjustable gastric band capsule by tissue sampling during sleeve gastrectomy performed at different time points after band removal

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) is gaining popularity as a revision option after failed laparoscopic adjustable gastric banding (LAGB). Data have shown that single stage revisions may be associated with a higher complication rate. A histologic basis for this observation has not been studied. The objective of this study was to document the histologic properties of the LAGB capsule across the gastric staple line after SG at various time points after LAGB removal.

METHODS

Gastric sleeve specimens of all LAGB to SG revisions were identified from January to May 2013 and underwent histologic evaluation of the LAGB capsule. Single blinded pathologist interpretation was performed, with inflammation, fibrosis, neovascularization, foreign body (FB) reaction, and wall thickness assessed semi-quantitatively and scored from 0-3. Based on combined features, an attempt was made to predict the timing of revision surgery.

RESULTS

The study identified 19 revisions performed for inadequate excess weight loss or weight regain. The mean age for revision was 44 (19-65). The minimum time to revision was 42 days, the longest 1,188 days. There were no surgical complications. Varying degrees of inflammation and fibrosis were common features at all times. Angiogenesis, neovascularization and FB reaction were prominent in revisions performed before 80 days. The gastric wall was thicker during early revision. The optimal time to perform revision was difficult to determine.

CONCLUSIONS

LAGB caused varying degrees of inflammatory and FB reaction that time did not fully resolve. The lower leak rates observed with delayed revisions do not appear to be attributable to gastric histology.