Laparoscopic revision from LAP-BAND to gastric bypass

Reasons and outcomes of laparoscopic revisional surgery after laparoscopic adjustable gastric banding for morbid obesity

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) is a purely restrictive procedure that has been proved to be an effective tool in achieving weight loss. The low operative morbidity and reversibility are often seen as advantages of this procedure compared with other bariatric approaches. We have attempted to define the reasons for revisional surgery after LAGB and the outcomes.

METHODS

A retrospective review of a prospectively maintained database was performed from February 2001 to October 2008 at a center of excellence after institutional review board approval. The patients who had undergone revisional surgery after primary LAGB were evaluated.

RESULTS

Of 343 patients who had undergone primary LAGB, 60 subsequently underwent a revisional procedure. In addition, 28 revisional procedures were performed on patients who had undergone primary LAGB at an outside institution. These procedures included 39 (44.3%) band removals alone, 12 (13.6%) band removals with conversion to sleeve gastrectomy, 13 (14.8%) band removals with conversion to Roux-en-Y gastric bypass, 9 (10.2%) band repositioning, and 2 (2.3%) band replacements. In addition, 13 (14.8%) port-related procedures (3 relocations, 6 reconnections, and 4 replacements/removals) were performed.

CONCLUSION

Although reversible and efficacious, LAGB appears to have a high incidence of complications requiring revisional surgery and/or band removal. The results of our study have shown that laparoscopic revisional surgery after primary LAGB is safe and can be performed with minimal morbidity.

Laparoscopic conversion of adjustable gastric banding and vertical banded gastroplasty to duodenal switch

BACKGROUND

The aim of this retrospective consecutive study was to evaluate the feasibility, safety, and efficacy of the conversion of laparoscopic adjustable gastric banding (LAGB) and open vertical banded gastroplasty (VBG) into duodenal switch (DS) by laparoscopy.

METHODS

From November 2003 to February 2007, laparoscopic conversion into DS was performed in 1-step in 43 patients, 31 after LAGB and 12 after VBG. The reason for conversion was weight loss issues, such as insufficient excess weight loss (EWL) or weight regain. The mean interval from LAGB and VBG to conversion to the DS was 42.7 +/- 28.7 months and 172.2 +/- 86.9 months, respectively. The mean %EWL at conversion was 8.3% +/- 19.3% after LAGB and 20.8% +/- 30% after VBG.

RESULTS

The mean operative time was 205.8 +/- 44.8 minutes for LAGB and 210.9 +/- 53.7 minutes for VBG. No conversions to open surgery occurred. One patient in the LAGB group died on the third postoperative day of sudden death syndrome, as shown by the postmortem examination. Major complications occurred in 6.4% of patients with LAGB (1 hemoperitoneum and 1 ileoileostomy leak) and in 50% with VBG (1 sleeve gastrectomy leak with subsequent duodenoileostomy leak, 3 duodenoileostomy leaks, 1 pancreatitis, and 1 respiratory insufficiency). The mean hospital stay was 5.5 +/- 5 days for the LAGB group and 34.5 +/- 50.3 days for the VBG group. After a mean follow-up of 28 +/- 15.7 months for LAGB to DS and 43.5 +/- 6 months for VBG to DS, reoperations for late complications were required in 6 patients (20.6%) in the LAGB to DS group and in 5 patients (62.5%) in the VBG to DS group. Three patients (25%) died within 8 months after conversion of VBG. The 29 surviving patients (LAGB to DS) showed a mean %EWL and percentage of excess body mass index loss of (%EBMIL) 78.4% +/- 24.9% and 77.8% +/- 23.7%, respectively. The 8 surviving patients (VBG to DS) had a mean %EWL and %EBMIL of 85.1% +/- 20% and 85.8% +/- 18.7%, respectively.

CONCLUSION

According to these results, laparoscopic conversion of LAGB to DS seems feasible and effective, despite the 1 death. However, in our hands, laparoscopic conversion of VBG to DS had an unacceptable rate of complications and deaths.

Laparoscopic sleeve gastrectomy after gastric banding removal: a feasibility study

BACKGROUND AND OBJECTIVES

Laparoscopic adjustable gastric banding (LAGB) is a commonly performed bariatric procedure. When LAGB fails, restrictive procedures such as gastric bypass have been performed. Laparoscopic sleeve gastrectomy (LSG) has been suggested as an alternative, but it has not yet been fully studied. Evaluated in this report are the experiences of patients who underwent LSG, a restrictive procedure, as a rescue procedure for failed LAGB.

METHODS

From June 2002 to June 2007, charts of patients who underwent LAGB were reviewed to find those who had undergone LSG as a rescue procedure.

RESULTS

Of 294 patients who underwent LAGB, 10 later underwent LSG. Median excess weight loss (EWL) prior to LSG had been 34%; after LSG, median EWL was 55%. Before LSG was performed, patients had a median 11.5 comorbidities, all of which improved after LSG. No major complications or deaths resulted.

CONCLUSION

The results suggest LSG might be a reasonable choice for patients who fail LAGB. A formal study comparing LSG with other rescue procedures should be performed.

Feasibility and technique of laparoscopic conversion of adjustable gastric banding to sleeve gastrectomy

BACKGROUND

To evaluate the feasibility, safety, and short-term efficacy of the conversion of laparoscopic adjustable gastric banding (LAGB) to laparoscopic sleeve gastrectomy (LSG) because of inadequate weight loss.

METHODS

The inclusion criteria were an inadequate percentage of excess weight loss (%EWL), defined as <30% at > or =1 year after LAGB. From August 2002 to October 2007, 27 patients (17 women and 10 men) had undergone removal of their LAGB and conversion to LSG. The average age at LSG was 43.6 +/- 11.4 years (range 25-66). Before LAGB, the mean weight and body mass index was 129.8 +/- 21.9 kg (range 95-178) and 45 +/- 8.1 kg/m(2) (range 35-64), respectively. The average interval between LAGB and LSG was 51.2 +/- 30.1 months (range 22-132). Before conversion, the mean weight, body mass index, and %EWL was 117.9 +/- 27.3 kg (range 63-170), 39 +/- 9.6 kg/m2 (range 24-61), and 18.1% +/- 18.3%, respectively. Of the 27 patients, 12 had 19 obesity-related co-morbidities, including arterial hypertension in 7, type 2 diabetes mellitus in 2, degenerative joint disease in 7, and sleep apnea in 3.

RESULTS

The mean operative time was 120.6 +/- 32.4 minutes (range 65-195). No conversion to open surgery was required, and no patient died. The postoperative complications included a subphrenic hematoma that required laparoscopic drainage; no postoperative leaks developed. The mean hospital stay was 3.2 +/- 1.4 days (range 2-8). After a mean follow-up of 18.6 +/- 14.8 months (range 1-59) for 23 patients (4 patients were lost to follow-up), the mean weight, body mass index, and weight loss was 100.7 +/- 23.5 kg (range 61-152), 34.6 +/- 8.7 kg/m2 (range 21-50.4), and 23 +/- 12.4 kg (range 2-55), respectively. The patients had had an additional 16.7% EWL after LSG for a total average %EWL of 34.8% +/- 21.8% (P <.05). Of the 12 patients with obesity-related co-morbidities, 5 had had resolution, including arterial hypertension in 1, type 2 diabetes mellitus in 1, degenerative joint disease in 2, and sleep apnea in 2.

CONCLUSION

The results of this study support the safety of LSG in the case of an inadequate %EWL after LAGB. However, the degree of weight loss and co-morbidity resolution is of concern.

Early results of conversion of laparoscopic adjustable gastric band to Roux-en-Y gastric bypass

BACKGROUND

As the number of laparoscopic adjustable gastric bands (LAGBs) placed has increased, the number of patients requiring removal of the device has also increased.

METHODS

The data from our institution, a U.S. university medical center, were reviewed to determine the feasibility, patient characteristics, and early results of converting patients from LAGB to laparoscopic Roux-en-Y gastric bypass.

RESULTS

A total of 350 patients underwent LAGB placement at our institution from 2001 to 2008. Of these, 26 required conversion to laparoscopic Roux-en-Y gastric bypass for the following reasons: slippage, poor weight loss, LAGB intolerance, esophageal dilation, infection, and gastric ischemia. All conversions were completed laparoscopically. The average operating time and length of stay was 160 minutes and 3 days, respectively. Three complications developed. The average interval to conversion was 29 months. The average follow-up after conversion was 18 months. The average percentage of excess body weight loss at conversion was 23%. At 12 months after conversion, the patients had achieved an average percentage of excess body weight loss of 56% from their pre-LAGB weight.

CONCLUSION

The increasing popularity of the LAGB has led to a considerable number of revisions of the device. Our early experience has shown that converting patients from LAGB to laparoscopic Roux-en-Y gastric bypass is feasible and safe and can offer patients substantial additional weight loss.

One-year weight loss after primary or revisional Roux-en-Y gastric bypass for failed adjustable gastric banding

BACKGROUND

Adjustable gastric banding has been widely used in Europe, but recently gastric bypass (Roux-en-Y gastric bypass [RYGB]) has become the procedure of choice. With a gastric banding failure rate of nearly 40% at 5 years, the need for revisional surgery is increasing. The effect of a failed previous bariatric surgery on the weight loss curve after RYGB is still a controversial issue.

METHODS

A total of 259 patients underwent RYGB from 2003 to 2007, 58 after failed gastric banding and 201 as primary surgery. All the procedures were laparoscopically performed by the same surgeon at a single institution. The postoperative course and the percentage of excess weight loss were compared between the 2 groups.

RESULTS

The 2 groups were similar in age and initial body mass index (46.3 +/- 7.2 kg/m(2) for revision versus 47.7 +/- 6.7 kg/m(2) for primary RYGB). In contrast, the prerevision body mass index was 43.2 +/- 7.0 kg/m(2). Revisional RYGB required a significantly longer operative time (128.3 +/- 25.9 minutes versus 89.0 +/- 14.7 minutes, P <.0001) and the morbidity was greater (8.6% versus 5.5%), but no patient died in the postoperative period after revision. As determined from the initial body mass index, the 1-year percentage of excess weight loss was comparable between the 2 groups (66.1% +/- 26.8% and 70.4% +/- 18.9%).

CONCLUSION

When RYGB is performed after an adjustable gastric band failure to restore weight loss or because of a complication, the weight loss curve is similar to that after primary RYGB. Therefore, the strategy of adjustable gastric banding first is an option that does not seem to preclude satisfactory weight loss after revision to RYGB.

Biliopancreatic diversion with duodenal switch or gastric bypass for failed gastric banding: retrospective study from two institutions with preliminary results

BACKGROUND

Of patients who have undergone gastric banding, 11-25% will require a major reoperation with band removal and conversion to another bariatric procedure after they have failed to lose sufficient weight or have developed dysphagia or reflux. The aim of this study was to evaluate the respective benefits of Roux-en-Y gastric band (RYGB) or biliopancreatic diversion with duodenal switch (BPD-DS) after failed gastric banding and whether 1 of the 2 procedures might be a better procedure for such cases.

METHODS

RYGB or BPD-DS was performed according to the institutional protocols with synchronous band removal, irrespective of the reason for failure.

RESULTS

Of the 53 patients, 32 underwent laparoscopic RYGB for a body mass index (BMI) of 43.1 +/- 6.4 kg/m(2) (BMI 45.8 +/- 6.4 kg/m(2) before laparoscopic adjustable gastric banding) and 21 underwent BPD-DS for a BMI of 46.0 +/- 5.5 kg/m(2) (BMI 49.6 +/- 5.2 kg/m(2) before laparoscopic adjustable gastric banding). BPD-DS required significantly longer operative times (239.7 +/- 55.8 versus 135 +/- 26.7 minutes) and resulted in more complications (62% versus 12.5%; P <.002). No patients died postoperatively. The 2 groups of patients had a similar BMI at 12 and 18 months after revision (BMI 33.4 +/- 5.6 kg/m(2) and 31.4 +/- 3.5 kg/m(2)). The weight loss was greater after BPD-DS than after RYGB compared with the prerevision weight loss (66.2% versus 58.8% excess weight loss) or initial weight (73% versus 61.8%), although this was not significant.

CONCLUSION

Despite an excessive rate of complications that were, in part, related to the learning curve in this series, BPD-DS resulted in greater weight loss compared with RYGB. However, both procedures were successful after failed gastric banding. A more accurate definition of failure could help to determine the respective indications for revisional surgery.

Gastric banding: conversion to sleeve, bypass, or DS

A review of conversions of gastric banding for obesity to Roux-en-Y gastric bypass, gastric sleeve, or duodenal switch attempts to determine which revisional procedure best enhances weight loss. Indications for these conversions are multiple and include hardware problems, motility problems, and miscellaneous like inadequate weight loss. Analysis of band conversions to band of 193 patients, and bands to gastric bypass in 214 patients reveals better weight loss with the latter strategy. Smaller cohorts of patients who underwent a biliopancreatic diversion or simply a sleeve gastrectomy are too small to conclude on their efficacy. Prospective randomized trials are needed to determine which revisional procedure is best in the setting of inadequate weight loss of excessive weight regain after gastric adjustable banding for severe obesity.