Single stage conversion from adjustable gastric banding to sleeve gastrectomy or Roux-en-Y gastric bypass: an analysis of 4875 patients

The SAGES MASTERS program bariatric surgery pathway selects 10 seminal publications on adjustable gastric banding

BACKGROUND

Bariatric surgery is one of the clinical pathways of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program, and laparoscopic adjustable gastric banding (LAGB) is one of the three anchoring bariatric procedures. To improve surgeon lifelong learning, the Masters Program seeks to identify sentinel articles of each of the 3 bariatric anchoring procedures. In this article, we present the top 10 articles on LAGB.

METHODS

A systematic literature search of papers on LAGB was completed, and publications with the most citations and citation index were selected and shared with SAGES Metabolic and Bariatric Surgery Committee members for review. The individual committee members then ranked these papers, and the top 10 papers were chosen based on the composite ranking.

RESULTS

The top 10 sentinel publications on LAGB contributed substantially to the body of literature related to the procedure, whether for surgical technique, novel information, or outcome analysis. A summary of each paper including expert appraisal and commentary is presented here.

CONCLUSION

These seminal articles have had significant contribution to our understanding and appreciation of the LAGB procedure. Bariatric surgeons should use this resource to enhance their continual education and acquisition of specialized skills.

Adjuvant and Neo-Adjuvant Anti-Obesity Medications and Bariatric Surgery: A Scoping Review

PURPOSE OF REVIEW

To comprehensively summarize the current body of literature on the topic of adjuvant and neoadjuvant pharmacotherapy used in combination with bariatric surgery.

RECENT FINDINGS

Anti-obesity medications (AOMs) have been used since the mid-1900s; however, their use in combination with bariatric surgery is a newer area of research that is rapidly growing. Pharmacotherapy may be used before (neoadjuvant) or after (adjuvant) bariatric surgery. Recent literature suggests that adjuvant AOMs may address weight regain and inadequate weight loss following bariatric surgery. Research on neoadjuvant AOM used to optimize weight loss before bariatric surgery is more limited. A literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Thirty-four studies were included after screening and exclusion of irrelevant records. Included studies were as follows: seven prospective studies on adjuvant AOM use, 23 retrospective studies on adjuvant AOM use, one prospective study on adjuvant and neoadjuvant AOM use, one retrospective study on adjuvant or neoadjuvant AOM use, one prospective study on neoadjuvant AOM use, and one case series on neoadjuvant AOM use. In the following scoping review, each of these studies is discussed with the goal of presenting a complete synthesis of the current body of literature on AOM use in combination with bariatric surgery.

Quality of Life in Patients Undergoing Revisional Bariatric Surgery: From Sleeve Gastrectomy to Roux-en-Y Gastric Bypass

Sleeve gastrectomy (SG) is the most performed bariatric surgery worldwide. However, this surgery may be associated with long-term weight regain and severe gastroesophageal reflux disease (GERD), sometimes necessitating conversion to Roux-en-Y gastric bypass (RYGB) to improve quality of life (QoL). We conducted a systematic review on QoL measures following the conversion of SG to RYGB. We searched various databases for studies conducted between January 2005 and September 2023. Four studies, involving 196 participants in total, met the inclusion criteria. Different assessment methods were used to evaluate QoL following the conversion. In the included studies, we observed that GERD symptoms and proton pump inhibitor (PPI) use both decreased following conversion to RYGB. Excess weight loss (EWL) was also observed in all studies.

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.

Roux-en-Y Gastric Bypass as Conversion Procedure of Failed Gastric Banding: Short-Term Outcomes of 1295 Patients in One Single Center

PURPOSE

Laparoscopic adjustable gastric band (LAGB) has high technical and weight loss failure rates. We evaluate here the 1-year morbidity, mortality, and weight loss of laparoscopic Roux-en-Y-gastric bypass (LRYGB) as a feasible conversion strategy.

METHODS

Patients with a failed primary LAGB who underwent LRYGB from July 2004 to December 2019 were selected from an electronic database at our center. Patients had a conversion to LRYGB at the same time (one-stage approach) or with a minimum of 3 months in between (two-stage approach). Primary outcomes included 30-day morbidity and mortality. Secondary outcomes were body mass index (BMI), percent excess weight loss (%EWL), and percent excess BMI lost (%EBMIL) at 1 year postoperatively.

RESULTS

A total of 1295 patients underwent a conversion from LAGB to LRYGB at our center: 1167 patients (90.1%) in one stage and 128 patients (9.9%) in two stages. There was no mortality. An early (30-day) postoperative complication occurred in 93 patients (7.2%), with no significant difference found between groups. Hemorrhage was the most common complication in 39 patients (3.0%), and the reoperation was required in 19 patients (1.4%). At 1 year postoperatively, the mean BMI was 28.0 kg/m2, the mean %EWL 72.8%, and the mean %EBMIL 87.0%. No statistically significant difference was found between the groups.

CONCLUSION

Conversion to LRYGB can be considered as a safe and effective option with low complication rate and good weight loss outcomes at 1 year. One-stage conversion provides the same early outcome as two-step surgery with a competent surgeon.

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.

Long-Term Matched Comparison of Primary and Revisional Laparoscopic Sleeve Gastrectomy

BACKGROUND

Reports of long-term (> 5-15-year) outcomes assessing the safety and efficacy of primary revisional laparoscopic sleeve gastrectomy (LSG) are few.

METHODS

Retrospective long-term comparisons of primary (pLSG) and revisional (rLSG) procedures were matched for gender, age ± 5 years, and body mass index (BMI) ± 5 kg/m². Weight loss, associated medical condition status, and patient satisfaction were evaluated.

RESULTS

Between May 1, 2006, and December 31, 2016, 194 matched patients with severe obesity (mean BMI 44.1 ± 6.7 kg/m²; age 44.2 ± 10.0 years, 67.0% female) underwent pLSG (n = 97) or rLSG (n = 97) and were followed for a mean 12.1 ± 1.5 vs 7.6 ± 2.1 years. Respective mean weight regain from nadir was 15.0 ± 14.4 kg vs 11.9 ± 12.2 kg. Respective percent mean total weight loss and excess weight loss were 20.9 ± 12.7% and 51.8 ± 33.1%, and 18.3 ± 12.8% and 43.4 ± 31.6% at last follow-up, with no significant difference between groups. Resolution of type 2 diabetes (HbA1_C < 6.5%, off medications) was 23.1% vs 11.1%; hypertension 36.0% vs 16.0%; and hyperlipidemia 37.1% vs 35.3%. Patients in the pLSG group were significantly more satisfied with LSG (59.8% vs 43.3%, p < 0.05) and more likely to choose the procedure again.

CONCLUSIONS

There were no significant differences in long-term weight loss or associated medical condition outcomes in matched pLSG and rLSG patients.

Propensity score matching analysis comparing outcomes between primary and revision Roux-en-Y gastric bypass after adjustable gastric banding: a retrospective record-based cohort study

BACKGROUND

One-stage revision Roux-en-Y gastric bypass (RRYGB) after Laparoscopic adjustable gastric banding (LAGB) is widely adopted, but its safety is still debated.

OBJECTIVE

This study aimed to compare outcomes between primary Roux-en-Y gastric bypass (PRYGB and RRYGB after LAGB.

METHOD

A retrospective record-based cohort study of patients who underwent PRYGB and RRYGB for failed LAGB and completed at least 2 years of follow-up from 2008 to 2019. Propensity score matching (PSM) analysis was conducted to obtain a balanced sample of patients with RRYGB and PRYGB interventions by adjusting for baseline covariates including age and sex.

RESULTS

Patients with PRYGB (n = 558) and RRYGB (n = 156) were included. PSM identified 98 patients for RRYGB and 98 patients for PRYGB. Both cohorts exhibited significant reductions in BMI compared to baseline values (p < 0.001), but reductions were significantly higher in PRYGB compared to those in RRGYB at 6 months (- 10.55 ± 8.54 vs. - 8.38 ± 5.07; p = 0.032), 1-year (- 21.50 ± 8.19 vs. 16.14 ± 6.93; p < 0.001), and 2 years (- 24.02 ± 7.85 vs. - 18.93 ± 6.80; p < 0.001), respectively. A significant improvement in food tolerance from the 1st to the 2nd year was seen after RYGB (p < 0.001). The rates of early and late complications were similar in both cohorts (p = 0.537, p = 1.00). Overall re-intervention rates were 5.1 and 3.1% for RRYGB and PRYGB p = 0.721). Both cohorts exhibited significant improvement in comorbidities after 2 years (p < 0.001).

CONCLUSIONS

One-stage RRYGB for failed LAGB is safe and effective with comparable rates of complications, re-interventions, and resolution of associated comorbid conditions compared to PRYGB.

Revisional Surgery After Adjustable Gastric Banding: Sleeve Gastrectomy or Gastric Bypass?

Adjustable gastric banding was the most common type of bariatric surgery performed in Korea prior to 2019. Many patients that have undergone this procedure require revisional bariatric surgery while removing the gastric band, and it is important to select an appropriate revisional procedure. If reoperation is performed owing to insufficient weight loss or weight regain, a 1-step procedure can be considered. However, a 2-step procedure is preferred when complications such as band erosion or stomach perforation have occurred. Previous studies from Western countries have shown that revisional Roux-en-Y gastric bypass (RYGB) can achieve more effective postoperative weight loss than revisional sleeve gastrectomy, although this procedure may also carry a higher risk of morbidity, reoperation, and readmission to hospital. In Korea, the short-term outcomes of the 2 procedures may be similar. However, the potential risk of gastric cancer in the remnant stomach after RYGB must also be considered. The type of revisional surgery should be selected following discussions with the patient regarding the advantages and disadvantages associated with each procedure.

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.

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.

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.

Laparoscopic extraction of gastric self-expandable metallic stent after migration in ileum: A case report

Revisional surgery in bariatric patients can sometimes lead to life-threatening complications that need a fast diagnosis and treatment as well as a multidisciplinary approach. If left undiagnosed or untreated, this may lead to sepsis, multiple organ failure, and death. In this case report, we describe the management of a gastric perforation which occurred after conversion of a gastric banding to a sleeve gastrectomy.

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.

Bariatric procedures in adolescents are safe in accredited centers

BACKGROUND

With the rise of obesity in adolescents, there is an exponential increase in bariatric procedures in this patient population.

OBJECTIVES

The purpose of our study was to examine perioperative outcomes after bariatric surgery in this cohort.

SETTING

University hospital, involving a large database in New York State.

METHODS

The Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program public use file was queried to identify all adolescent patients (age <19 years) undergoing primary laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) in 2015. We assessed 30-day postoperative complications.

RESULTS

We identified 1072 patients who underwent Roux-en-Y gastric bypass (n = 279) or SG (n = 793). The majority were Caucasian (n = 790) and female (n = 857) with mean body mass index and age of 47.9 ± 8.1 kg/m² and 18.2 ± 1 years, respectively, preoperative hypertension, type 2 diabetes, and obstructive sleep apnea were present in 90 (8.4%), 139 (13%), and 165 (15.4%) of patients, respectively. There was significant difference in preoperative gastroesophageal reflux disease (18.6% versus 13.4%, P = .033), obstructive sleep apnea (19.7% versus 13.9%, P = .02), and body mass index (48.6 ± 7.9 versus 47.6 ± 8.2 kg/m², P = .03) between patients undergoing Roux-en-Y gastric bypass and SG, respectively. Thirty-day reoperation, readmission, and reintervention were reported in 1.5%, 3.3%, and 1.6% of the adolescent cohort, respectively. Four patients (.4%) developed a staple line/anastomotic leak, and 1 patient (.09%) died within 30 days; 93.9% of all adolescent patients experienced an uneventful 30-day recovery. Uneventful recovery was significantly more likely for patients undergoing SG (95.3% versus 90%, P = .001; adjusted odds ratio 2.2, 95% confidence interval 1.31-3.69).

CONCLUSION

Perioperative safety of bariatric surgery in adolescents in accredited centers is safer than previously reported with low rate of 30-day events. SG is a safer procedure in this patient population.