Laparoscopic revision of vertical banded gastroplasty to Roux-en-Y gastric bypass: outcomes of 105 patients

Rates and Risk Factors for 30-Day Morbidity After One-Stage Vertical Banded Gastroplasty Conversions: A Retrospective Analysis

Background: The vertical banded gastroplasty (VBG) is a historic restrictive bariatric operation often requiring further surgery. In this investigation utilizing the 2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) national dataset, we aim to better define the outcomes of VBG conversions.Methods: We queried the 2021 MBSAQIP dataset for patients who underwent a conversion from a VBG to Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Demographics, comorbidities, laboratory values, and additional patient factors were examined. Rates of key consequential outcome measures 30-day readmission, reoperation, reintervention, mortality, and a composite endpoint (at least 1 of the 4) were further calculated.Results: We identified 231 patients who underwent conversion from VBG to SG (n = 23), RYGB (n = 208), or other anatomy (n = 6), of which 93% of patients were female, and 22% of non-white race. The median age was 56 years and body-mass index (BMI) was 43 kg/m2. The most common surgical indications included weight considerations (48%), reflux (25%), anatomic causes (eg, stricture, fistula, and ulcer; 10%), and dysphagia (6.5%). Thirty-day morbidity rates included reoperation (7.8%), readmission (9.1%), reintervention (4.3%), mortality (.4%), and the composite endpoint (15%). Upon bivariate analysis, we did not identify any specific risk factor for the 30-day composite endpoint.Discussion: One-stage VBG conversions to traditional bariatric anatomy are beset with higher 30-day morbidity relative to primary procedures. Additional MBSAQIP data will be required for aggregation, to better characterize the risk factors inherent in these operations.

Prevalence, Indications, and Complications of Conversional Surgery After Vertical Banded Gastroplasty: A MBSAQIP Analysis

PURPOSE

Vertical banded gastroplasty (VBG) was once the most popular bariatric procedure in the 1980's, with many patients subsequently requiring conversional surgery. However, knowledge regarding the prevalence and outcomes of these procedures remains limited. This study aims to determine the prevalence, indications, rate of 30-day serious complications, and mortality of conversional surgery after VBG.

MATERIALS AND METHODS

A retrospective analysis of the MBSAQIP database from 2020 to 2022 was conducted. Individuals undergoing conversional or revisional surgery after VBG were included. The primary outcomes were 30-day serious complications and mortality.

RESULTS

Of 716 VBG conversions, the common procedures included 660 (92.1%) Roux-en-Y gastric bypass (RYGB) and 56 (7.9%) sleeve gastrectomy (SG). The main indication for conversion was weight gain for RYGB (31.0%) and for SG (41.0%). RYGB had longer operative times than SG (223.7 vs 130.5 min, p < 0.001). Although not statistically significant, serious complications were higher after RYGB (14.7% vs 8.9%, p = 0.2). Leak rates were higher after SG (5.4 vs 3.5%) but this was not statistically significant (p = 0.4). Mortality was similar between RYGB and SG (1.2 vs 1.8%, p = 0.7). Multivariable regression showed higher body mass index, longer operative time, previous cardiac surgery and black race were independently associated with serious complications. Conversion to RYGB was not predictive of serious complications compared to SG (OR 0.96, 95%CI 0.34-2.67, p = 0.9).

CONCLUSIONS

Conversional surgery after VBG is uncommon, and the rate of complications and mortality remains high. Patients should be thoroughly evaluated and informed about these risks before undergoing conversion from VBG.

Laparoscopic Conversion of Vertical Banded Gastroplasty to Roux-en-Y Gastric Bypass Gives Better Result Compared to an Open Approach

BACKGROUND

Vertical banded gastroplasty (VBG) has a relatively high failure rate in the long run, requiring revisional surgery in 30-65%. A common conversion option is to Roux-en-Y gastric bypass (RYGB), which can be performed laparoscopically or open. Current literature contains small cohorts and inconclusive results. Therefore, we set out to compare our series of open and laparoscopic VBG to RYGB conversions.

METHODS

All conversions performed between 1996 and 2020 were included. Patients were divided into 3 groups based on conversion indication: weight recurrence (group 1), excessive weight loss (group 2), and eating/pouch difficulties (group 3). The primary outcome was postoperative complications according to the Clavien-Dindo (CD) classification. Secondary outcome was %total weight loss (%TWL) 1 to 5 years after revisional surgery.

RESULTS

We included 205 patients (84.9% female) of whom 105 underwent laparoscopic and 100 open VBG to RYGB conversion. Twenty-three short-term complications occurred in the laparoscopic group, with 16 > CD3a. In the open group, 33 complications occurred with 12 > CD3a. Overall complications were 33.3% in laparoscopic and 64% in open patients. There were no significant differences between the laparoscopic and open group in BMI (p = 0.76) and %TWL (p = 0.694) after 5 years. After 5 years, lost to follow-up was 97% in the open group. Twenty-eight percent of patients who reached follow-up in the laparoscopic group had available data.

CONCLUSIONS

We demonstrate that the overall complication rate is lower in the laparoscopic group compared to the open group. Regarding BMI, an improvement was achieved in both groups after 5 years.

Comparison of 5-Year Follow-up Outcomes Between Primary and Revision Roux-en-Y Gastric Bypasses After Open Vertical Banded Gastroplasty: an Inverse Propensity Score-Weighted Analysis

INTRODUCTION

Vertical banded gastroplasty (VBG) is associated with high weight regain; Roux-en-Y gastric bypass (RYGB) is used as a revision procedure in patients with VBG experiencing weight regain. This study compared the 5-year follow-up outcomes of primary (PRYGB) and revision RYGB after VBG (RRYGB).

METHODS

Patients who underwent PRYGB or RRYGB after VBG from 2008 to 2016 were enrolled. Data on weight regain, weight loss (WL), food tolerance (FT), early and late complications, and resolution or improvement in associated medical conditions were analyzed.

RESULTS

PRYGB and RRYGB groups had 558 and 156 patients, respectively, after exclusion of the lost to follow-up patients. PRYGB group showed significantly lower mean body mass index (over the entire follow-up period), early complications, reintervention rates for late complications, and overall reintervention rates than that of the RRYGB group. On the other hand, FT scores, odds of late complications, and improvements (in the fifth year) in associated medical conditions were comparable between the two groups.

CONCLUSION

RRYGB in patients with VBG who regained weight showed comparable safety and resolution of associated diseases to that of PRYGB over the 5-year follow-up period. The WL in the RRYGB group was acceptable despite being less than that of the PRYGB group. FT was better after RRYGB than that of PRYGB in the first year; however, both were comparable at the fifth year follow-up. Patients with VBG undergoing RYGB should receive attentive treatment and evaluation of associated factors.

Use of a Lumen-Apposing Metal Stent for Management of Pouch Outlet Stenosis After Vertical Banded Gastroplasty

Lumen-apposing metal stents (LAMSs) offer a novel alternative for the treatment of anastomotic strictures or short, benign gastrointestinal strictures. In the bariatric realm, LAMSs provide a potentially safer, efficacious, and nonsurgical approach to surgical revision. Here, we present a case where a LAMS was successfully used to manage pouch outlet stenosis from a previous vertical banded gastroplasty.

Laparoscopic Roux-en-Y Gastric Bypass After Failed Vertical Banded Gastroplasty: 2-Year Follow-up of 102 Patients

BACKGROUND

Vertical banded gastroplasty (VBG) is now discarded from being a restrictive procedure for morbid obesity due to its many drawbacks, doubtful efficacy, and lots of post-operative complications. Roux-en-Y gastric bypass (RYGB) is the most commonly performed procedure for VBG revision. So we aimed at reporting our experience in conversional RYGB for a failed VBG.

MATERIAL AND METHODS

Analyzing follow-up records of 102 patients who underwent revisional RYGB after failed VBG in the period from April 2014 to January 2018.

RESULTS

A total of 102 laparoscopic revisions of failed VBGs to RYGB were performed. The mean operating time was 161.9 min ±29.2 and the mean length of the hospital stay was 1.5 days ±1.2. Fourteen patients (13%) developed early post-operative complications (gastrojejunostomy leak 5; bleeding 9). Four patients (4.7%) developed late complications (Port site hernia 2; internal hernia 1; Stomal ulcer 1). The mean BMI pre-RYGB was 46.6 ± 5.9 kg/m², and the mean %EBWL (percent excess body weight lost) of the patients at 12 and 24 months post-revision were 56.2% and 64.3%, respectively. Our patients had immediate post-revision resolution of VBG-related complications like dysphagia and vomiting. We also report improvement in all obesity-related health problems with (75.7%) complete remission rate and (24.3%) partial remission or improvement rate of diabetes mellitus.

CONCLUSION

Conversion of VBG to RYGB is a feasible procedure and is associated with acceptable early morbidity rates and reduced lengths of hospitalization also it provides acceptable weight loss and improvement in obesity-related health problems. Graphical Abstract.

Enhanced Recovery After Revisional Bariatric Surgery: a Retrospective Study of 321 Patients with Laparoscopic Conversion of Failed Gastric Banding or Failed Mason Gastroplasty to Roux-en-Y Gastric Bypass

PURPOSE

With the rising incidence of failed bariatric procedures, the importance of revisional surgery has been increasing. These revisional procedures come with a higher risk of complications leading to longer hospital stays. We believe though that enhanced recovery after revisional bariatric surgery is possible and needs to be advocated.

MATERIALS AND METHODS

We retrospectively analyzed our laparoscopic conversions of failed gastric banding and failed Mason gastroplasty to Roux-en-Y gastric bypass. A total of 321 patients was included in the study, from February 2010 until December 2019. The primary endpoints were length of stay (LoS), in-hospital complication rate, and early readmission rate (< 30 days). Logistic regression was used to investigate the impact of several independent variables on complication and readmission rates.

RESULTS

Fifty-four patients were male and 267 female. The mean age was 44.2 years and mean BMI at the time of conversion was 37.9 kg/m². We converted 273 failed adjustable gastric bandings (85,0%) and 48 failed Mason gastroplasties (15.0%). The main reason for conversion was the recurrence of obesity. A mean LoS of 2.10 days was calculated. We had an overall in-hospital complication rate of 3.73% and the overall early readmission rate was 3.43%. The odds ratio for LoS on early readmission is 1.52 (p=0.0079; CI 95% [1.12-2.07]).

CONCLUSION

The above data imply that the implementation of advanced ERAS principles for revisional surgery in our center is safe and does not lead to a higher risk of early readmission.

Revision of Mason's procedure (vertical banded gastroplasty) to Roux-en-Y gastric bypass: role of an associated fundectomy in weight loss outcomes

BACKGROUND

Vertical banded gastroplasty (VBG) presents a significant rate of long-term complications, and revisions are often necessary. Conversion to Roux-en-Y gastric bypass (RYGB) seems to be preferred, but literature data remain limited.

OBJECTIVES

To analyze the indications, safety, results of conversions from VBG to RYGB, and to identify predictive factors of success or failure.

SETTING

Two specialized centers of bariatric surgery.

METHODS

This bicentric retrospective study included all the patients who benefited from a conversion from VBG to RYGB between 2008 and January 2020. Demographic characteristics, indications, preoperative workups, intraoperative data, complications, and weight loss results were analyzed.

RESULTS

During the study period, 85 patients underwent a conversion to RYGB. The mean body mass index (BMI_ before conversion was 40.6 kg/m². 82.3% of the patients were converted because of weight loss failure and 17.6% because of a complication of their VBG. The global rate of complications was 25%. After an average follow-up of 35 months and a rate of loss to follow-up of 33%, the mean BMI was 33.5 kg/m. The weight loss success rate according to Reinhold's criteria was 64.7%, and resolution of complications was obtained in 89.1%. The association of a fundectomy was a predictive factor of weight loss (odds ratio, .27; P = .04), whereas primary failure of the VBG was a predictive factor of failure.

CONCLUSION

Conversion from VBG to RYGB remains the procedure of choice to achieve satisfying weight loss and resolution of functional complications. The addition of a fundectomy appeared to have a significant positive impact on weight loss outcomes.

Roux-en-Y Gastric Bypass Versus One Anastomosis Gastric Bypass as a Preferred Revisional Bariatric Surgery After a Failed Silastic Ring Vertical Gastroplasty

BACKGROUND

Over the years, the silastic ring vertical gastroplasty (SRVG) has shown poor long-term outcomes with both weight regain and complications. Therefore, most bariatric surgeons have been presented with the need to perform a successful and safe conversion procedure. Yet the preferred and recommended conversion surgery regarding weight loss, comorbidity improvement, and postoperative complications remains under debate.

OBJECTIVE

The aim of this study is to compare the outcomes of conversion from SRVG with either Roux-en-Y gastric bypass (RYGBP) or one anastomosis gastric bypass (OAGB).

MATERIALS AND METHODS

A retrospective study was conducted from our bariatric surgery units' database. We reviewed the files of patients who underwent either a RYGBP or OAGB after a previous SRVG. Demographics, obesity-related comorbidities, BMI before and after the procedure, postoperative complications, and length of hospital stay were analyzed.

RESULTS

Between May 2008 and August 2018, fifty-four patients underwent conversion from a failed SRVG. Twenty-one patients underwent conversion to OAGB (39%), and thirty-three patients underwent conversion to RYGBP (61%). Major complications were reported in 9.5% of the OAGB group and 15.1% of the RYGBP group. At a mean follow-up of 28 months, the OAGB group achieved a 78.5% excess BMI loss compared with 57.6% in the RYGBP group (p = 0.137). One patient (4.7%) of the OGBP group and 5 (15.1%) of the RYGBP group needed reoperations due to complications (p = 0.224).

CONCLUSION

The OGBP is gaining popularity and evidence as an effective and safe procedure. Here we show the successful utilization of the OGBP, when compared with RYGBP, as a revisional procedure after SRVG.

Bariatric revisional surgery: What are the challenges for the patient and the practitioner?

Bariatric revisional surgery represents an important new issue for obese patients because of the considerable rate of failure and complications following bariatric surgery. As the frequency of bariatric procedures increases, so too does the incidence of revisional surgery, which has become becoming increasingly important. The surgeon must know the indications and the results of the various revisional procedures in order to best guide the therapeutic decision. The current challenge is to correctly select the patients for revisional surgery and to choose the appropriate procedure in each case. Multidisciplinary management is essential to patient re-assessment and to prepare the patient for a re- intervention. The objective of this update, based on data from all the most recent studies concerning revisional surgery, is to guide the surgeon in the choice of the revisional procedure, depending on patient characteristics, co-morbidities, the previously performed procedure, the type of failure or complication observed, but also on the surgeon's own habits and the center's expertise. The collected results show that revisional surgery is difficult, with higher complication rates and weight-loss results that are often lower than those of first-intent surgery. For these reasons, patient selection must be rigorous and multidisciplinary and the management in expert centers of these difficult situations must be encouraged.

Twelve-Year Experience with Roux-en-Y Gastric Bypass as a Conversional Procedure for Vertical Banded Gastroplasty: Are We on the Right Track?

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.

Conversion of both Versions of Vertical Banded Gastroplasty to Laparoscopic Roux-en-Y Gastric Bypass: Analysis of Short-term Outcomes

BACKGROUND

Conversional bariatric surgery has relatively high rates of complications. We aimed to analyze our single-center experience with patients requiring conversional laparoscopic Roux-en-Y gastric bypass (LRYGB) following a failed primary open or laparoscopic vertical banded gastroplasty (OVBG or LVBG, respectively).

METHODS

The records of patients who underwent LRYGB as a conversional procedure after VBG between November 2004 and December 2017 were reviewed. Characteristics, body mass index (BMI), operation time, intraoperative problems, length of hospitalization, and early (< 30 days) morbidity and mortality were analyzed. Data were expressed as mean ± standard deviation or frequency.

RESULTS

A total of 329 patients (81.76% females) who underwent conversional RYGB were included. For the LVBG group (224 patients) and OVBG group (105 patients), respectively, BMI was 34.15 ± 6.38 and 37.79 ± 6.31 kg/m2 (p < 0.05), the operation time was 96.00 ± 31.40 and 123.15 ± 40.26 min (p < 0.05), hospitalization duration was 2.96 ± 1.13 and 3.20 ± 1.20 days (p = 0.08), the early complication rate was 7.14 and 11.43% (p = 0.19), and the reoperation rate was 2.23 and 2.86% (p = 0.73). There were no major intraoperative problems. Three patients with OVBG were converted to open RYGB (2.86%). There was no mortality.

CONCLUSION

The conversion of OVBG and LVBG to laparoscopic RYGB is technically feasible and provides comparably low early morbidity rates and length of hospitalization. However, compared to LVBG, conversional laparoscopic RYGB following OVBG is technically more challenging and time-consuming, with a slightly higher risk of conversion to open surgery. We support the use of such conversional bariatric surgery in specialized, high-volume bariatric centers.

Laparoscopic Roux-en-Y Gastric Bypass for Failed Vertical Banded Gastroplasty

BACKGROUND

Although the vertical banded gastroplasty (VBG) is effective in achieving weight loss without metabolic side effects during the first few years, late failures cause weight regain in about 20% of the patients. The laparoscopic Roux-en-Y gastric bypass (LRYGB) is the procedure of choice to convert a failed VBG.

MATERIALS AND METHODS

Between August 2014 and June 2016, 37 patients (23 females and 14 males) underwent revisional LRYGBs after failed VBGs. Thirty-four patients had open VBGs and two patients had laparoscopic butterfly gastroplasties. These patients completed follow-ups of at least 1 year.

RESULTS

The median operating time was 164 min (range 132-246), and the mean length of the hospital stay was 2.4 days (range 2-7). The mean body mass index (BMI) of the study group was 42.5 kg/m², while the mean BMI and the percentage of excess body weight loss (%EBWL) for the patients 6 months after the operation were 31.7 kg/m² and 52.1%, respectively. The mean BMI and %EBWL for the patients 1 year after the operation were 29.5 kg/m² and 67.7%, respectively. There were neither intraoperative complications nor postoperative mortalities, but the overall complication rate was 22% (eight patients).

CONCLUSION

An LRYGB following a VBG is technically challenging, but safe, with low morbidity and mortality rates. Moreover, a revisional LRYGB provides excellent weight loss results.

Clinical Indicators of Postoperative Bleeding in Bariatric Surgery

The purpose of this study was to evaluate the relationship between patient, clinical and laboratory characteristics, and bleeding after bariatric surgery. A retrospective chart review was performed for all patients, who underwent a laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy at our institution between March 2012 and May 2014. In total, 788 patients were included in this study. Seventeen patients had postoperative bleeding. The demographics, comorbidities, and preoperative medications were similar between the groups. Mean postoperative hemoglobin in the bleeding group was significantly lower (94 vs. 126; P<0.001) with a larger decrease from the baseline value (-43 vs. -12; P<0.001). The mean heart rate (91 vs. 81; P<0.001) and its increase from baseline (12 vs. -0.01; P<0.001) were significantly different in the bleeding patients. Postoperative hemoglobin and heart rate were associated with bleeding but not systolic blood pressure or patient characteristics. Further research is needed to develop a robust predictive model.

Re-operations after Secondary Bariatric Surgery: a Systematic Review

This paper reviews reoperations rates for short- and long-term complications following secondary bariatric procedures and need for further bariatric surgery. The search revealed 28 papers (1317 secondary cases) following at least 75 % of patients for 12 months or more. For adjustable gastric banding (AGB), rebanding had higher re-revisional rates than conversions into other procedures. Conversion of AGB to Roux-en-Y gastric bypass had the highest number of short- (10.7 %) and long-term (22.0 %) complications. We estimated 194 additional reoperations per 1000 patients having a secondary procedure, 8.8 % needing tertiary surgery. Despite being poorly reported, risks of reoperations for long-term complications and tertiary bariatric surgery are higher than usually reported risks of short-term complications and should be taken into account when choosing a secondary bariatric procedure and for economic evaluations.

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.

Quality criteria in bariatric surgery: Consensus review and recommendations of the Spanish Association of Surgeons and the Spanish Society of Bariatric Surgery

Bariatric surgery has proven to be highly effective in controlling obesity and metabolic syndrome; the results of this surgery are not only expressed in terms of weight loss, but also in terms of resolution of comorbidities, improved quality of life and complications. The different parameters used to measure these outcomes require uniformity and reference patterns. Therefore, it is essential to identify those indicators and quality criteria that are helpful in defining the «best practice» principles in bariatric surgery. In this regard, the Section of Obesity of the Spanish Association of Surgeons, in collaboration with the Spanish Society for Bariatric Surgery (SECO), present as an objective to identify the key points that define «quality» in this type of surgery. We describe the main indicators based on the published literature as well as the criteria for referral of the main comorbidities according to the evidence found and grades of recommendation.

[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.

Redo Surgery after Failed Open VBG: Laparoscopic Minigastric Bypass versus Laparoscopic Roux en Y Gastric Bypass-Which Is Better?

Background. Long-term studies have reported that the rate of conversion surgeries after open VBG ranged from 49.7 to 56%. This study is aiming to compare between LMGB and LRYGB as conversion surgeries after failed open VBG with respect to indications and operative and postoperative outcomes. Methods. Sixty patients (48 females and 12 males) presenting with failed VBG, with an average BMI of 39.7 kg/m² ranging between 26.5 kg/m² and 53 kg/m², and a mean age of 38.7 ranging between 24 and 51 years were enrolled in this study. Operative and postoperative data was recorded up to one year after the operation. Results. MGB is a simple procedure that is associated with short operative time and low rate of complications. However, MGB may not be applicable in all cases with failed VBG and therefore RYGB may be needed in such cases. Conclusion. LMGB is a safe and feasible revisional bariatric surgery after failed VBG and can achieve early good weight loss results similar to that of LRYGP. However, the decision to convert to lap RYGB or MGB should be taken intraoperatively depending mainly on the actual intraoperative pouch length.

FROM COMPLEX EVOLVING TO SIMPLE: CURRENT REVISIONAL AND ENDOSCOPIC PROCEDURES FOLLOWING BARIATRIC SURGERY

Background

Roux-en-Y gastric bypass (RYGB) is a standard therapy in bariatric surgery. Sleeve gastrectomy and gastric banding, although with good results in the literature, are showing higher rates of treatment failure to reduce obesity-associated morbidity and body weight. Other problems after bariatric may occur, as band erosion, gastroesophageal reflux disease and might be refractory to medication. Therefore, a laparoscopic conversion to a RYGB can be an effective alternative, as long as specific indications for revision are fulfilled.

Objective

The objective of this study was to analyse own and literature data on revisional bariatric procedures to evaluate best alternatives to current practice.

Methods

Institutional experience and systematic review from the literature on revisional bariatric surgery.

Results

Endoscopic procedures are recently applied to ameliorate failure and complications of bariatric procedures. Therapy failure following RYGB occurs in up to 20%. Transoral outlet reduction is currently an alternative method to reduce the gastrojejunal anastomosis. The diameter and volume of sleeve gastrectomy can enlarge as well, which can be reduced by endoscopic full-thickness sutures longitudinally. Dumping syndrome and severe hypoglycemic episodes (neuroglycopenia) can be present in patients following RYGB. The hypoglycemic episodes have to be evaluated and usually can be treated conventionally. To avoid partial pancreatectomy or conversion to normal anatomy, a new laparoscopic approach with remnant gastric resection and jejunal interposition can be applied in non-responders alternatively. Hypoglycemic episodes are ameliorated while weight loss is sustained.

Conclusion

Revisional and endoscopic procedures following bariatric surgery in patients with collateral symptomatic or treatment failure can be applied. Conventional non-surgical approaches should have been applied intensively before a revisional surgery will be indicated. Former complex surgical revisional procedures are evolving to less complicated endoscopic solutions.

Revisional metabolic/bariatric surgery: a moral obligation

Revisional metabolic/bariatric surgery is a moral obligation; for not to perform revisional surgery is a denial of the precepts of our discipline and an abandonment of the underprivileged population who has placed its trust and future in our hands.

Roux-en-Y gastric bypass for intractable biliary reflux in an individual with incomplete tetraplegia

CONTEXT

Gastroesophageal reflux disease (GERD) is a common complication in the spinal cord injury (SCI) population. Surgical treatment of GERD has a unique risk/benefit profile in this population.

FINDINGS

This 68-year-old male with chronic incomplete tetraplegia, dyslipidemia, and well-controlled diabetes mellitus underwent Roux-en-Y gastric bypass surgery (RYGBP) for intractable biliary reflux. Postoperatively, the patient had resolution of his symptoms but he also presented with significant weight loss and dumping syndrome. While he did have improvement in his dyslipidemia there was no change in his functional status.

CONCLUSIONS

RYGBP is an option for refractory GERD treatment in the SCI population but preoperative risk assessment and close monitoring postoperatively is essential.

Perioperative risk and complications of revisional bariatric surgery compared to primary Roux-en-Y gastric bypass

INTRODUCTION

Growing number of patients requires revisional bariatric surgery. This study compares perioperative course and outcomes of revisional versus primary bariatric surgery.

METHODS

Patients who underwent revisional bariatric surgery from Jan 1997 to Sept 2012 were reviewed retrospectively. Every revisional patient with BMI >35 and age <70 was matched with a primary Roux-en-Y gastric bypass control patient based on preoperative BMI, age, sex, and year of surgery. Patients' preoperative indications, intraoperative/postoperative course, and complications were analyzed.

RESULTS

Two hundred and fifty five patients underwent revisional bariatric surgery with resulting Roux-en-Y gastric bypass anatomy while 1,674 patients underwent primary gastric bypass in the same time interval. Of 255 patients, 172 patients were paired with 172 primary gastric bypass patients. Revisional bariatric group had preoperative BMI 48 ± 9, age 52 ± 9 years, 93 % female, 44 % laparoscopic, 30 % diabetic, 60 % hypertensive. Primary bypass patients had preoperative BMI 49 ± 8, age 52 ± 9 years, 93 % female, 97 % laparoscopic, 49 % diabetic, 67 % hypertensive. Compared to primary bypass patients, revisional patients had significantly higher estimated blood loss (463.7 vs. 113.3 mL), longer operative time (272.5 vs. 175.5 min), greater risk for ICU stay (N = 24, 14 % vs. N = 2, 1 %), and longer hospital stay (5.6 vs. 2.5 days). There were significantly more intraoperative liver (N = 13, 8 % vs. N = 1, 1 %) and spleen (N = 18, 10 % vs. N = 0) injuries, and more enterotomies (N = 9, 5 % vs. N = 0) in the revisional group. There were also significantly more postoperative complications (N = 94, 55 % vs. N = 48, 28 %), readmissions (N = 27, 16 % vs. N = 12, 7 %), and reoperations (N = 16, 9 % vs. N = 3, 2 %) within 30 days of surgery. Mean percentage weight loss at 1 year was significantly less for revisional patients (27 vs. 37 %). There was no significant difference in 30 day mortality between the two groups (N = 6 vs. 0).

CONCLUSION

Even in experienced hands, complex revisional bariatric surgery should be approached with significant caution, especially given that weight loss is less substantial.

Revisional bariatric surgery for unsuccessful weight loss and complications

BACKGROUND

There are growing numbers of patients who require revisional bariatric surgery due to the undesirable results of their primary procedures. The aim of this study was to review our experience with bariatric patients undergoing revisional surgery.

METHODS

We conducted a retrospective analysis to review the indications for revisional bariatric procedures and assess their postoperative outcomes.

RESULTS

From 04/04 to 01/11, 2,918 patients underwent bariatric surgery at our institution. A total of 154 patients (5.3%) of these cases were coded as revisional procedures. The mean age at revision was 49.1 ± 11.3 and the mean BMI was 44.0 ± 13.7 kg/m2. Revisional surgery was performed laparoscopically in 121 patients (78.6%). Laparoscopic revisions had less blood loss, shorter length of hospital stay, and fewer complications compared to open revisions. Two groups (A and B) were defined by the indication for revision: patients with unsuccessful weight loss (group A, n = 106) and patients with complications of their primary procedures (group B, n = 48). In group A, 74.5% of the patients were revised to a bypass procedure and 25.5% to a restrictive procedure. Mean excess weight loss was 53.7 ± 29.3% after revision of primary restrictive procedures and 37.6 ± 35.1% after revision of bypass procedures at >1-year follow-up (p < 0.05). In group B, the complications prompting revision were effectively treated by revisional surgery.

CONCLUSIONS

Revisional bariatric surgery effectively treated the undesirable results from primary bariatric surgery. Laparoscopic revisional surgery can be performed after both failed open and laparoscopic bariatric procedures without a prohibitive complication rate. Carefully selected patients undergoing revision for weight regain have satisfactory additional weight loss.

Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force

BACKGROUND

Reoperative bariatric surgery has become a common practice in many bariatric surgery programs. There is currently little evidence-based guidance regarding specific indications and outcomes for reoperative bariatric surgery. A task force was convened to review the current evidence regarding reoperative bariatric surgery. The aim of the review was to identify procedure-specific indications and outcomes for reoperative procedures.

METHODS

Literature search was conducted to identify studies reporting indications for and outcomes after reoperative bariatric surgery. Specifically, operations to treat complications, failed weight loss, and weight regain were evaluated. Abstract and manuscript reviews were completed by the task force members to identify, grade, and categorize relevant studies.

RESULTS

A total of 819 articles were identified in the initial search. After review for inclusion criteria and data quality, 175 articles were included in the systematic review and analysis. The majority of published studies are single center retrospective reviews. The evidence supporting reoperative surgery for acute and chronic complications is described. The evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. Procedure-specific outcomes are described. Complication rates are generally reported to be higher after reoperative surgery compared to primary surgery.

CONCLUSION

The indications and outcomes for reoperative bariatric surgery are procedure-specific but the current evidence does support additional treatment for persistent obesity, co-morbid disease, and complications.

Revisional bariatric surgery is more effective for improving obesity-related co-morbidities than it is for reinducing major weight loss

BACKGROUND

Patients having previous bariatric surgery are at risk for weight regain and return of co-morbidities. If an anatomic basis for the failure is identified, many surgeons advocate revision or conversion to a Roux-en-Y gastric bypass. The aim of this study was to determine whether revisional bariatric surgery leads to sufficient weight loss and co-morbidity remission.

PATIENTS AND METHODS

From 2005-2012, patients undergoing revision were entered into a prospectively maintained database. Perioperative outcomes, including complications, weight loss, and co-morbidity remission, were examined for all patients with a history of a previous vertical banded gastroplasty (VBG) or Roux-en-Y gastric bypass (RYGB).

RESULTS

Twenty-two patients with a history of RYGB and 56 with a history of VBG were identified. Following the revisional procedure, the RYGB group experienced 35.8% excess weight loss (%EWL) and a 31.8% morbidity rate. For the VBG group, patients experienced a 46.2% %EWL from their weight before the revisional operation with a 51.8% morbidity rate. Co-morbidity remission rate was excellent. Diabetes (VBG:100%, RYGB: 85.7%), gastroesophageal reflux disease (VBG: 94.4%, RYGB: 80%), and hypertension (VBG: 74.2%, RYGB:60%) demonstrated significant improvement.

CONCLUSION

Revision of a failed RYGB or conversion of a VBG to a RYGB provides less weight loss and a higher complication rate than primary RYGB but provides an excellent opportunity for co-morbidity remission.

What happens after gastric band removal without additional bariatric surgery?

BACKGROUND

The laparoscopic adjustable gastric band (LAGB) is widely used for the treatment of morbid obesity. Many patients benefit from this procedure initially, but experience complications after a few years. The treatment for many complications is revisional bariatric surgery. A number of patients, however, request only band removal without secondary bariatric surgery. The aim of this study was to assess the perioperative and medium term outcomes of patients who had their LAGB removed without secondary bariatric surgery.

METHODS

Patients were retrospectively selected using a prospectively collected database. The LAGB had to be in situ for at least 1 year, and minimum postoperative follow-up had to be 12 months.

RESULTS

Thirty-eight patients who had their LAGB laparoscopically removed between 2000 and 2010 were included. Median follow-up after LAGB removal was 3.0 (1.4 to 8.9) years. Only 2 complications (5%) and no mortality occurred perioperatively. In the 21 patients who did not undergo additional bariatric surgery, the median excess weight loss (EWL) decreased from 41% (-12% to -100%) at band removal to 9% (-10% to 90%), 0% (-20% to 78%), and -11% (-12% to 56%) after 1, 2, and 5 years, respectively. Percentage weight loss (%WL) was 17% (-54% to -5%), 4% (-47% to -9%), 0% (-41% to 11%), and -5% (-29% to 9%) after these same time intervals, respectively. After a median 2.1 (.5 to 9.9) years, 17 patients underwent either a Roux-en-Y gastric bypass (14 patients) or a Scopinaro (3 patients) all because of weight regain. The current EWL and %WL in these patients is 67% (24% to 113%) and 30% (12% to 53%), respectively compared with -11% (-33% to 57%) and -4% (-14% to 34%) in patients without a secondary bariatric procedure (P< .001).

CONCLUSION

Patients who have their LAGB removed are guaranteed to suffer from weight regain. It is inadvisable to only remove the LAGB without performing an additional bariatric procedure when deemed technically feasible and safe. In this study, no patient was able to maintain the weight loss achieved with the LAGB after its removal.

The impact of bariatric surgery on obstructive sleep apnea: a systematic review

There is a strong relationship between obesity and the development of obstructive sleep apnea (OSA). Respectively, bariatric surgery is often touted as the most effective option for treating obesity and its comorbidities, including OSA. Nevertheless, there remains paucity of data in the literature of the comparison of all the specific types of bariatric surgery themselves. In an effort to answer this question, a systematic review was performed, to determine, of the available bariatric procedures [Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, or biliopancreatic diversion (BPD)], which procedures were the most efficacious in the treatment of OSA. A total of 69 studies with 13,900 patients were included. All the procedures achieved profound effects on OSA, as over 75 % of patients saw at least an improvement in their sleep apnea. BPD was the most successful procedure in improving or resolving OSA, with laparoscopic adjustable gastric banding being the least. In conclusion, bariatric surgery is a definitive treatment for obstructive sleep apnea, regardless of the specific type.

Short- and long-term outcomes of vertical banded gastroplasty converted to Roux-en-Y gastric bypass

BACKGROUND

Vertical banded gastroplasty (VBG) often necessitates revisional surgery for weight regain or symptoms related to gastric outlet obstruction. Roux-en-Y gastric bypass (RYGB) is considered as the revisional procedure of choice. However, revisional bariatric surgery is associated with relatively higher rates of complications. The aim of the current study is to analyse our single-centre experience with patients requiring revisional RYGB following primary VBG.

METHODS

Retrospective review of the prospectively collected database identified 153 patients who underwent RYGB as a revisional procedure after VBG from Feb 2004-Feb 2011. Early and late complications, weight data and resolution of symptoms related to gastric outlet obstruction were analysed.

RESULTS

One hundred twenty-three females and 30 males underwent revisional RYGB post VBG. Mean age was 44.4 (15-74) years with a mean pre-operative body mass index (BMI) of 34.2 (23.5-65.5) kg/m(2). Mean hospital stay was 4.3 days. Early complication rate was 3.9 % with a 30-day re-operation rate of 1.3 %. Mortality and leak rate were zero. After a mean follow-up of 48 months, the mean BMI decreased significantly to 28.8 kg/m(2) and a complete resolution of the obstructive symptoms was achieved in nearly all patients. Late complications developed in 11 (7.7 %) of the patients of which seven (4.9 %) required surgery.

CONCLUSIONS

Revisional RYGB following VBG is technically challenging but safe with low rates of morbidity and mortality, comparable to primary RYGB. It produces a significant reduction in body weight and in symptoms resolution. We recommend RYGB as the procedure of choice in patients requiring revisional surgery following VBG.

Revisional bariatric surgery: perioperative morbidity is determined by type of procedure

BACKGROUND

Revisional bariatric procedures are on the rise. The higher complexity of these procedures has been reported to lead to increased risk of complications. The objective of our study was to compare the perioperative risk profile of revisional bariatric surgery with primary bariatric surgery in our experience.

METHODS

A prospectively maintained database of all patients undergoing bariatric surgery by three fellowship-trained bariatric surgeons from June 2005 to January 2013 at a center of excellence was reviewed. Patient demographics, type of initial and revisional operation, number of prior gastric surgeries, indications for revision, postoperative morbidity and mortality, length of stay, 30-day readmissions, and reoperations were recorded. These outcomes were compared between revisional and primary procedures by the Mann-Whitney or Chi square tests.

RESULTS

Of 1,556 patients undergoing bariatric surgery, 102 patients (6.5%) underwent revisional procedures during the study period. Indications for revisions included inadequate weight loss in 67, failed fundoplications with recurrent gastroesophageal reflux disease in 29, and other in 6 cases. Revisional bariatric procedures belonged into four categories: band to sleeve gastrectomy (n = 23), band to Roux-en-Y gastric bypass (n = 25), fundoplication to bypass (n = 29), and other (n = 25). Revisional procedures were associated with higher rates of readmissions and overall morbidity but no differences in leak rates and mortality compared with primary procedures. Band revisions had similar length of stay with primary procedures and had fewer complications compared with other revisions. Patients undergoing fundoplication to bypass revisions were older, had a higher number of prior gastric procedures, and the highest morbidity (40%) and reoperation (20%) rates.

CONCLUSIONS

In experienced hands, many revisional bariatric procedures can be accomplished safely, with excellent perioperative outcomes that are similar to primary procedures. As the complexity of the revisional procedure and number of prior surgeries increases, however, so does the perioperative morbidity, with fundoplication revisions to gastric bypass representing the highest risk group.

Laparoscopic Roux-en-Y Gastric bypass after failed vertical banded gastroplasty: a multicenter experience with 203 patients

BACKGROUND

Vertical banded gastroplasty (VBG) has long been the main restrictive procedure for morbid obesity but has many long-term complications for which conversion to Roux-en-Y gastric bypass (RYGBP) is often considered the best option.

METHODS

This series regroups patients operated on by three different surgeons in four different centers. All data were collected prospectively, then pooled and analyzed retrospectively.

RESULTS

Out of 2,522 RYGBP performed between 1998 and 2010, 538 were reoperations, including 203 laparoscopic RYGBP after VBG. There were 175 women and 28 men. The mean BMI before VBG was 43.2 ± 6.3, and the mean BMI before reoperation was 37.4 ± 8.3. Most patients had more than one indication for reoperation and/or had regained significant weight. There was no conversion to open surgery. A total of 24 patients (11.8 %) developed complications, including nine (4.5 %) who required reoperation and one death. With a follow-up of 88.9 % after 8 years, the mean BMI after 1, 3, 5, 7, and 9 years was 29.1, 28.8, 28.7, 29.9, and 28.8, respectively.

CONCLUSIONS

On the basis of this experience, the largest with laparoscopic reoperative RYGBP after failed VBG, we conclude that this procedure can safely be performed in experienced hands, with weight loss results similar to those observed after primary RYGBP. In patients with too difficult an anatomy below the cardia, dividing the esophagus just above the esophago-gastric junction and performing an esophagojejunostomy may be a safe alternative to converting to a Scopinaro-type BPD, obviating the additional long-term risks associated with malabsorption.

Endoscopic revision (StomaphyX) versus formal surgical revision (gastric bypass) for failed vertical band gastroplasty

BACKGROUND

Weight regain secondary to VBG pouch dilation is a typical referral for Bariatric surgeons. In this study we compare an endoluminal pouch reduction (Stomaphyx) to RYGB for revision.

METHODS

A retrospective review was completed for patients with a previous VBG presenting with weight regain between 2003-2010.

RESULTS

Thirty patients were identified for study 23 RYGB, 14 StomaphyX. Significant post procedure BMI loss was seen in each cohort (RYGB, 47.7 ± 7 kg/m(2) to 35 ± 7 kg/m(2); StomaphyX 43 ± 10 kg/m(2) to 40 ± 9 kg/m(2), P = 0.0007). Whereas nausea and headache were the only complications observed in StomaphyX patients, the RYGB group had a 43.5% complication rate and 1 mortality. Complications following RYGB include: incisional hernia (13%), anastomotic leak (8.7%), respiratory failure (8.7%), fistula (8.7%), and perforation (4.35%). The median length of stay following RYGB was 6 days compared to 1.5 ± 0.5 days following StomaphyX.

CONCLUSION

This study suggests that while RYGB revision may achieve greater weight loss, the complication rates and severity is discouraging. StomaphyX may be a safe alternative. Further technical modifications of the device and longer follow-up may clarify the role of this approach.

Gastroesophageal reflux after vertical banded gastroplasty is alleviated by conversion to gastric bypass

BACKGROUND

Conversion operations after vertical banded gastroplasty (VBG) are sometimes performed because of vomiting and/or acid regurgitation. Primary operation with gastric bypass (GBP) is known to reduce gastroesophageal reflux (GERD). Previous studies have not been designed to differentiate between the effects of the altered anatomy and of the ensuing weight loss. No series has reported data on acid reflux before and after conversion from VBG to GBP.

METHODS

We invited eight VBG patients with current symptoms of GERD. All had intact staple lines as assessed by barium meal and gastroscopy. Acid reflux was quantified using 48-h Bravo capsule measurements. Conversion operations were performed creating an isolated 15-20-ml pouch; the previously banded part of gastric wall was excised. Gastrojejunostomy was made end to end with a 28-mm circular stapler. The study is based on five patients consenting to early postoperative endoscopy and pH measurement.

RESULTS

All patients were women with a mean age of 49.5 years and BMI of 36.3. Time since VBG was 132.1 months. Time from conversion to second measurement was 46.6 days and BMI at that time 32.7. There was no mortality and no serious morbidity. All patients improved clinically and no patient had to go back on proton pump inhibition or antacids. Total time with pH < 4.0 was reduced from 18.4% to 3.3% (p < 0.05). DeMeester score was reduced from 58.1 to 15.9 (p < 0.05).

CONCLUSIONS

The effect of converting VBG-operated patients to GBP results in a near-normalisation of acid reflux parameters and a discontinuation of proton pump inhibitor medication.

Revisional bariatric surgery

With the increase in bariatric surgical procedures, an increase in revision operations is expected. A thorough preoperative work-up is essential to formulate an appropriate revision strategy. Outcomes vary according to the primary operation and chosen approach to revision. Recent studies have shown acceptably low complication rates and good weight loss with the associated health benefits. Although there is no direct evidence in the form of randomized studies indicating which patients with inadequate weight loss or weight regain will benefit most from revision, or to support one particular revision approach rather than another, it is possible to develop general, effective strategies.

Obesity and GERD: pathophysiology and effect of bariatric surgery

Epidemiologic, endoscopic, and pathophysiologic studies document the relationship between obesity and gastroesophageal reflux disease (GERD). Increased body mass index and accumulation of visceral fat are associated with a two- to threefold increased risk of developing reflux symptoms and esophageal lesions. Given this association, many studies were designed to evaluate the outcome of reflux symptoms following conventional and surgical treatment of obesity. Among bariatric procedures, gastric sleeve and banded gastroplasty were shown to have no effect or even worsen reflux symptoms in the postoperative setting. Gastric banding improves reflux symptoms and findings (endoscopic and pH-measured distal esophageal acid exposure) in many patients, but is associated with de novo reflux symptoms or lesions in a considerable proportion of patients. To date, Roux-en-Y gastric bypass is the most effective bariatric procedure that consistently leads to weight reduction and improvement of GERD symptoms in patients undergoing direct gastric bypass and among those converted from restrictive bariatric procedures to gastric bypass.