The SAGES MASTERS program bariatric surgery pathway selects 10 seminal publications on revisional bariatrics

BACKGROUND

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program designated bariatric surgery as a clinical pathway. Among the tiers of the Masters Program, revisional bariatric surgery is the highest tier of "mastery" within the pathway. This article presents the top 10 seminal studies representing the current landscape of revisional bariatrics.

METHODS

The literature was systematically searched and seminal articles designated by consensus agreement of the SAGES Metabolic and Bariatric Surgery committee using multiple criteria, including impact on the field, citation frequency, and expert opinion. Articles were reviewed by committee members and presented in summarized fashion.

RESULTS

The top 10 papers are presented in grouped thematic categories covering the early evolution of revisional bariatrics, changing criteria for reoperative bariatric surgery, divergence of revision versus conversion bariatric surgery, and recent technologic innovations in revisional bariatric surgery. Each summary is presented with expert appraisal and commentary.

CONCLUSION

These seminal papers represent a snapshot of the dynamic field of revisional bariatric surgery and emphasize the need to not only remain current with contemporary trends but also keep a patient-oriented perspective on patient and intervention selection for optimal success.

Conversion of gastric sleeve to Roux-en-Y gastric bypass and biliopancreatic diversion/duodenal switch: safe and viable options

BACKGROUND

Sleeve gastrectomy (SG) remains the most performed bariatric surgery. As numbers of SG increase, so do the numbers of patients requiring conversion for insufficient weight loss or weight regain. However, the literature has cited complication rates as high as 30% for reoperative bariatric surgery.

OBJECTIVE

With the recent inclusion of conversion surgery variables in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, we compared the safety and efficacy of SG conversion to Roux-en-Y gastric bypass (RYGB) versus biliopancreatic diversion and duodenal switch (BPD/DS).

SETTING

MBSAQIP database.

METHODS

Analysis of the 2020 MBSAQIP Participant Use Files revealed 6020 patients who underwent SG conversion to RYGB (5348) and BPD/DS (672). We examined 30-day outcomes including death, anastomotic leak, readmission, any complication, dehydration, and weight loss.

RESULTS

There was no statistically significant difference in mortality (.12% versus 0%) or; complication rate (6.5% versus 5.1%) with SG conversion to RYGB or BPD/DS. There was a statistically significant difference in anastomotic leak (.5% versus 1.2%, P = .024). Interestingly, BPD/DS was less likely to require dehydration treatments (4.2% versus 2.2%, P = .009) and had fewer readmissions within 30 days (7.3% versus 5.4%, P = .043).

CONCLUSIONS

Complication rates after conversion of SG to RYGB or BPD/DS may be significantly lower than previously reported and only slightly higher than after primary weight loss surgery. SG conversion to either RYGB or BPD/DS remain safe, viable options for patients who had insufficient weight loss or regain, and BPD/DS may be the better option in the appropriate patient.

Secondary Bariatric Surgery-Does the Type of Index Procedure Affect Outcomes After Conversion?

BACKGROUND

Although revisions account for 17% of cases performed at bariatric centers of excellence, scarce data exists on whether index operation type influences outcomes after secondary operations.

OBJECTIVE

We designed a study investigating the effect of primary procedure type on weight loss and perioperative complications after conversion bariatric surgery.

SETTING

Tertiary Referral Hospital, USA.

METHODS

We performed a retrospective review of patients undergoing conversion from sleeve gastrectomy (SG) or adjustable gastric band (AGB) to Roux-en-Y gastric bypass (RYGB) from 2009 to 2019. Post-operatively, we measured short- and medium-term complications and changes in body weight at various time points. Univariate and regression analyses were performed.

RESULTS

Forty-two (SG) patients and 116 (AGB) patients underwent conversion to RYGB, most commonly for GERD (57.1%) in SG patients vs. weight regain (77.6%) in AGB patients. Mean pre-conversion BMI was 36.7 kg/m² (SG) vs 43.8 kg/m² (AGB). Mean time to conversion (months) was 52.9 (SG) vs 94.7 (AGB). Complication rate was 9.5% (SG) vs 6% (AGB) at 30 days (p = 0.48) and 31%(SG) vs 14.5% (AGB) (p = 0.02) at 2 years. Mean post conversion %TWL was 11.6% (SG) vs 24.6% (AGB) in patients with GERD/dysphagia (p = 0.014) and 20.7% (SG) vs 27.6% (AGB) in patients converted for weight-related reasons (p = 0.027) at 1 year. Overall mean %TWL was 13.2% (SG) vs 24.7% (AGB) at 2 years (p < 0.0035).

CONCLUSION

After conversion to RYGB, patients with AGB experience better short- and medium-term weight loss than those with SG, even after accounting for conversion indications. SG to RYGB conversions have a higher resolution of reflux disease.