Single-stage versus 2-stage sleeve gastrectomy as a conversion after failed adjustable gastric banding: 30-day outcomes

Decision-making Considerations in Revisional Bariatric Surgery

OBJECTIVE

With drastic variations in bariatric practices, consensus is lacking on an optimal approach for revisional bariatric surgeries.

MATERIALS AND METHODS

The authors reviewed and consolidated bariatric surgery literature to provide specific revision suggestions based on each index surgery, including adjustable gastric band (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS), single anastomosis duodenal-ileal bypass with sleeve (SADI-S), one anastomosis gastric bypass (OAGB), and vertical banded gastroplasty (VBG).

RESULTS

AGB has the highest weight recurrence rate and can be converted to RYGB, SG, and BPD-DS. After index SG, common surgical options include a resleeve or RYGB. The RYGB roux limb can be distalized and pouch resized in context of reflux, and the entire anatomy can be revised into BPD-DS. Data analyzing revisional surgery after a single anastomosis duodenal-ileal bypass with sleeve was limited. In patients with one anastomosis gastric bypass and vertical banded gastroplasty anatomy, most revisions were the conversion to RYGB.

CONCLUSIONS

As revisional bariatric surgery becomes more common, the best approach depends on the patient's indication for surgery and preexisting anatomy.

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.

A Comparison of One- and Two-Stage Laparoscopic Sleeve Gastrectomy Following Failed Laparoscopic Adjustable Gastric Banding Using the BAROS Score

INTRODUCTION

Revision of a failed band can be done by laparoscopic sleeve gastrectomy (LSG). It can be performed synchronously with band removal or during two separate procedures.

AIM

Comparing single- and two-staged LSG following a failed LAGB in terms of short- and mid-term outcomes, with an emphasis on postoperative quality of life.

METHODS

A retrospective cohort study comparing revisional LSG's safety and efficacy after failed LAGB removal. Data included patients' medical files, as telephone interviews. We compared demographics, weight loss, complications, long-term outcomes, and quality-of-life measures, including the Bariatric Analysis and Reporting Outcome System (BAROS).

RESULTS

Ninety-three patients were enrolled, of which 68 (73.1%) underwent a single-stage revisional LSG. Of these, 40 were males (35.1%) with a mean age of 44.9 years (± 12.9). The two-staged group were older. The reasons for band removal differed between the groups: whereas in the two-stage surgery, the common causes were slippage (29.2%) or band intolerance (25%); in the single-stage group, it was weight gain (51%). There were no differences in short- and mid-term complications, weight loss, and quality of life.

CONCLUSION

In selected cases, laparoscopic sleeve gastrectomy as a revision of failed gastric banding in one stage is as safe as a two-stage procedure in terms of short- and mid-term complications, weight loss, and quality of life. We believe that there is little benefit in performing elective surgery in two stages unless there are clinical indications. Exceptions for two-stage revision should include cases of band erosion and acute slippage with patient preference for band removal.

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.

Laparoscopic Sleeve Gastrectomy Following Failed Laparoscopic Adjustable Gastric Banding-a Comparison Between One- and two-Stage Procedures, an Israeli National Database Study

PURPOSE

The optimal revisional bariatric surgery procedure following a previous failed gastric band surgery is yet to be determined. The aim of our study was to compare single- and two-stage laparoscopic sleeve gastrectomy (LSG) following laparoscopic adjustable gastric banding (LAGB) in terms of short- and mid-term outcomes.

MATERIALS AND METHODS

Patients who underwent LSG after a failed LAGB in Israel during 2014-2017 were included. Data were obtained from the Israeli National Bariatric Surgery Registry. Data analyzed included comorbidities, postoperative complications, and anthropometric outcomes.

RESULTS

Of 595 patients included in the data analysis, 381 (64%) underwent one-stage and 214 (36%) had two-stage LSG. No differences were observed between the groups in complication rates (5.0 vs. 5.1%, p=0.93). Percent of total weight loss was lower following one-stage than two-stage procedure at both 6 months (19.3±9.3 vs. 21.5±8.1%; p=0.02) and 1 year postoperative (24.9±10.4 vs. 27.8±9.9%; p=0.02). No difference was observed in the percent excess weight loss (51 vs. 56%; p=0.34 and 66 vs. 72%; p=0.38, at 6 months and 12 months postoperative, respectively). In a regression analysis, percent excess weight loss was greater in the two-stage procedure (p=0.02), with no difference in the complication rates (p=0.98).

CONCLUSION

Single-step LSG had a similar safety profile as two-stage LSG following a failed LAGB. Better weight loss was seen following two-stage LSG. Further prospective studies should investigate long-term follow-up after one- and two-stage procedure.

Revisional Bariatric Surgery

Revisional bariatric surgery is a growing subset of all bariatric procedures. Although revisions can be associated with higher morbidity rates and less optimal outcomes than those seen with primary procedures, they can be safely performed, with excellent outcomes and improved quality of life for patients. Facility and familiarity with revisional principles and techniques are necessary components of bariatric surgical practice.

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.

Sleeve gastrectomy as a rescue of failed gastric banding: comparison of 1- and 2-step approaches

BACKGROUND

Series comparing gastric banding (GB) removal and sleeve gastrectomy (SG) when procedures are performed as a 1- or a 2-step approach are contradictory in their outcomes. No series comparing these approaches with midterm weight loss is available.

OBJECTIVES

Compare the outcomes and weight loss of SG performed as 1- and 2-step approaches as a revisional procedure for GB failure.

SETTING

University Hospital, France, public practice.

METHODS

Between February 2006 and January 2017, all patients undergoing SG with a previous history of implementation of GB (n = 358) were included in this 2-center, retrospective, observational study. Revisional surgery was proposed in patients with insufficient excess weight loss (excess weight loss ≤50%) or weight regain after GB. A 1-step (1-step group, n = 270) or 2-step (2-step group, n = 88) approach was decided depending on patient's choice and/or surgeon's preference. The primary efficacy endpoint was the comparison of weight loss in the 1- and 2-step groups at the 2-year follow-up. The secondary efficacy endpoints were short-term outcomes (overall mortality and morbidity at postoperative day 30, specific morbidity, reoperation, length of hospital stay, and readmission).

RESULTS

In the 1-step group, the mean preoperative body mass index before SG was 40.5 kg/m² (27.0-69.0), while in the 2-step group, the mean preoperative body mass index was 43.5 kg/m² (31.5-61.7). Mean operating time was 109 minutes (50-240) in the 1-step group and 78.7 minutes (40-175) in the 2-step group (P = .22). In the 1-step group, 6 conversions to laparotomy occurred, while in the 2-step group, 2 conversions to laparotomy occurred (P = .75). One death (.2%, in the 2-step group) and 39 complications (30 in the 1-step group [11.1%] and 9 in the 2-step group [10.2%]) also occurred. The mean length of hospital stay was 6.2 days in the 1-step group and 4.1 days in the 2-step group. At 2-year follow-up, mean body mass index was 32.4 kg/m² in the 1-step group and 33.2 kg/m² in the 2-step group (P = .15), representing excess weight losses of 61.9 and 50.1 (P = .05), respectively. The rates of revisional surgery were .7% and 2.2%, respectively.

CONCLUSIONS

SG after previous GB is efficient with similar outcomes depending on the 1- or 2-step approach. The 1-step approach seems to have increased weight loss compared with the 2-step approach.

Conversion to laparoscopic sleeve gastrectomy after failure of laparoscopic gastric band: A systematic review of the literature and cost considerations

No universal consensus has been achieved as to whether the laparoscopic adjustable gastric band to laparoscopic sleeve gastrectomy conversion should be performed in one or two steps. To determine the differences in operative outcomes and cost, a systematic, comprehensive review of the literature was conducted using the PubMed database from the National Institutes of Health. Nine studies were included with 809 patients. Weighted averages were calculated to compare operative outcomes, and cost analyses were conducted with these averages. Results indicate a longer operative time for the one-step approach than the two-step approach, but studies included in the meta-analysis found no statistical difference between the two. The two-step approach was found to have a longer length of hospital stay, but this finding refuted included studies that indicate no significant difference. Complication rates were higher for the one-step approach than the two-step approach, and costs associated with complications average $806 more for one-step patients than two-step patients. This suggests that the two-step approach could prove better for patient safety and cost outcomes, but both approaches are comparable in operating time and length of stay.

Postoperative Bleeding and Leakage After Sleeve Gastrectomy: a Single-Center Experience

BACKGROUND

Sleeve gastrectomy is being performed increasingly, mainly due to its low morbidity and mortality, but complications do occur. The aim of this study was to evaluate bleeding and leakage rates of primary and revisional sleeve gastrectomy in a personal series of 664 consecutive patients.

METHODS

Medical charts of all patients undergoing a primary or revisional sleeve gastrectomy between August 2008 and December 2014 were reviewed retrospectively. Subgroup analysis compared bleeding in patients after reduced port versus multiport technique and primary versus revisional sleeve gastrectomy.

RESULTS

A total of 664 sleeve gastrectomies (489 women and 175 men) were performed. Mean age and body mass index were 36.03 ± 11.4 years and 42.9 ± 8.3 kg/m², respectively. Mean operative time was 58.5 ± 20.0 min, with a 0.15 % conversion rate. Mean hospital stay was 2.1 ± 0.3 days. The overall 30-day complication rate was 7.5 %. Thirteen patients sustained postoperative bleeding (2 %), three of whom required reoperation (0.5 %). Staple line leakage and mortality were both nil in this series. No difference in postoperative complications was found between the subgroups.

CONCLUSIONS

In this single-surgeon, single-center experience, sleeve gastrectomy was a safe and effective bariatric procedure with a low complication rate. Staple line reinforcement by oversewing was associated with low bleeding complications and no leakage. The majority of patients with postoperative bleeding could be managed conservatively. In our experience, reduced port technique and revisional sleeve gastrectomy had similar complication rates compared to multiport and primary sleeve gastrectomy.

Revisional Bariatric Surgery

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.

Gastric Band Removal in Revisional Bariatric Surgery, One-Step Versus Two-Step: a Systematic Review and Meta-analysis

We aimed to systematically review the literature comparing the safety of one-step versus two-step revisional bariatric surgery from laparoscopic adjustable gastric banding (LAGB) to Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). There is debate on the safety of removing the gastric band and performing revisional surgery immediately or in a delayed, two-step fashion due to potential higher complications in one-step revisions. A systematic and comprehensive search of the literature was conducted. Included studies directly compared one-step and two-step revisional surgery. Eleven studies were included with 1370 patients. Meta-analysis found comparable rates of complications, morbidity, and mortality between one-step and two-step revisions for both RYGB and SG groups. This suggests that immediate or delayed revisional bariatric surgeries are both safe options for LAGB revisions.