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Sánchez-Pernaute A, López-Antoñanzas L, Torres AJ, Dziakova J, Rubio MA, Pérez-Aguirre E. Avoiding Complications During Revisional Bariatric Surgery with Indocyanine Green Fluorescence Imaging. Obes Surg 2023; 33:972-974. [PMID: 36595146 DOI: 10.1007/s11695-022-06433-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/17/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023]
Affiliation(s)
| | | | - A J Torres
- Department of Surgery, Complutense University, Madrid, Spain
| | - J Dziakova
- Department of Surgery, Complutense University, Madrid, Spain
| | - M A Rubio
- Department of Endocrinology, Complutense University, Madrid, Spain
| | - E Pérez-Aguirre
- Department of Surgery, Complutense University, Madrid, Spain
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Lourensz K, Himantoko I, Shaw K, Laurie C, Becroft L, Forrest E, Nottle P, Fineberg D, Burton P, Brown W. Long-Term Outcomes of Revisional Malabsorptive Bariatric Surgery: Do the Benefits Outweigh the Risk? Obes Surg 2022; 32:1822-1830. [PMID: 35352269 PMCID: PMC9072481 DOI: 10.1007/s11695-022-06019-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 11/22/2022]
Abstract
Purpose To evaluate the long-term outcomes of revisional malabsorptive bariatric surgery. Materials and Methods Malabsorptive bariatric procedures are increasingly performed in the revisional setting. We collated and analysed prospectively recorded data for all patients who underwent a revisional Biliopancreatic diversion + / − duodenal switch (BPD + / − DS) over a 17-year period. Results We identified 102 patients who underwent a revisional BPD + / − DS. Median follow-up was 7 years (range 1–17). There were 21 (20.6%) patients permanently lost to follow-up at a median of 5 years postoperatively. Mean total weight loss since the revisional procedure of 22.7% (SD 13.4), 20.1% (SD 10.5) and 17.6% (SD 5.5) was recorded at 5, 10 and 15 years respectively. At the time of revisional surgery, 23 (22.5%) patients had diabetes and 16 (15.7%) had hypercholesterolaemia with remission of these occurring in 20 (87%) and 7 (44%) patients respectively. Nutritional deficiencies occurred in 82 (80.4%) patients, with 10 (9.8%) patients having severe deficiencies requiring periods of parenteral nutrition. Seven (6.9%) patients required limb lengthening or reversal procedures. There were 16 (15.7%) patients who experienced a complication within 30 days, including 3 (2.9%) anastomotic leaks. Surgery was required in 42 (41.2%) patients for late complications. Conclusion Revisional malabsorptive bariatric surgery induces significant long-term weight loss and comorbidity resolution. High rates of temporary and permanent attrition from follow-up are of major concern, given the high prevalence of nutritional deficiencies. These data question the long-term safety of malabsorptive bariatric procedures due to the inability to ensure compliance with nutritional supplementation and long-term follow-up requirements. Graphical abstract ![]()
Key points • Revisional bariatric surgery workload is increasing • Revisional malabsorptive surgery is efficacious for weight loss and comorbidity resolution • Revisional malabsorptive surgery is associated with high rates of nutritional deficiencies • Attrition from follow-up in this specific cohort of patients is of particular concern due to the risk of undiagnosed and untreated nutritional deficiencies Supplementary Information The online version contains supplementary material available at 10.1007/s11695-022-06019-7.
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Wang A, Wang H, Abdurakhmanov A, Vijayanagar V, Thompson KJ, Mckillop IH, Barbat S, Bauman R, Gersin KS, Kuwada TS, Nimeri A. Safety of Primary Versus Revisional Biliopancreatic Diversion with Duodenal Switch in Patients with Super Obesity Using the MBSAQIP database. Obes Surg 2022; 32:1459-1465. [PMID: 35137289 DOI: 10.1007/s11695-022-05953-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/29/2022] [Accepted: 02/03/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION For patients with super obesity (BMI > 50 kg/m2), biliopancreatic diversion/duodenal switch (BPD/DS) can be an effective bariatric operation. Technical challenges and patient safety concerns, however, have limited its use as a primary procedure. This study sought to assess the safety of primary versus revisional BPD/DS. MATERIALS AND METHODS The MBSAQIP database was queried for primary and revisional BPD/DS (2015-2018). Inclusion criteria were patients ≥ 18 years of age, BMI > 50 kg/m2, and with no concurrent procedures. Preoperative variables were compared using a chi-square test or Wilcoxon two-sample tests. Multivariate logistic or robust linear regression models were used to compare outcomes. RESULTS There were 3,378 primary BPD/DS and 487 revisional BPD/DS patients. Primary BPD/DS patients had higher BMI (56.5 [IQR4.4] versus 54.8 [IQR4] kg/m2, p < 0.0001) and had more diabetes mellitus type II (29.1% versus 17.2%, p < 0.0001). Intraoperatively, revisional BPD/DS had longer operative time (165 [IQR47] min versus 139 [IQR100] min, p < 0.0001). After adjusting for preoperative characteristics, there was no difference in 30-day readmission or ED visits (primary 12.9% versus revisional 14.6%), reoperation or reintervention (primary 5.7% versus revisional 7.8%), or mortality (primary 0.4% versus revisional 0.6%). In contrast, the revisional BPD/DS patients had higher odds of major morbidity (primary 3.4% versus revisional 5.3%, OR 1.9, CI 1.1-3.2, p = 0.019). CONCLUSIONS Revisional BPD/DS is associated with higher morbidity than primary BPD/DS in patients with super obesity. These patients should thus be counselled appropriately when choosing a primary or revisional bariatric procedure.
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Affiliation(s)
- Alice Wang
- Department of Surgery, Wright State University, Dayton, OH, 45324, USA
| | - Huaping Wang
- Division of Research, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | | | | | - Kyle J Thompson
- Division of Research, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Iain H Mckillop
- Division of Research, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Selwan Barbat
- Atrium Health Weight Management, Section of Bariatric & Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, 2630 East 7th Street, Charlotte, NC, 28204, USA
| | - Roc Bauman
- Atrium Health Weight Management, Section of Bariatric & Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, 2630 East 7th Street, Charlotte, NC, 28204, USA
| | - Keith S Gersin
- Atrium Health Weight Management, Section of Bariatric & Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, 2630 East 7th Street, Charlotte, NC, 28204, USA
| | - Timothy S Kuwada
- Atrium Health Weight Management, Section of Bariatric & Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, 2630 East 7th Street, Charlotte, NC, 28204, USA
| | - Abdelrahman Nimeri
- Atrium Health Weight Management, Section of Bariatric & Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, 2630 East 7th Street, Charlotte, NC, 28204, USA.
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4
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Minimally invasive versus open duodenal switch: a nationwide retrospective analysis. Surg Endosc 2022; 36:7000-7007. [DOI: 10.1007/s00464-022-09020-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 01/03/2022] [Indexed: 11/25/2022]
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Al-Mazrou AM, Cruz MV, Dakin G, Bellorin-Marin OE, Pomp A, Afaneh C. Robotic Duodenal Switch Is Associated with Outcomes Comparable to those of Laparoscopic Approach. Obes Surg 2021; 31:2019-2029. [PMID: 33462669 PMCID: PMC7813533 DOI: 10.1007/s11695-020-05198-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/20/2020] [Accepted: 12/29/2020] [Indexed: 12/26/2022]
Abstract
Introduction/Purpose This study evaluates the outcomes of robotic duodenal switch (RDS) when compared to conventional laparoscopy (LDS). Materials and Methods Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), patients who underwent RDS were compared to those of LDS (2015–2018) for perioperative characteristics and thirty-day postoperative outcomes. Operative complexity, complications, and resource utilization trends were plotted over the included years for the two approaches. Multivariable analysis was conducted to characterize the impact of each approach on these outcomes. Results Of 7235 minimally invasive operations, 5720 (79.1%) were LDS while 1515 (20.9%) were RDS. Intraoperative endoscopy, anastomosis testing, and shorter operative duration were associated with LDS. RDS group had more concomitant procedures with less attending assistance. The odds ratios of organ space infection and sepsis were equivalent. RDS increased the odds ratios for venous thromboembolism [VTE] (odds ratio [OR] = 2.3, 95% confidence interval [CI] = 1.1–4.8, p = 0.02) and early discharge (OR = 7.3, CI = 4.9–10.9, p < 0.01). The difference in wound infection between LDS and RDS has been decreasing (1.5% and 1.5% in 2018 from 2.3% and 4.1% in 2015, respectively) over the years. Similarly, the decreasing trends were noted for systemic infections. Conclusion While the development of VTE after RDS was higher, most of the other complications were comparable between LDS and RDS in this study. RDS may reduce the need for advanced intraoperative assistance and minimize hospital stay in select cases, without increasing morbidity. The recent trends suggest a gradual decrease in the variations between LDS and RDS outcomes over time.
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Affiliation(s)
- Ahmed M Al-Mazrou
- Division of GI Metabolic and Bariatric Surgery, Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medicine, 525 East 68th Street Box 294, New York, NY, 10065, USA
| | - Mariana Vigiola Cruz
- Division of GI Metabolic and Bariatric Surgery, Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medicine, 525 East 68th Street Box 294, New York, NY, 10065, USA
| | - Gregory Dakin
- Division of GI Metabolic and Bariatric Surgery, Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medicine, 525 East 68th Street Box 294, New York, NY, 10065, USA
| | - Omar E Bellorin-Marin
- Division of GI Metabolic and Bariatric Surgery, Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medicine, 525 East 68th Street Box 294, New York, NY, 10065, USA
| | - Alfons Pomp
- Division of GI Metabolic and Bariatric Surgery, Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medicine, 525 East 68th Street Box 294, New York, NY, 10065, USA
| | - Cheguevara Afaneh
- Division of GI Metabolic and Bariatric Surgery, Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medicine, 525 East 68th Street Box 294, New York, NY, 10065, USA.
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Khewater T, Yercovich N, Grymonprez E, Horevoets J, Mulier JP, Dillemans B. Twelve-Year Experience with Roux-en-Y Gastric Bypass as a Conversional Procedure for Vertical Banded Gastroplasty: Are We on the Right Track? Obes Surg 2020; 29:3527-3535. [PMID: 31187456 DOI: 10.1007/s11695-019-04002-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Talal Khewater
- Department of Surgery, AZ Sint-Jan Brugge-Oostende AV, Campus Sint-Jan, Ruddershove 10, 8000, Brugge, Belgium.
| | - Nathalie Yercovich
- Department of Surgery, AZ Sint-Jan Brugge-Oostende AV, Campus Sint-Jan, Ruddershove 10, 8000, Brugge, Belgium
| | - Edouard Grymonprez
- Faculty of Medicine, KU Leuven University, Herestraat 49, 3000, Leuven, Belgium
| | - Julie Horevoets
- Department of Surgery, AZ Sint-Jan Brugge-Oostende AV, Campus Sint-Jan, Ruddershove 10, 8000, Brugge, Belgium
| | - Jan Paul Mulier
- Department of Anesthesia, AZ Sint-Jan Brugge-Oostende AV, Campus Sint-Jan, Ruddershove 10, 8000, Brugge, Belgium
| | - Bruno Dillemans
- Department of Surgery, AZ Sint-Jan Brugge-Oostende AV, Campus Sint-Jan, Ruddershove 10, 8000, Brugge, Belgium
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Marti-Fernandez R, Cassinello-Fernandez N, Cuenca-Ramirez MD, Lapeña-Rodriguez M, Fernandez-Moreno MC, Alfonso-Ballester R, Ortega-Serrano J. Roux-en-Y Gastric Bypass as an Effective Bariatric Revisional Surgery after Restrictive Procedures. Obes Facts 2020; 13:367-374. [PMID: 32492679 PMCID: PMC7445544 DOI: 10.1159/000507710] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/02/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Revisional surgery must be considered when insufficient weight loss is attained or weight is subsequently regained. This study aimed to investigate the value of Roux-en-Y gastric bypass (RYGB) as a revisional procedure after restrictive surgery. MATERIALS AND METHODS An observational, retrospective study including patients initially operated on for morbid obesity with restrictive techniques (vertical-banded gastroplasty [VBG], adjustable gastric band [AGB], and sleeve gastrectomy) and reoperated with RYGB in our centre between December 1994 and January 2019. Demographic and anthropometric data, associated comorbidities (diabetes mellitus type II, arterial hypertension, dyslipidaemia, and chronic obstructive pulmonary disease) and surgery-related data (approach, complications, and hospital stay) were evaluated at 5 different time points: initial (prior to first intervention), after the first surgical intervention, before the second intervention (gastric bypass), after the gastric bypass, and at present. RESULTS A total of 63 patients were included. VBG was the most frequent initial procedure (n = 33). The mean age was 39 ± 9.52 years, and the average initial weight was 143.53 ± 28.6 kg. Weight loss was achieved in all groups, with a median excess weight loss of 58% after the first surgery and 40.3% after gastric bypass. In terms of weight loss, the best results after the second surgery were obtained when the first surgery was AGB, with statistically significant differences. CONCLUSIONS RYGB is effective as a conversion procedure after a previous restrictive surgery, obtaining a significant reduction in weight and BMI. It has an acceptable morbidity rate and is more effective after an AGB.
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Affiliation(s)
- Rosa Marti-Fernandez
- Department of General and Digestive Surgery, Hospital Clinico Universitario, Valencia, Spain
| | - Norberto Cassinello-Fernandez
- Department of General and Digestive Surgery, Hospital Clinico Universitario, Valencia, Spain
- Department of Surgery, University of Valencia, Valencia, Spain
| | | | - Maria Lapeña-Rodriguez
- Department of General and Digestive Surgery, Hospital Clinico Universitario, Valencia, Spain
| | | | | | - Joaquin Ortega-Serrano
- Department of General and Digestive Surgery, Hospital Clinico Universitario, Valencia, Spain,
- Department of Surgery, University of Valencia, Valencia, Spain,
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Moura DTHD, Sachdev AH, Lu PW, Ribeiro IB, Thompson CC. Acute bleeding after argon plasma coagulation for weight regain after gastric bypass: A case report. World J Clin Cases 2019; 7:2038-2043. [PMID: 31423435 PMCID: PMC6695547 DOI: 10.12998/wjcc.v7.i15.2038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/21/2019] [Accepted: 07/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is the most commonly performed surgical procedure used to treat obesity worldwide. Despite satisfactory results in terms of weight loss, over time many patients experience weight regain. There are many factors that contribute to weight regain after RYGB, including the diameter of the gastric-jejunal anastomosis (GJA). One of the most commonly performed endoscopic procedures for weight regain after RYGB is argon plasma coagulation (APC). We report a case of hematemesis after outlet revision with APC. We highlight several treatment modalities that can be used to treat this complication.
CASE SUMMARY A 45-year-old female with a history of weight regain after RYGB was referred for possible endoscopic treatment for weight regain. On endoscopic evaluation, the diameter of the GJA was 22 mm. Due to the dilated GJA, treatment with APC was performed. Several months later she reported a return of poor satiety and an increased appetite. A repeat endoscopy was then performed. The GJA was approximately 15 mm and was incompetent. APC was performed. One day post procedure she had four episodes of hematemesis. An endoscopy was performed and a large ulcer with a visible arterial vessel was visualized at the GJA. Coagulation was attempted using a Coagrasper and after initial contact with the vessel, the vessel started oozing. Due to fibrosis and the depth of ulceration in the area, clips and repeat APC could not be used. Therefore, an attempt to inject epinephrine injection was made. However, persistent oozing was noted. As a result, hemostatic powder was applied to the region of the bleeding vessel. Subsequently, no more bleeding was observed. On follow-up, the patient remained hemodynamically stable and a second look endoscopy was not performed. The patient was discharged three days later.
CONCLUSION APC revision of the GJA is known to be a relatively safe and effective strategy to manage weight regain post RYGB. Anastomotic site bleeding is an infrequent and potentially life-threatening complication associated with this therapy. Endoscopic management is the first line therapy used to achieve hemostasis in these cases.
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Affiliation(s)
- Diogo Turiani Hourneaux de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
- Department of Gastroenterology, Clinics Hospital of São Paulo University, São Paulo 05403-00, Brazil
| | - Amit H Sachdev
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Po-Wen Lu
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan City, 33305, Taiwan
| | - Igor Braga Ribeiro
- Department of Gastroenterology, Clinics Hospital of São Paulo University, São Paulo 05403-00, Brazil
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
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Hourneaux De Moura DT, Thompson CC. Endoscopic management of weight regain following Roux-en-Y gastric bypass. Expert Rev Endocrinol Metab 2019; 14:97-110. [PMID: 30691326 DOI: 10.1080/17446651.2019.1571907] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 01/16/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION With the cumulative increase in the number of patients undergoing bariatric surgery, postoperative weight regain has become a considerable challenge. Mechanisms for weight regain are not fully understood and the process is likely multifactorial in many cases. Endoluminal revisions that reduce gastric pouch size and diameter of the gastrojejunal anastomosis may offer an effective and less invasive management strategy for this population. AREAS COVERED We critically review data from case series, retrospective and prospective studies, and meta-analyses pertaining to weight regain after gastric bypass. A variety of endoscopic revision approaches are reviewed, including technique details, procedural safety and efficacy, and post-procedure care. EXPERT COMMENTARY Given the proliferation of endoluminal therapies with evidence showing safety and efficacy in the treatment of weight regain, it is likely that endoscopic revision will be the gold standard to treat weight regain in patients with gastric bypass.
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Affiliation(s)
- Diogo Turiani Hourneaux De Moura
- a Division of Gastroenterology, Hepatology and Endoscopy , Harvard Medical School, Brigham and Women's Hospital , Boston , MA , USA
| | - Christopher C Thompson
- a Division of Gastroenterology, Hepatology and Endoscopy , Harvard Medical School, Brigham and Women's Hospital , Boston , MA , USA
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Devaraj P, Gavini H. Endoscopic management of postoperative fistulas and leaks. GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Prathab Devaraj
- Department of Gastroenterology, Hepatology, and Nutrition, Banner University Medical Center, Tucson, AZ, USA
| | - Hemanth Gavini
- Department of Gastroenterology, Hepatology, and Nutrition, Banner University Medical Center, Tucson, AZ, USA
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Abstract
Revisional bariatric procedures are increasingly common. With more primary procedures being performed to manage severe obesity and its complications, 5% to 8% of these procedures will fail, requiring revisional operation. Reasons for revisional bariatric surgery are either primary inadequate weight loss, defined as less than 25% excess body weight loss, or weight recidivism, defined as a gain of more than 10 kg based on the nadir weight; however, each procedure also has inherit specific complications that can also be indications for revision. This article reviews the history of each primary bariatric procedure, indications for revision, surgical options, and subsequent outcomes.
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Affiliation(s)
- Noah J Switzer
- Department of Surgery, University of Alberta, Room 405 CSC, 10240 Kingsway Avenue, Edmonton, Alberta T5H 3V9, Canada
| | - Shahzeer Karmali
- Department of Surgery, Minimally Invasive Gastrointestinal and Bariatric Surgery, University of Alberta, Room 405 CSC, 10240 Kingsway Avenue, Edmonton, Alberta T5H 3V9, Canada
| | - Richdeep S Gill
- Department of Surgery, Peter Lougheed Hospital, University of Calgary, 3rd Floor West Wing, Room 3656, 3500 26th Avenue Northeast, Calgary, Alberta, T1Y 6J4, Canada
| | - Vadim Sherman
- Weill Cornell Medical College, Bariatric and Metabolic Surgery Center, Houston Methodist Hospital, 6550 Fannin Street, SM 1661, Houston, TX 77030, USA.
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12
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Kumar N, Thompson CC. Transoral outlet reduction for weight regain after gastric bypass: long-term follow-up. Gastrointest Endosc 2016; 83:776-9. [PMID: 26344204 DOI: 10.1016/j.gie.2015.08.039] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 08/15/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Dilated gastrojejunal anastomosis aperture is associated with weight regain after Roux-en-Y gastric bypass (RYGB). Transoral outlet reduction (TORe) has proved safe and effective for the treatment of weight regain. The objective of this study was to determine the long-term weight trend and number needed to treat for TORe. METHODS This prospective series included consecutive post-RYGB patients with weight regain and a gastrojejunal anastomosis aperture greater than 15 mm. TORe was performed with a full-thickness endoscopic suturing device. RESULTS A total of 150 patients who had regained 49.9% ± 3.6% of the weight lost after gastric bypass (4.1 ± 0.3 kg/y after nadir) before TORe. At TORe, body mass index was 40.2 ± 0.8 kg/m(2) and weight was 110.7 ± 2.2 kg. At 1 year, weight loss was 10.5 ± 1.2 kg or 24.9 ± 2.6% excess weight loss (EWL); at 2 years, weight loss was 9.0 ± 1.7 kg or 20.0% ± 6.4% EWL; at 3 years, weight loss was 9.5 ± 2.1 kg or 19.2% ± 4.6% EWL. The number needed to treat for arrest of weight regain was 1.0 at 6 months, 1.1 at 1 year, and 1.2 at 2 and 3 years. The number needed to treat to maintain weight loss of ≥5 kg from TORe was 1.2 at 6 months, 1.5 at 1 year, 1.9 at 2 years, and 2.0 at 3 years. CONCLUSION TORe safely and effectively arrested weight regain and provided durable weight loss with a low number needed to treat. Patients with weight regain after RYGB should be evaluated for dilation of the gastrojejunal anastomosis, as TORe can be part of a multidisciplinary strategy to address post-RYGB weight regain.
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Affiliation(s)
- Nitin Kumar
- Developmental Endoscopy Lab, Brigham and Women's Hospital, Boston, Massachusetts, USA
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13
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Laparoscopic conversion of failed vertical banded gastroplasty to Roux-en-Y gastric bypass or biliopancreatic diversion. Surg Obes Relat Dis 2015; 11:1085-91. [DOI: 10.1016/j.soard.2015.01.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 12/21/2014] [Accepted: 01/31/2015] [Indexed: 11/19/2022]
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14
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Nguyen D, Dip F, Hendricks L, Lo Menzo E, Szomstein S, Rosenthal R. The Surgical Management of Complex Fistulas After Sleeve Gastrectomy. Obes Surg 2015. [DOI: 10.1007/s11695-015-1788-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Kumar N. Endoscopic therapy for weight loss: Gastroplasty, duodenal sleeves, intragastric balloons, and aspiration. World J Gastrointest Endosc 2015; 7:847-859. [PMID: 26240686 PMCID: PMC4515419 DOI: 10.4253/wjge.v7.i9.847] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 01/06/2015] [Accepted: 06/11/2015] [Indexed: 02/05/2023] Open
Abstract
A new paradigm in the treatment of obesity and metabolic disease is developing. The global obesity epidemic continues to expand despite the availability of diet and lifestyle counseling, pharmacologic therapy, and weight loss surgery. Endoscopic procedures have the potential to bridge the gap between medical therapy and surgery. Current primary endoscopic bariatric therapies can be classified as restrictive, bypass, space-occupying, or aspiration therapy. Restrictive procedures include the USGI Primary Obesity Surgery Endolumenal procedure, endoscopic sleeve gastroplasty using Apollo OverStitch, TransOral GAstroplasty, gastric volume reduction using the ACE stapler, and insertion of the TERIS restrictive device. Intestinal bypass has been reported using the EndoBarrier duodenal-jejunal bypass liner. A number of space-occupying devices have been studied or are in use, including intragastric balloons (Orbera, Reshape Duo, Heliosphere BAG, Obalon), Transpyloric Shuttle, and SatiSphere. The AspireAssist aspiration system has demonstrated efficacy. Finally, endoscopic revision of gastric bypass to address weight regain has been studied using Apollo OverStitch, the USGI Incisionless Operating Platform Revision Obesity Surgery Endolumenal procedure, Stomaphyx, and endoscopic sclerotherapy. Endoscopic therapies for weight loss are potentially reversible, repeatable, less invasive, and lower cost than various medical and surgical alternatives. Given the variety of devices under development, in clinical trials, and currently in use, patients will have multiple endoscopic options with greater efficacy than medical therapy, and with lower invasiveness and greater accessibility than surgery.
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Abu-Gazala S, Sadot E, Maler I, Golomb I, Carmeli I, Keidar A. Laparoscopic conversion of failed silastic ring vertical gastroplasty (SRVG) and vertical banded gastroplasty (VBG) into biliopancreatic diversion (BPD). J Gastrointest Surg 2015; 19:625-30. [PMID: 25560186 DOI: 10.1007/s11605-014-2736-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 12/16/2014] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Samir Abu-Gazala
- The Department of Surgery, Hadassah Hebrew University Medical Center, PO Box 12000, Ein Kerem, Jerusalem, 91120, Israel,
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Abstract
OBJECTIVE To assess the impact of revisional surgery after laparoscopic adjustable gastric banding (LAGB) on weight loss at 12 and 24 months. BACKGROUND There is no uniform consensus as to the optimal procedure for patients requiring revision after LAGB. Few studies address the issue of weight loss after band salvage procedures, despite this being a critical factor in deciding which reoperative procedure to choose. METHODS A retrospective analysis was conducted of adult patients who underwent LAGB from January 1, 2001 to June 30, 2009 at a single institution. Patients who required revision for pouch-related problems including band slippage, pouch dilation, and hiatal hernia were studied. Demographic data, body mass index (BMI), percentage excess weight loss (% EWL), and operative details were recorded. Weights were recorded at 12 and 24 months after revision. These were compared with initial weight, weight before revision, and weight in patients who did not have a reoperation. RESULTS Of 3876 patients, 390 patients were included in analysis of weight outcomes after revision. The procedure-related mortality was 0%. Early (30-day) complications occurred in 0.5%, late complications (erosion) in 0.5%, and 29 patients (7.4%) required a second revision. For patients undergoing revision, the initial weight was 124.06 ± 21.28 kg and BMI was 44.80 ± 6.12 kg/m. At reoperation, weight was 89.18 ± 20.51 kg, BMI was 32.25 ± 6.50 kg/m and, %EWL was 54.13 ± 21.80%. Twelve months postrevision, weight was 92.24 ± 20.22 kg, BMI was 33.32 ± 6.41 kg/m, and %EWL was 48.81 ± 22.71%. Weight was 92.42 ± 19.91 kg, BMI was 33.53 ± 6.25 kg/m, and %EWL was 47.50 ± 22.91% twenty-four months postrevision. CONCLUSIONS Reoperation for pouch-related problems after LAGB is safe and effective. Weight loss is maintained after reoperation.
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Laparoscopic gastric sleeve with band removal. Surg Obes Relat Dis 2014; 10:759-63. [DOI: 10.1016/j.soard.2014.02.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 02/18/2014] [Accepted: 02/19/2014] [Indexed: 11/20/2022]
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Kumar N, Thompson CC. Comparison of a superficial suturing device with a full-thickness suturing device for transoral outlet reduction (with videos). Gastrointest Endosc 2014; 79:984-9. [PMID: 24721521 PMCID: PMC5038592 DOI: 10.1016/j.gie.2014.02.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 02/03/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Larger gastrojejunal (GJ) anastomosis aperture is one independent predictor for weight regain after Roux-en-Y gastric bypass. Transoral outlet reduction (TORe) has proven safe and effective for treatment of weight regain by using a superficial-thickness (ST) suturing device. Full-thickness (FT) suturing devices are now available, potentially providing more effective results. OBJECTIVE To compare effectiveness of superficial-thickness with full-thickness TORe. DESIGN Matched cohort study: patients were matched sequentially by GJ anastomosis aperture, body mass index, and age. SETTING Tertiary-care center. PATIENTS A total of 59 consecutive patients undergoing full-thickness TORe were matched with 59 patients undergoing superficial-thickness TORe. All had GJ anastomosis apertures >20 mm. INTERVENTION Transoral outlet reduction. MAIN OUTCOME MEASUREMENTS Weight loss and rate of adverse events. RESULTS Post-TORe GJ anastomosis apertures were similar between groups (ST 6.9 ± 0.2 mm vs FT 7.1 ± 0.3 mm). Weight loss was greater at 6 months in the FT group (10.6 ± 1.8 kg in FT vs 4.4 ± 0.8 kg in ST; P < .01) and at 1 year (8.6 ± 2.5 kg in FT vs 2.9 ± 1.0 kg in ST; P < .01). Excess weight loss was greater in the FT group at 6 months (20.4 ± 3.3% in FT vs 8.1 ± 2.5% in ST; P < .01) and at 1 year (18.9 ± 5.4% in FT vs 9.1 ± 2.3% in ST; P = .03). LIMITATIONS This was a single-center, retrospective, cohort study. CONCLUSION There is level 1b evidence for effectiveness of TORe by using a superficial mucosal suturing device. This matched cohort study compared TORe by using the same ST suturing device with TORe by using a newer, FT suturing device and the same operative methods. FT TORe resulted in significantly more weight loss than ST TORe at 6 months and at 1 year. Full-thickness TORe is a significant improvement over ST TORe for endoscopic therapy of weight regain in patients with dilated GJ anastomosis.
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Affiliation(s)
- Nitin Kumar
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts
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Laparoscopic removal of poor outcome gastric banding with concomitant sleeve gastrectomy. Obes Surg 2014; 23:782-7. [PMID: 23462858 DOI: 10.1007/s11695-013-0895-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Laparoscopic adjustable gastric banding (LAGB) has a significant incidence of long-term failure, which may require an alternative revisional bariatric procedure to remediate. Unfortunately, there is few data pinpointing which specific revisional procedure most effectively addresses failed gastric banding. Recently, it has been observed that laparoscopic sleeve gastrectomy (LSG) is a promising primary bariatric procedure; however, its use as a revisional procedure has been limited. This study aims to evaluate the safety and efficacy of LSG performed concomitantly with removal of a poor-outcome LAGB. METHODS A retrospective review was performed on patients who underwent LAGB removal with concomitant LSG at King Saud University in Saudi Arabia between September 2007 and April 2012. Patient body mass index (BMI), percentage of excess weight loss (%EWL), duration of operation, length of hospital stay, complications after LSG, and indications for revisional surgery were all reviewed and compared to those of patients who underwent LSG as a primary procedure. RESULTS Fifty-six patients (70 % female) underwent conversion of LAGB to LSG concomitantly, and 128 (66 % female) patients underwent primary LSG surgery. The revisional and primary LSG patients had similar preoperative ages (mean age 33.5 ± 10.7 vs. 33.6 ± 9.0 years, respectively; p = 0.43). However, revisional patients had a significantly lower BMI at the time of surgery (44.4 ± 7.0 kg/m(2) vs. 47.9 ± 8.2; p < 0.01). Absolute BMI postoperative reduction at 24 months was 14.33 points in the revision group and 18.98 points in the primary LSG group; similar %EWL was achieved by both groups at 24 months postoperatively (80.1 vs. 84.6 %). Complications appeared in two (5.5 %) revisional patients and in nine (7.0 %) primary LSG patients. No mortalities occurred in either group. CONCLUSIONS Conversion of LAGB by means of concomitant LSG is a safe and efficient procedure and achieves similar outcomes as primary LSG surgery alone.
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Obinwanne KM, Kothari SN. Revisions for Failed Weight Loss. CURRENT SURGERY REPORTS 2013. [DOI: 10.1007/s40137-013-0022-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Kumar N, Thompson CC. Endoscopic management of complications after gastrointestinal weight loss surgery. Clin Gastroenterol Hepatol 2013; 11:343-53. [PMID: 23142331 DOI: 10.1016/j.cgh.2012.10.043] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 10/23/2012] [Accepted: 10/26/2012] [Indexed: 02/07/2023]
Abstract
As more patients undergo bariatric surgery, gastroenterologists will increasingly encounter variant postsurgical anatomies and postoperative complications. We discuss the diagnosis and management of bleeding, ulcers, foreign bodies, stenoses, leaks, fistulas, pancreaticobiliary diseases, weight regain, and dilated outlets.
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Affiliation(s)
- Nitin Kumar
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Kumar N, Thompson CC. Endoscopic therapy for postoperative leaks and fistulae. Gastrointest Endosc Clin N Am 2013; 23:123-36. [PMID: 23168123 DOI: 10.1016/j.giec.2012.10.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic techniques for the treatment of postoperative fistulae and leaks are rapidly developing. Conventional surgical therapy for postsurgical leaks and fistulae is associated with significant morbidity and mortality. Novel endoscopic therapies have demonstrated safety, despite the inherent challenges of intervention in this patient population, and are steadily building evidence for efficacy relative to surgical management. The article examines endoscopic therapy for leaks and fistulae after esophageal, gastric, bariatric, colonic, and pancreaticobiliary surgery.
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Affiliation(s)
- Nitin Kumar
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA 02115, USA
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Revisional surgery after failed laparoscopic adjustable gastric banding: a systematic review. Surg Endosc 2012; 27:740-5. [PMID: 22936440 DOI: 10.1007/s00464-012-2510-2] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2012] [Accepted: 07/11/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Laparoscopic adjustable gastric banding (LAGB) has emerged as one of the most commonly performed bariatric procedures worldwide. Unfortunately, revisional surgery is required in 20-30 % of cases. Several revisional strategies have been proposed, but there is no consensus regarding the best surgical option. This systematic review was designed to determine which revisional surgery (laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, or laparoscopic biliopancreatic diversion with duodenal switch) is best suited to enhance weight loss following failed LAGB due to complications or inadequate weight loss. METHODS EMBASE, MEDLINE, PsycINFO, and Cochrane Clinical Trials were searched using the most comprehensive timeline for each database. A total of 24 relevant articles were identified. Two investigators independently extracted data, and differences were resolved by consensus. The weighted means were calculated for weight loss measurements. RESULTS A total of 106, 514, and 71 patients underwent conversion from LAGB to laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), and laparoscopic biliopancreatic diversion and duodenal switch (BPDDS), respectively. Before revisional surgery, the weighted mean body mass index (BMI) was 38.8 (6.9), 43.3 (8.1), and 41.3 (7.2) kg/m(2) for the LSG, LRYGB, and BPDDS groups, respectively. The majority of data was reported at 12-24 months follow-up. The mean BMI within this interval was 28 (10.5), 32.2 (6.4), and 33 (5.7) kg/m(2) for the LSG, LRYGB, and BPDDS groups, respectively. In addition, the mean excess weight loss (EWL) was 22 % (2.8), 57.8 % (11.7), 47.1 % (14) for the LSG, LRYGB, and BPDDS groups, respectively. The EWL reached 78.4 % (35) in the BPPDS group after 2-year follow-up. CONCLUSIONS Failed LAGB is best managed with conversion to another bariatric procedure. Stable weight loss occurs with salvage LRYGB. Although results for revisional BPPDS appear promising, additional research, with higher methodological quality, is needed.
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Abstract
The biliopancreatic diversion with a duodenal switch (BPD-DS) is a less commonly performed but very effective bariatric procedure that has been in existence for more than 20 years. It is particularly effective for the resolution of diabetes and is associated with the highest weight loss among other bariatric operations. Typically, the BPD-DS is not associated with postgastrectomy symptoms, such as dumping and marginal ulceration. Because of its complexity, it has usually been performed by laparotomy in the past; but, more recently, minimally invasive techniques are being used with acceptable risk.
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Affiliation(s)
- Ranjan Sudan
- Department of Surgery, Duke University Medical Center, Box 2834, Durham, NC 27710, USA.
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Is biliopancreatic diversion with duodenal switch a solution for patients after laparoscopic gastric banding failure? Surg Obes Relat Dis 2011; 8:393-9. [PMID: 22030148 DOI: 10.1016/j.soard.2011.09.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 08/26/2011] [Accepted: 09/08/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND Weight loss failure after laparoscopic gastric banding (LAGB) can occur in ≤ 25% of patients. Conversion to a malabsorptive procedure might provide more durable weight loss. The present study evaluated biliopancreatic diversion with duodenal switch (BPD/DS) after LAGB failure with a 3-year follow-up period. METHODS A total of 35 patients underwent BPD/DS after LAGB failure and were prospectively analyzed using a multidisciplinary approach. Weight indexes, co-morbidities, complications, morbidity/mortality, and nutritional status were analyzed. RESULTS Excess weight decreased from 91% (134 kg, body mass index 48 kg/m(2)) to 75% (124 kg, body mass index 44 kg/m(2)) after LAGB failure and decreased further to 40% (100 kg, body mass index 35 kg/m(2)) after BPD/DS. The mean percentage of excess weight loss was 55% after LAGB and BPD/DS together and 48% after BPD/DS alone. The incidence of co-morbidities, such as diabetes, sleep apnea, hypertension, hyperlipidemia, joint problems, and chronic obstructive pulmonary disease was reduced after BPD/DS. Nutritional deficiencies were already present after LAGB failure (e.g., iron, ferritin, vitamins B(12), B(6), A, D, and E, albumin, and calcium) and either increased (folic acid, potassium, and vitamin B(12)), remained stable (iron, ferritin, vitamin A), or decreased after BPD/DS (albumin and vitamins B(6) and E). CONCLUSION BPD/DS provided substantial weight loss after LAGB failure and reduced the incidence of obesity-related co-morbidities during a 3-year period. Long-term nutritional follow-up is advocated for all patients after malabsorptive BPD/DS.
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Systematic literature review of reoperations after gastric banding: is a stepwise approach justified? Surg Obes Relat Dis 2011; 7:99-109. [DOI: 10.1016/j.soard.2010.10.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Revised: 09/27/2010] [Accepted: 10/05/2010] [Indexed: 11/18/2022]
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Greenbaum DF, Wasser SH, Riley T, Juengert T, Hubler J, Angel K. Duodenal switch with omentopexy and feeding jejunostomy--a safe and effective revisional operation for failed previous weight loss surgery. Surg Obes Relat Dis 2010; 7:213-8. [PMID: 21215708 DOI: 10.1016/j.soard.2010.10.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 09/17/2010] [Accepted: 10/29/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND As the number of weight loss operations has increased, the number of patients who have failed to maintain sufficient weight loss has also increased, providing a management challenge to the bariatric surgeon. Conversion to a duodenal switch with omentopexy and feeding jejunostomy was performed for these patients. METHODS Between September 2006 and January 2010, 41 revisional operations were performed at 1 institution and by 1 operating surgeon. The data were prospectively collected and reviewed for several parameters, including excess weight loss, mortality, and morbidity. These results are reported. RESULTS A total of 41 patients underwent conversion of their original bariatric operation to a duodenal switch with omentopexy and feeding jejunostomy. The initial operations had been gastric bypass in 32 patients, vertical banded gastroplasty in 5, and laparoscopic adjustable gastric banding in 4. The average excess weight loss was 54% in 31 patients at 6 months, 66% in 22 patients at 1 year, and 75% in 9 patients at 2 years. No patients died. The average hospital stay was 6.4 days. A total of 9 proven or suspected leaks (22%) developed. One was at the enverted staple line of a jejunojejunostomy that was diagnosed and treated the next day with little subsequent morbidity. The others were at the gastrogastrostomy or lateral gastric staple line and all occurred in conversions from gastric bypass. They were all ischemic type leaks and presented 5-11 days after surgery and closed relatively uneventfully with J-tube feedings and antibiotic/antifungal treatment. Other major complications included 1 pulmonary embolism (2%), 1 small bowel obstruction at the site of the feeding jejunostomy (2%), 2 stenoses (4%)-1 at the duodenoenterostomy and 1 in the body of the vertical gastrectomy. This gives a total major complication rate of 30%. A total of 3 patients required reoperation because of a jejunojejunostomy leak, small bowel obstruction, and stenosis at the vertical gastrectomy. No gastrogastrostomy leaks required surgical or radiologic intervention. One required revision for malnutrition, but otherwise the nutrition remained good. CONCLUSION Revisional surgery to a duodenal switch is a complex operation and carries a high potential for major complications. Nonetheless, it can be accomplished safely with good long-term results. Omentopexy, drainage, and feeding jejunostomy should be considered at surgery to treat the high potential for delayed ischemic leaks.
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Affiliation(s)
- David F Greenbaum
- Lourdes Medical Center of Burlington County, Willingboro, New Jersey, USA.
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Dapri G, Cadière GB, Himpens J. Laparoscopic repeat sleeve gastrectomy versus duodenal switch after isolated sleeve gastrectomy for obesity. Surg Obes Relat Dis 2010; 7:38-43. [PMID: 21115409 DOI: 10.1016/j.soard.2010.08.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2010] [Revised: 06/20/2010] [Accepted: 08/10/2010] [Indexed: 12/25/2022]
Abstract
BACKGROUND Repeat sleeve gastrectomy (re-SG) and the addition of the duodenal switch (DS) are possible options to increase weight loss after isolated SG (ISG). We report the feasibility, safety, and outcomes of laparoscopic re-SG versus DS in patients presenting with insufficient weight loss or weight regain after ISG. METHODS From November 2003 to December 2009, 7 and 19 patients underwent laparoscopic re-SG and DS, respectively, mainly because of the patients' dietary habits: volume eating (hyperphagia) was treated by re-SG and eating meals too frequently (polyphagia) by DS. RESULTS At ISG, the mean weight and BMI was 127.7 ± 31.4 kg, and 45.1 ± 11.8 kg/m(2) for the re-SG group and 119.8 ± 20.9 kg and 41.2 ± 5.5 kg/m(2) for the DS group, respectively. The mean interval between ISG and reoperation was 37.1 ± 20.3 months for the re-SG group and 29.8 ± 24.9 months for the DS group. At reoperation, the mean weight, BMI, and percentage of excess weight loss (%EWL) was 109.7 ± 21 kg, 38.9 ± 8.7 kg/m(2), 24.3 ± 16.6% for the re-SG group and 107.6 ± 19.6 kg, 36.9 ± 4.2 kg/m(2), and 19.5 ± 19.9% for the DS group, respectively. The mean operative time was 137.5 ± 75.5 minutes for the re-SG group and 152.6 ± 54.3 minutes for the DS group. No conversion to open surgery was required, and no mortality occurred. One patient in the re-SG group developed a leak at the angle of His. In the DS group, 1 patient presented with bleeding, 1 patient with a duodenoileostomy leak, and 1 patient with a duodenoileostomy stenosis. The mean hospital stay was 11.5 ± 20.5 days for the re-SG group and 4.7 ± 2.7 days for the DS group. The mean follow-up was 23.2 ± 11.1 months for the re-SG group and 24.9 ± 20.1 months for the DS group. The mean weight, BMI, and %EWL was 100 ± 21.1 kg, 35.3 ± 8.3 kg/m(2), 43.7 ± 24.9% for the re-SG group and 80.7 ± 22.5 kg, 27.3 ± 5.2 kg/m(2), 73.7 ± 27.7% for the DS group, respectively. During follow-up, 3 patients in the DS group required corrective surgery for late complications. CONCLUSION The results of the present study have shown that laparoscopic re-SG is feasible but carries the risk of fistula development, which is difficult to treat. Laparoscopic DS was also shown to be feasible at a cost of not negligible complications, which are easier to manage than with re-SG. The efficacy seemed greater after DS than after re-SG.
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Affiliation(s)
- Giovanni Dapri
- Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium.
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Daskalakis M, Berdan Y, Theodoridou S, Weigand G, Weiner RA. Impact of surgeon experience and buttress material on postoperative complications after laparoscopic sleeve gastrectomy. Surg Endosc 2010; 25:88-97. [PMID: 20526621 DOI: 10.1007/s00464-010-1136-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Accepted: 04/20/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND Sleeve gastrectomy is gaining popularity whether as a primary, staged or revisional operation. The aim of this study is to evaluate the perioperative safety and the learning curve for laparoscopic sleeve gastrectomy (LSG). METHODS We performed a retrospective review of the prospectively collected data for all patients who underwent LSG for the treatment of morbid obesity at our institution from January 2003 to December 2008. RESULTS Data from 230 consecutive patients [male 47%, female 53%; mean age 44.0 ± 10.0 years, mean preoperative body mass index (BMI) 56.7 ± 11.5 kg/m(2)], who were operated upon by three surgeons with different degrees of bariatric experience, were analyzed. There was no 30-day mortality, but there were two cases of late mortality (0.87%). Early complications were noted in 23 cases (10.0%), including 10 cases of leak (4.3%) and 10 cases of hemorrhage (4.3%). In 17 cases (7.4%) reoperations were performed. The rates of overall and major complications did not differ among surgeons or between early and late period of experience for the three surgeons; this trend held true individually and in subgroups. Overall, over the course of the learning curve, a significant decrease in operative time was noted. The only factor that was independently associated with complications was use of buttress material; the likelihood of complications was found to be 72% lower in patients in whom buttress material was used. CONCLUSIONS LSG constitutes a potentially safe anti-obesity procedure with acceptable morbidity. Experience at the beginning can be discouraging, even for surgeons with advanced laparoscopic skills. LSG can be performed safely, with proper mentoring and in appropriate settings, even by less experienced bariatric surgeons. The use of staple-line reinforcement was associated with improved perioperative outcomes, and it should be considered in an attempt to decrease leaks.
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Affiliation(s)
- Markos Daskalakis
- Center for Minimal-Invasive Surgery, Department of General and Bariatric Surgery, Krankenhaus Sachsenhausen, Frankfurt am Main, Germany
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Laparoscopic conversion of Roux-en-Y gastric bypass to biliopancreatic diversion. Surg Endosc 2010; 24:1490-3. [DOI: 10.1007/s00464-009-0796-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Accepted: 11/15/2009] [Indexed: 11/30/2022]
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Dapri G, Cadière GB, Himpens J. Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing three different techniques. Obes Surg 2009; 20:462-7. [PMID: 20012507 DOI: 10.1007/s11695-009-0047-9] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2009] [Accepted: 11/17/2009] [Indexed: 12/26/2022]
Abstract
BACKGROUND Gastric leak and hemorrhage are the most important challenges after laparoscopic sleeve gastrectomy (LSG). In order to reduce these complications, the staple line can be reinforced by absorbable sutures or by the use of glycolide trimethylene carbonate copolymer onto the linear stapler (Gore Seamguard; W.L. Gore & Associates, Inc, Flagstaff, AZ). To our knowledge, there are no randomized studies showing the utility of staple line reinforcement during LSG. The purpose of this study was to randomly compare three techniques in LSG: no staple line reinforcement (group 1), buttressing of the staple line with Gore Seamguard (group 2), and staple line suturing (group 3). METHODS Between January 2008 and February 2009, 75 patients were prospectively and randomly enrolled in the three different techniques of handling the staple line during LSG. The patient groups were similar (NS). RESULTS Mean operative time to perform the stomach sectioning was 15.9 +/- 5.9 min (group 1), 20.8 +/- 8.1 min (group 2), and 30.8 +/- 10.1 min (group 3) (p < 0.001). Mean total operative time was 47.4 +/- 10.7 min (group 1), 48.9 +/- 18.4 min (group 2), and 59.9 +/- 19.6 min (group 3) (p = 0.02). Mean blood loss during stomach sectioning was 19.5 +/- 21.3 mL (group 1), 3.6 +/- 4.7 mL (group 2), and 16.7 +/- 23.5 mL (group 3) (p < 0.001). Mean total blood loss was 48.9 +/- 67.1 mL (group 1), 32.5 +/- 46.5 mL (group 2), and 61.9 +/- 69.4 mL (group 3) (p = 0.03). Mean number of stapler cartridges used was 5.6 +/- 0.7 (group 1), 5.7 +/- 0.7 (group 2), and 5.8 +/- 0.6 (group 3) (NS). Postoperative leak affected one patient (group 1), two patients (group 2), and one patient (group 3) (NS). Mean hospital stay was 3.6 +/- 1.4 days (group 1), 3.9 +/- 1.5 days (group 2), and 2.8 +/- 0.8 days (group 3) (p = 0.01). CONCLUSIONS In LSG, buttressing the staple line with Gore Seamguard statistically reduces blood loss during stomach sectioning as well as overall blood loss. No staple line reinforcement statistically decreases the time to perform stomach sectioning and the total operative time. No significant difference is evidenced in terms of postoperative leak between the three techniques of LSG.
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Affiliation(s)
- Giovanni Dapri
- Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Rue Haute, Brussels, Belgium.
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