Conversion of failed laparoscopic adjustable gastric banding: Sleeve gastrectomy or Roux-en-Y gastric bypass?

Five-year outcomes of revisional bariatric surgery: gastric band to sleeve gastrectomy or to Roux-en-Y gastric bypass

BACKGROUND

Revisional bariatric surgery after an index adjustable gastric band (AGB) may be indicated to remedy weight relapse or band-related complications. We examined outcomes five years following revision from AGB to laparoscopic sleeve gastrectomy (AGB-LSG) or to Roux-en-Y gastric bypass (AGB-RYGB).

METHODS

We conducted a retrospective review to identify patients (men and women, age 18-80) who underwent one revisional bariatric procedure with AGB as the index procedure at two medical centers in our healthcare system between January 2012 and February 2017. We only included patients with a pre-revision BMI > 30 kg/m2 for whom 5-year follow-up data were available. We compared 5-year weight loss and remission of comorbidities in patients undergoing AGB-LSG and AGB-RYGB conversion.

RESULTS

A total of 114 patients met inclusion criteria (65 AGB-LSG, 49 AGB-RYGB). At 5-year post-revision, percent total weight loss (3.4% vs 19.9%; p < 0.001), percent excess weight loss (7.0% vs 50.8%; p < 0.001) and decrease in BMI (1.5 vs 8.8; p < 0.001) was greater in AGB-RYGB vs. AGB-LSG. No significant difference in remission or development of new comorbidities was observed.

CONCLUSION

Conversion of AGB to RYGB is associated with superior intermediate-term weight loss compared to conversion of AGB to LSG. Future multicenter studies with larger sample sizes are necessary to further describe the intermediate-term outcomes of revisional bariatric surgery.

Long-term Outcomes of Laparoscopic Sleeve Gastrectomy as a Revisional Procedure Following Adjustable Gastric Banding: Variations in Outcomes Based on Indication

BACKGROUND

Significant controversy exists regarding the indications and outcomes after laparoscopic adjustable gastric banding (LAGB) conversions to laparoscopic sleeve gastrectomy (LSG).

AIM

To comprehensively determine the long-term outcomes of sleeve gastrectomy as a revisional procedure after LAGB across a range of measures and determine predictors of outcomes.

METHODS

Six hundred revision LSG (RLSG) and 1200 controls (primary LSG (PLSG)) were included. Patient demographics, complications, follow-up, and patient-completed questionnaires were collected.

RESULTS

RLSG vs controls; females 87% vs 78.8%, age 45 ± 19.4 vs 40.6 ± 10.6 years, p = 0.561; baseline weight 119.7 ± 26.2 vs 120.6 ± 26.5 kg p = 0.961). Follow-up was 87% vs 89.3%. Weight loss in RLSG at 5 years, 22.9% vs 29.6% TBWL, p = 0.001, 10 years: 19.5% vs 27% TBWL, p = 0.001. RLSG had more complications (4.8 vs 2.0% RR 2.4, p = 0.001), re-admissions (4.3 vs 2.4% RR 1.8, p = 0.012), staple line leaks (2.5 vs 0.9%, p = 0.003). Eroded bands and baseline weight were independent predictors of complications after RLSG. Long-term re-operation rate was 7.3% for RLSG compared to 3.2% in controls. Severe oesophageal dysmotility predicted poor weight loss. RLSG reported lower quality of life scores (SF-12 physical component scores 75.9 vs 88%, p = 0.001), satisfaction (69 vs 93%, p = 0.001) and more frequent regurgitation (58% vs 42%, p = 0.034).

CONCLUSION

RLSG provides long-term weight loss, although peri-operative complications are significantly elevated compared to PLSG. Longer-term re-operation rates are elevated compared to PLSG. Four variables predicted worse outcomes: eroded band, multiple prior bands, severe oesophageal dysmotility and elevated baseline weight.

Medium Term Outcomes of Revision Laparoscopic Sleeve Gastrectomy after Gastric Banding: A Propensity Score Matched Study

PURPOSE

Revision bariatric surgery may be undertaken after weight loss failure and/or complications following primary bariatric surgery. This study aims to compare the efficacy and safety of revision laparoscopic sleeve gastrectomy (RLSG) after gastric banding (GB) to those of primary laparoscopic sleeve gastrectomy (PLSG).

MATERIALS AND METHODS

A retrospective, propensity-score matched study was conducted to compare between PLSG (control) patients and RLSG after GB (treatment) patients. Patients were matched using 2:1 nearest neighbor propensity score matching without replacement. Patients were compared on weight loss outcomes and postoperative complications for up to five years.

RESULTS

144 PLSG patients were compared against 72 RLSG patients. At 36 months, PLSG patients had significantly higher mean %TWL than RLSG patients (27.4 ± 8.6 [9.3-48.9]% vs. 17.9 ± 10.2 [1.7-36.3]%, p < 0.01). At 60 months, both groups had similar mean %TWL (16.6 ± 8.1 [4.6-31.3]% vs. 16.2 ± 6.0 [8.8-22.4)]%, p > 0.05). Early functional complication rates were slightly higher with PLSG (13.9% vs. 9.7%), but late functional complication rates were comparatively higher with RLSG (50.0% vs. 37.5%). The differences were not statistically significant (p > 0.05). Both early (0.7% vs 4.2%) and late (3.5% vs 8.3%) surgical complication rates were lower in PLSG patients compared to RLSG patients but did not reach statistical significance (p > 0.05).

CONCLUSION

RLSG after GB has poorer weight loss outcomes than PLSG in the short-term. Although RLSG may carry higher risks of functional complications, the safety of RLSG and PLSG are overall comparable.

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.

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.

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.

Revisional Roux-en-Y gastric bypass after failed gastric banding: a case-matched study

BACKGROUND

Revisional surgery is technically demanding and is usually associated with higher intraoperative and perioperative risks than primary procedures. The objective of this study is to compare outcomes of patients who had gastric bypass procedures performed as a rescue procedure for failed gastric banding, with those who had a primary gastric bypass.

MATERIALS AND METHODS

The group of patients undergoing revisional gastric bypass for failed gastric band was matched in a 1:2 ratio with control patients who underwent a primary RYGB, based on gender, score, preoperative body mass index, and comorbidities. Data were retrospectively retrieved.

RESULTS

Thirty one (33.3%) patients underwent band removal and gastric bypass (group A) and 62 (66.6%) only primary gastric bypass (group B). Nonsignificant differences were seen in operative time, operative bleeding, or length of stay. Complications were more frequent in group A. Postoperative weight at 12-month follow-up was greater in group A, however, not statistically significant. Changes in weight, both absolute, and percentage were not different between groups. This observation was also true for BMI, in which no significant differences were seen. Overall, mean follow-up was 16 ± 3.2 months.

CONCLUSION

Gastric bypass can be performed as revisional bariatric surgery, with low complication rates and acceptable outcomes, though not with the same safety as a primary procedure. Gastric bypass is a satisfactory option for patients with a failed gastric band.

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.

Efficacy and safety of bariatric revisions in patients older than 65 years old

BACKGROUND

Bariatric surgery in advanced age patients (>65-years-old) has been proven safe and effective. Revisional bariatric surgery is infrequently required for cases of refractory obesity. However, there is a paucity of data regarding revisional surgery for the elderly. We hypothesize that revisional bariatric surgery is viable and safe in elderly patients.

METHODS

Retrospective chart review of all bariatric revisions performed at two high-volume bariatric centers of excellence between 2011 and 2018. Perioperative and long-term outcomes were compared between patients >65 and those <65-years-old.

RESULTS

145 bariatric revisions were performed for weight loss. 10% (N = 15) were >65 years old. There were no differences in mortality between the two groups There was a longer median length of stay in the younger cohort (2 vs 1 day, p = 0.001). Percent excess weight loss was similar at 12-months, as was resolution of comorbidities.

CONCLUSIONS

Bariatric revisions in elderly patients appears to be safe and effective. Revisional surgery in this population was not shown to have increased morbidity or mortality with similar excess body weight loss when compared to a younger cohort.

Conversion of Adjustable Gastric Banding to Stapling Bariatric Procedures: Single- or Two-stage Approach

OBJECTIVE

The aim of this study was to compare the safety of single- versus two-stage conversion of adjustable gastric band (AGB) to gastric bypass (RYGB) or sleeve gastrectomy (SG).

SUMMARY BACKGROUND DATA

AGB patients often present for conversion to RYGB or SG. The impact of single- or two-stage approach of such conversion remains unclear.

METHODS

A statewide database was used to identify all patients who underwent AGB removal and concurrent (single-stage) or interval (two-stage) RYGB or SG. Propensity score matching schemes were constructed to account for differences in baseline comorbidities and demographics, allowing for matched pairs available for comparisons.

RESULTS

A total of 4330 patients underwent AGB conversion. Complications, readmissions, and ED visits were noted in 394 (9.1%), 278 (6.42%), and 589 (13.6%) patients, respectively. Three hundred sixty-seven matched pairs underwent RYGB; single-stage patients experienced shorter length of stay (LOS) (median difference -1 d, P < 0.0001), less complications [risk difference (RD): -8.4%, 95% confidence interval (CI), -13.4% to -3.5%], readmissions (RD: -5.2%, 95% CI, -9.6% to -0.8%), and ED visits (RD: -5.7%, 95% CI, -11.3% to -0.2%). Eight hundred seventy-five matched pairs underwent SG; single-stage patients experienced improved outcomes in all measures examined. For single-stage procedures (809 pairs), RYGB was associated with longer LOS, and more complications (RD: 3.3%, 95% CI, 0.9%-5.8%), with similar readmissions, and ED visits.

CONCLUSIONS

AGB conversion procedures have low morbidity. Single-stage conversion is associated with lower morbidity compared with the two-stage approach. Conversion to SG seems to be safer than RYGB.

Weight Regain After Gastric Plication: Reoperative Sleeve Gastrectomy or Roux-en-Y Gastric Bypass?-Analysis of 116 Consecutive Cases

PURPOSE

In France, laparoscopic gastric plication (GP) has rarely been utilized as a weight loss procedure. Although relatively safe and efficient, its long-term results are still controversial. The goal of this study is to assess the indications and outcomes of revisional surgery post-GP.

MATERIALS AND METHODS

Between February 2010 and September 2017, patient characteristics undergoing GP were prospectively collected from our database. Failure of conservative treatment or presence of anatomical anomaly explaining weight loss insufficiency was an indication for revisional surgery (RS).

RESULTS

A total of 300 patients were included, 41 patients were lost to follow-up (13.7%), 124 patients (41.3%) had total weight loss (TWL) > 30%, and 116 patients (38.7%) underwent RS. Revisional procedures were laparoscopic Roux-en-Y gastric bypass (RYGB) in 72 patients (62.1%) and sleeve gastrectomy (SG) in 44 patients (37.9%). The median interval to RS was 29 months. The mean operative time was 60 min for the SG and 125 min for the RYGB (p < 0.0001). Mortality was nil. Significant morbidity occurred in eight patients (6.9%) including 4 non-abdominal complications, 1 gastric leak, 1 case of hemorrhage, 1 case of hematoma, and 1 intra-abdominal abscess. The mean length of hospital stay (LOS) was 2.9 days (range, 1-11) for the SG group vs 3.2 days (range, 2-8) for the RYGB group (p = 0.608).

CONCLUSION

GP is associated with a relatively high rate of weight regain or insufficient weight loss. When compared to SG, RYGB seems to be the safer revisional procedure with fewer surgical complications.

Relationship Between Bariatric Surgery and Gastroesophageal Reflux Disease: a Systematic Review and Meta-analysis

The purpose of this study was to investigate the relationship between bariatric surgery (laparoscopic sleeve gastrectomy [LSG] and laparoscopic Roux-en-Y gastric bypass [LRYGB]) and gastroesophageal reflux disease (GERD). The number of obese patients with newly onset, worsened, or improved GERD after bariatric surgery in each article were extracted. In the pooled analysis, LSG was associated with a higher risk of GERD than LRYGB (odds ratio [OR] = 5.10, 95% confidence interval [CI] 3.60-7.23, p < 0.001). Compared with LSG, LRYGB had a better effect on GERD (OR = 0.19, 95% CI 0.12-0.30, p < 0.001). LRYGB was more effective for treating GERD in obese patients than LSG and the incidence of newly onset GERD after LRYGB was lower.

Reoperations for Long-Term Complications Following Laparoscopic Adjustable Gastric Banding: Analysis of Incidence and Causality

Background: Laparoscopic adjustable gastric banding (LAGB) gained popularity in the early 2000s as a purely restrictive procedure with modest weight loss. The potential for complications requiring reoperation has since become evident. A retrospective review was performed to determine the incidence of long-term complications and predictive factors requiring surgical reintervention after LAGB.

Methods: Institutional review board approval was obtained, and a retrospective review of 200 consecutive patients undergoing LAGB over a period of six years was conducted at a single institution with American Society of Metabolic and Bariatric Surgery Center of Excellence designation. Data were collected on patient characteristics, comorbid conditions and complications requiring reintervention. Statistical analysis was performed using SPSS Statistics software (IBM Corp., Armonk, NY).

Results: Of the 200 patients, 176 (90.7%) were female with an average age of 53.6 years and preoperative body mass index (BMI) of 44.2 kg/m². The average follow-up was 46 months. Complications occurred in 55 (28.4%) patients with band slippage/prolapse as the most common need for reoperation. Younger age, lack of comorbidities and diet/exercise compliance were associated with reintervention.

Conclusions: LAGB has a high rate of reoperation secondary to complications associated with younger age. Alternative bariatric procedures may be more appropriate in these patients who have fewer comorbid conditions and are motivated to improve his or her health.

Clinical Outcomes of Sleeve Gastrectomy Versus Roux-En-Y Gastric Bypass After Failed Adjustable Gastric Banding

BACKGROUND

Over recent decades, laparoscopic adjustable gastric banding (LAGB) has been among the most common bariatric surgeries. Nowadays, many patients require revision surgery due to insufficient weight loss and band-related complications. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the two most common revision surgeries for failed LAGB, but the conclusions about their efficacy and safety have been inconsistent. This meta-analysis aimed to review the clinical outcomes of SG and RYGB after failed LAGB.

METHODS

In accordance with the PRISMA guidelines, the PubMed, Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were systematically searched for articles that had studied the efficacy and safety of SG and RYGB. The most appropriate effects model was chosen based on the heterogeneity of the articles included in this meta-analysis. Statistical analysis was conducted using Stata 14.0.

RESULTS

Of 586 articles that were retrieved, 16 articles which examined 2141 SG and 2990 RYGB patients met the inclusion criteria. The patients in RYGB groups showed increased percent excess weight loss (%EWL) at 12 and 24 months after revision surgery but no statistically significant change was found about %EWL after 3, 6, or 36 months. In addition, RYGB was associated with a higher rate of complications, interventions, and readmission in addition to being of more operative time.

CONCLUSIONS

This review suggested that RYGB was more effective at demonstrating weight loss after 12 and 24 months, but comparisons of the long-term efficacy of RYGB with that of SG remain inconclusive. In addition, RYGB was accompanied by a greater number of post-operative complications, interventions, and readmissions. Thus, surgeons should consider the overall status of the patients and their comorbidities as crucial factors when selecting a form of revision surgery. Additional high-quality randomized controlled studies are required to further compare the efficacy and safety of these treatments with longer follow-up times.

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.

Efficiency of Laparoscopic One-Step Revision of Failed Adjusted Gastric Banding to Gastric Sleeve: a Retrospective Review of 101 Consecutive Patients

BACKGROUND

Until recently, laparoscopic adjustable gastric banding (LAGB) was one of the most commonly performed bariatric surgeries worldwide. Today, its high rate of complications and failure rates up to 70% requires revisional surgery. The one-stage conversion from LAGB to laparoscopic sleeve gastrectomy (LSG) has been shown to be safe, although there are some concerns on efficacy and long-term weight loss.

OBJECTIVES

To demonstrate that one-step revision of LAGB to another restrictive procedure, such as LSG, might have efficient long-term outcomes.

METHODS

The charts from 133 revisional LSGs for failed or complicated LAGB were retrospectively reviewed for the period between January 2010 and August 2017. Thirty-two patients were excluded for loss to follow-up. Demographics, complications, and percentage of excess weight loss (%EWL) were determined.

RESULTS

One hundred one patients were included (85 women and 16 men), with a mean age of 48.5 years, and a mean body mass index of 47.1 kg/m². During the follow-up, 15 patients (15%) underwent a second revisional surgery for weight loss failure (8 Roux-en-Y gastric bypass (RYGBP), 3 biliopancreatic diversion, 3 single anastomosis duodenal-ileal bypass, 1 revisional LSG). Ten patients (10%) had long-term complications (8 severe reflux and 2 stenosis) during this period and underwent a second revisional surgery (10 RYGBP). The remaining 76 had a mean follow-up of 4.3 years and a mean %EWL of 53.2%.

CONCLUSION

Single-stage conversion to LSG is a safe and appropriate solution for failed or complicated LAGB with good long-term weight loss.

Roux-en-Y gastric bypass, sleeve gastrectomy, or one anastomosis gastric bypass as rescue therapy after failed adjustable gastric banding: a multicenter comparative study

BACKGROUND

To date, laparoscopic adjustable gastric banding remains the third most commonly performed surgical procedure for weight loss. Some patients fail to get acceptable outcomes and undergo revisional surgery at rates ranging from 7% to 60%. Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB), and sleeve gastrectomy (SG) are among the most common salvage options for failed laparoscopic adjustable gastric banding.

OBJECTIVE

To compare the outcomes of converting failed laparoscopic adjustable gastric banding to RYGB, OAGB, or SG.

METHODS

Data collected from 7 experienced bariatric centers around the world were retrospectively collected, reviewed, and analyzed. Final body mass index (BMI), change in BMI, percentage excess BMI loss, and major complications with particular attention to leaks, hemorrhage, and mortality were reported.

RESULTS

Of 1219 patients analyzed, 74% underwent RYGB, 16% underwent OAGB, and 10% underwent SG after banding failure. The mean age was 38 years (±10 yr), and 82% of patients were women. The mean follow-up was 33 months. The follow-up rate was 100%, 87%, and 52% at 1, 3, and 5 years, respectively. At the latest follow-up, percentage excess BMI loss >50% was achieved by 75% of RYGB, 85% of OAGB, and 67% of SG patients. Postoperative complications occurred in 13% of patients after RYGB, 5% after OAGB, and 15% after SG.

CONCLUSION

Our data show that it is possible to achieve or maintain significant weight loss with an acceptable complication rate with all 3 surgical options.

Gastric band conversion to Roux-en-Y gastric bypass shows greater weight loss than conversion to sleeve gastrectomy: 5-year outcomes

BACKGROUND

Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are often used as revisional surgeries for a failed laparoscopic adjustable gastric band (LAGB). There is debate over which procedure provides better long-term weight loss.

OBJECTIVE

To compare the weight loss results of these 2 surgeries.

SETTING

University hospital, United States.

METHODS

A retrospective review was conducted of all LAGB to RYGB and LAGB to LSG surgeries performed at a single institution. Primary outcomes were change in body mass index (BMI), percent excess BMI lost, and percent weight loss. Secondary outcomes included 30-day complications and reoperations.

RESULTS

The cohort included 192 conversions from LAGB to RYGB and 283 LAGB to LSG. The baseline age and BMI were similar in the 2 groups. Statistical comparisons made between the 2 groups at 24 months postconversion were significant for BMI (RYGB = 32.93, LSG = 38.34, P = .0004), percent excess BMI lost (RYGB = 57.8%, LSG = 29.3%, P < .0001), and percent weight loss (RYGB = 23.4%, LSG = 12.6%, P < .0001). However, the conversion to RYGB group had a higher rate of reoperation (7.3% versus 1.4%, P = .0022), longer operating room time (RYGB = 120.1 min versus LSG = 115.5 min, P < .0001), and longer length of stay (RYGB = 3.33 d versus LSG = 2.11 d, P < .0001) than the LAGB to LSG group. Although not significant, the conversion to RYGB group had a higher rate of readmission (7.3% versus 3.5%, P = .087).

CONCLUSION

Weight loss is significantly greater for patients undergoing LAGB conversion to RYGB than LAGB to LSG. However, those undergoing LAGB conversion to RYGB had higher rates of reoperation and readmission. Patients looking for the most effective weight loss surgery after failed LAGB should be advised to have RYGB performed, while also understanding the increased risks of the procedure.

Revisional Surgery Following Laparoscopic Gastric Plication

BACKGROUND

The laparoscopic gastric plication (LGP) is a relative new bariatric procedure that has gained popularity over the last few years, but no real consensus exists and the evidence is unclear, especially in its real efficacy, safety, and durability.

METHODS

Retrospective study analyzing the records patients submitted to LGP between 2009 and 2010. The primary objective was to describe the characteristics and outcomes of patients submitted to revisional surgery. Baseline data and evolution were obtained and analyzed. Surgical analysis included revision cause, perioperative outcome, type of surgery, complications, and weight loss after 18 months. A comparison between gastric bypass and sleeve gastrectomy was performed.

RESULTS

One hundred LGP were performed. After a mean time of 13.5 months, 42 patients presented an overall excess weight loss (EWL) <50 % and 38 had severe symptoms. Thirty patients accepted revisional surgery with BMI before conversion of 38.6 ± 4.2 kg/m². There were 17 laparoscopic sleeve gastrectomy (LSG) and 13 laparoscopic gastric bypass (LGBP) with comparable preoperative characteristics. The LSG group had lower pneumoperitoneum time and less hospital stay. At 18 months, the LGBP group had lower BMI (24.1 ± 1.1 vs. 25.8 ± 1.3 kg/m² for the LSG; p = 0.006) and higher %EWL (75.7 ± 16.1 vs. 61.4 ± 14.5 % for the LSG; p = 0.008).

CONCLUSION

In our series, LGP presented a high failure rate and an increased number of symptomatic patients. Revisional surgery proved to be safe and effective. Revision to LSG was faster and had less hospital stay. Revision to LGBP showed better %EWL at 18 months.

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.

[Conversional and endoscopic procedures following bariatric surgery]

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

Simultaneous sleeve gastrectomy and hiatus hernia repair: a systematic review

Sleeve gastrectomy can exacerbate gastro-oesophageal reflux disease in some patients and cause de novo reflux in others. Some surgeons believe Roux-en-Y gastric bypass is the best bariatric surgical procedure for obese patients with hiatus hernia. Others believe that even patients with hiatus hernia can also be safely offered sleeve gastrectomy if combined with a simultaneous hiatus hernia repair. Still, others will offer these patients sleeve gastrectomy without any attempt to diagnose or repair hiatus hernia repair. The effectiveness of concurrent hiatal hernia repair in reducing the incidence of postoperative reflux after sleeve gastrectomy is unclear. This review systematically investigates the results and techniques of simultaneous sleeve gastrectomy and hiatus hernia repair for the treatment of obesity in accordance with PRISMA guidelines.

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

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

Conversion of failed laparoscopic adjustable gastric banding to Roux-en-Y gastric bypass is safe as a single-step procedure

BACKGROUND

Several different procedures have been proposed as a revisional procedure for treatment of failed laparoscopic adjustable gastric banding (LAGB). Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been advocated as the procedure of choice for revision. In this study, we compare the single- and two-step approaches for the revision of failed LAGB to LRYGB.

METHOD

All patients who underwent bariatric surgery were included in a prospective database. For the purpose of this study, patients who underwent revisional surgery from LAGB to LRYGB were selected. Records for individual patients were completed by data review. Complication rates and weight development were recorded until 2 years postoperatively. Data were compared between both procedures and with complications rates reported in literature.

RESULTS

Revisional gastric bypass surgery was performed in 257 patients. This was done as a planned single-step procedure in 220 (86 %) patients without indications for acute band removal and in 32 patients as a planned 2 step procedure. Five patients were planned as a single-step procedure but were intraoperatively converted to a 2-step procedure based on poor pouch tissue quality. No postoperative mortality occurred in both groups. No differences in early major morbidity and stricture formation were seen between the two groups. Gastric ulceration was more frequently observed after 2-steps procedure (8.5 vs. 1.7 %, p < 0.05). In comparison with data reported in literature, the single-step procedure had similar to lower complication rates. Percentage excess weight loss two years after revisional gastric bypass procedure was, respectively, 53 versus 67 % (p = 0.147) for single- and two-step procedure.

CONCLUSION

In patients without indications for acute band removal, the planned conversion of gastric banding to Roux-Y gastric bypass can be safely done in a single-step procedure without increase in morbidity and no difference in postoperative weight loss.

Impact of bariatric surgery on ghrelin and obestatin levels in obesity or type 2 diabetes mellitus rat model

We aimed to evaluate the therapeutic efficacy on weight control by different bariatric surgeries and investigate the ghrelin and obestatin changes after these surgeries in obesity and nonobese type 2 diabetes mellitus (T2DM) rats. Obese rats were randomly assigned to receive sleeve gastrectomy (SG, n = 8), minigastric bypass (MGBP, n = 8), roux-en-Y gastric bypass (RYGBP, n = 8), and sham operation (SO, n = 4). Another 4 rats served as control. Besides, Goto-Kakisaki (GK) rats were also randomly divided into similar groups except for total gastrectomy (TG, n = 8) group. The results showed that in obese rats, weigh loss in RYGBP group was similar to that in MGBP group but larger than that in SG group. Ghrelin significantly increased in RYGB group, but obestatin increased in MGBP group. Ghrelin/obestatin ratio significantly decreased in SG group. In GK rats, weight loss was most obvious in TG group. Postoperatively, ghrelin was significantly increased in MGBP and RYGB groups but decreased in TG group. Obestatin also showed an increase in MGBP and RYGB groups. Ghrelin/obestatin in TG group decreased significantly. In conclusion, RYGB and MGBP may be more suitable for obese rats, but TG may be the best strategy for T2DM rats to control weight with different mechanisms.

Laparoscopic choledochoduodenostomy as an alternate treatment for common bile duct stones after Roux-en-Y gastric bypass

BACKGROUND

After Roux-en-Y gastric bypass (RYGB), the new gastrointestinal configuration does not permit easy endoscopic access to the biliary system in the standard fashion. Common bile duct (CBD) stones have proved to be a challenge for both the surgeon and the endoscopist in this setting. We shall review our experience with laparoscopic choledochoduodenostomy as a treatment of choledocholithiasis after gastric bypass.

METHODS

Between January 2000 and July 2012, 3115 patients underwent RYGB at our institution. Patients were included if they had postoperative CBD stones regardless of previous cholecystectomy. Treatment modality was laparoscopic choledochoduodenostomy. A retrospective chart review of a prospectively collected data was completed, noting the outcomes and complications of the procedure.

RESULTS

Of 3115 patients, 11 patients were included in this study. There were 8 female and 3 male patients with a mean age of 50.5 ± 10.9 (range, 34-66) years. The average time between primary RYGB and choledochoduodenostomy was 39.7 ± 33.8 (range 8-113) months. The average body mass index at primary surgery was 48.2 ± 8.1 (range 38.4-67.4) kg/m(2) and at choledochoduodenostomy was 29.5 ± 6.8 (range 22.7-46.9) kg/m(2). One patient had bile leak that was managed with drain. All patients had resolution of symptoms at a mean follow-up of 24.8 ± 26.9 (range 2-84) months.

CONCLUSION

This small case series suggests that, in experienced hands, laparoscopic choledochoduodenostomy is an option for safe and effective treatment of choledocholithiasis after gastric bypass.

Laparoscopic sleeve gastrectomy as a revisional procedure for failed laparoscopic gastric banding with a "2-step approach": a multicenter study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has been proposed as an alternative revisional procedure for failed/complicated gastric banding. This is a retrospective cohort study of a prospectively maintained database of revisional LSG after band removal for insufficient weight loss and/or band-related complications, using a 2-step approach. The outcomes were compared with a control group of primary LSG. The study was conducted at a university hospital (Sapienza University of Rome-Polo Pontino, Icot, Latina, Italy) and 2 community general hospitals (Hospital Andosilla Civita Castellana, Viterbo, Italy and Hospital Villa D'Agri, Potenza, Italy).

METHODS

A total of 76 revisional LSG procedures was recorded; a control group of 279 LSG patients was selected. The primary endpoint was to compare the perioperative complication rate between the revisional versus the control group. Secondary endpoints were operative time, conversion rate, postoperative length of stay and percentage excess weight loss (%EWL) at 6, 12, and 24 months.

RESULTS

The indications for band removal were inadequate weight loss (47 patients), slippage (10 patients), erosion (7 patients), and pouch dilation (12 patients). All procedures were completed laparoscopically. The median operative time was 78 minutes for the revision LSG and 65 minutes for the control LSG (P<.05). In the revision group, the overall complication rate was 17.1%, and the median postoperative length of stay was 4 days; in the control group, the overall complication rate was 10.7%, and the median postoperative length of stay was 3. No complications requiring reoperation or readmission occurred in the revision group. In the control group, there were 5 cases of major complications. All the patients completed the follow-up. A total of 56 patients in the revision group and 184 patients in the control group were followed-up for at least 24 months. The %EWL at 6, 12, and 24 months was 46.5%, 66.4%, and 78.5%, respectively, in the revision group, and 49.8%, 78.2%, and 78%, respectively, in the control group.

CONCLUSION

Results confirmed that LSG, performed in 2 steps, is an effective revision procedure for failed or complicated laparoscopic adjustable gastric banding with good perioperative outcomes and 2-year weight loss.