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

Rates and Risk Factors for 30-Day Morbidity After One-Stage Vertical Banded Gastroplasty Conversions: A Retrospective Analysis

Background: The vertical banded gastroplasty (VBG) is a historic restrictive bariatric operation often requiring further surgery. In this investigation utilizing the 2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) national dataset, we aim to better define the outcomes of VBG conversions.Methods: We queried the 2021 MBSAQIP dataset for patients who underwent a conversion from a VBG to Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Demographics, comorbidities, laboratory values, and additional patient factors were examined. Rates of key consequential outcome measures 30-day readmission, reoperation, reintervention, mortality, and a composite endpoint (at least 1 of the 4) were further calculated.Results: We identified 231 patients who underwent conversion from VBG to SG (n = 23), RYGB (n = 208), or other anatomy (n = 6), of which 93% of patients were female, and 22% of non-white race. The median age was 56 years and body-mass index (BMI) was 43 kg/m2. The most common surgical indications included weight considerations (48%), reflux (25%), anatomic causes (eg, stricture, fistula, and ulcer; 10%), and dysphagia (6.5%). Thirty-day morbidity rates included reoperation (7.8%), readmission (9.1%), reintervention (4.3%), mortality (.4%), and the composite endpoint (15%). Upon bivariate analysis, we did not identify any specific risk factor for the 30-day composite endpoint.Discussion: One-stage VBG conversions to traditional bariatric anatomy are beset with higher 30-day morbidity relative to primary procedures. Additional MBSAQIP data will be required for aggregation, to better characterize the risk factors inherent in these operations.

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.

Medium and Long-Term Weight Loss After Revisional Bariatric Surgery: A Systematic Review and Meta-Analysis

Despite the current increase in revisional bariatric surgery (RBS), data on the sustainability of weight loss remain unclear. A systematic review and meta-analysis were performed to assess weight loss outcomes in adult patients undergoing RBS with follow-up > 2 years. Twenty-eight observational studies (n = 2213 patients) were included. The %TWL was 27.2 (95%CI = 23.7 to 30.6), and there was a drop in BMI of 10.2 kg/m2 (95%CI =  - 11.6 to - 8.7). The %EWL was 54.8 (95%CI = 47.2 to 62.4) but with a high risk of publication bias (Egger's test = 0.003). The overall quality of evidence was very low. Our data reinforce that current evidence on RBS is mainly based on low-quality observational studies, and further higher-quality studies are needed to support evidence-based practice.

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.

Laparoscopic Conversion of Vertical Banded Gastroplasty to Roux-en-Y Gastric Bypass Gives Better Result Compared to an Open Approach

BACKGROUND

Vertical banded gastroplasty (VBG) has a relatively high failure rate in the long run, requiring revisional surgery in 30-65%. A common conversion option is to Roux-en-Y gastric bypass (RYGB), which can be performed laparoscopically or open. Current literature contains small cohorts and inconclusive results. Therefore, we set out to compare our series of open and laparoscopic VBG to RYGB conversions.

METHODS

All conversions performed between 1996 and 2020 were included. Patients were divided into 3 groups based on conversion indication: weight recurrence (group 1), excessive weight loss (group 2), and eating/pouch difficulties (group 3). The primary outcome was postoperative complications according to the Clavien-Dindo (CD) classification. Secondary outcome was %total weight loss (%TWL) 1 to 5 years after revisional surgery.

RESULTS

We included 205 patients (84.9% female) of whom 105 underwent laparoscopic and 100 open VBG to RYGB conversion. Twenty-three short-term complications occurred in the laparoscopic group, with 16 > CD3a. In the open group, 33 complications occurred with 12 > CD3a. Overall complications were 33.3% in laparoscopic and 64% in open patients. There were no significant differences between the laparoscopic and open group in BMI (p = 0.76) and %TWL (p = 0.694) after 5 years. After 5 years, lost to follow-up was 97% in the open group. Twenty-eight percent of patients who reached follow-up in the laparoscopic group had available data.

CONCLUSIONS

We demonstrate that the overall complication rate is lower in the laparoscopic group compared to the open group. Regarding BMI, an improvement was achieved in both groups after 5 years.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Gastric Remnant Mucocele after Conversion of Vertical Band Gastroplasty to One Anastomosis Gastric Bypass: a Video Vignette

Conversional bariatric surgery is a challenging procedure to patients as well as the surgeon. One anastomosis gastric bypass (OAGB) is a known safe conversional procedure after primary restrictive weight loss surgeries such as vertical banded gastroplasty (VBG). A very rare reported complication after these operations is the formation of mucocele of gastric remnant during pouch creation. This is a video report of diagnosis and management of gastric remnant mucocele after conversion of VBG to OAGB.