Laparoscopic conversion of adjustable gastric banding to sleeve gastrectomy: a feasibility study

Safety of Revision Sleeve Gastrectomy Compared to Roux-Y Gastric Bypass After Failed Gastric Banding: Analysis of the MBSAQIP

OBJECTIVE

The aim of this study was to assess the safety of revisional surgery to laparoscopic sleeve gastrectomy (LSG) compared to laparoscopic Roux-Y gastric bypass (LRYGB) after failed laparoscopic adjustable gastric banding (LAGB).

BACKGROUND

The number of reoperations after failed gastric banding rapidly increased in the United States during the last several years. A common approach is band removal with conversion to another weight loss procedure such as gastric bypass or sleeve gastrectomy in a single procedure. The safety profile of those procedures remains controversial.

METHODS

Preoperative characteristics and 30-day outcomes from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Files 2015 were selected for all patients who underwent a 1-stage conversion of LAGB to LSG (conv-LSG) or LRYGB (conv-LRYGB). Conv-LSG cases were matched (1:1) with conv-LRYGB patients by age (±1 year), body mass index (±1 kg/m(2)), sex, and comorbidities including diabetes, hypertension, hyperlipidemia, venous stasis, and sleep apnea.

RESULTS

A total of 2708 patients (1354 matched pairs) were included in the study. The groups were closely matched as intended. The mean operative time in conv-LRYGB was significantly longer in comparison to conv-LSG patients (151 ± 58 vs 113 ± 45 minutes, P < 0.001). No mortality was observed in either group. Patients after conv-LRYGB had a clinically increased anastomotic leakage rate (2.07% vs 1.18%, P = 0.070) and significantly increased bleed rate (2.66% vs 0.44%, P < 0.001). Thirty-day readmission rate was significantly higher in conv-LRYGB patients (7.46% vs 3.69%, P < 0.001), as was 30-day reoperation rate (3.25% vs 1.26%, P < 0.001). The length of hospital stay was longer in conv-LRYGB.

CONCLUSIONS

A single-stage conversion of failed LAGB leads to greater morbidity and higher complication rates when converted to LRYGB versus LSG in the first 30 days postoperatively. These differences are particularly notable with regards to bleed events, 30-day reoperation, 30-day readmission, operative time, and hospital stay.

Single- or double-anastomosis duodenal switch versus Roux-en-Y gastric bypass as a revisional procedure for sleeve gastrectomy: A systematic review and meta-analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) is one of the most commonly performed bariatric procedure worldwide. There is currently no consensus on which revisional procedure is best after an initial SG.

OBJECTIVES

To compare the efficacy and safety between single-anastomosis duodeno-ileal bypass (SADI) or biliopancreatic diversion with duodenal switch (BPD-DS) versus Roux-en-Y gastric bypass (RYGB) as a revisional procedure for SG.

SETTING

University Hospital, Canada.

METHODS

MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and PubMed were searched up to August 2018. Studies were eligible for inclusion if they compared SADI or BPD-DS with RYGB as a revisional bariatric procedure for SG. Primary outcome was absolute percentage of total weight loss. Secondary outcomes were length of stay, adverse events, and improvement or resolution of co-morbidities (diabetes, hypertension, or hypercholesterolemia). Pooled mean differences were calculated using random effects meta-analysis.

RESULTS

Six retrospective cohort studies involving 377 patients met the inclusion criteria. The SADI/BPD-DS group achieved a significantly higher percentage of total weight loss compared with RYGB by 10.22% (95% confidence interval, -17.46 to -2.97; P = .006). However, there was significant baseline equivalence bias with 4 studies reporting higher initial body mass index (BMI) in the SADI/BPD-DS group. There were no significant differences in length of stay, adverse events, or improvement of co-morbidities between the 2 groups.

CONCLUSION

SADI, BPD-DS, and RYGB are safe and efficacious revisional surgeries for SG. Both SADI and RYGB are efficacious in lowering initial BMI but there is more evidence for excellent weight loss outcomes with the conversion to BPD-DS when the starting BMI is high. Further randomized trials are required for definitive conclusions.

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.

Fifth International Consensus Conference: current status of sleeve gastrectomy

BACKGROUND

For the purpose of building best practice guidelines, an international expert panel was surveyed in 2014 and compared with the 2011 Sleeve Gastrectomy Consensus and with survey data culled from a general surgeon audience.

OBJECTIVES

To measure advancement on aspects of laparoscopic sleeve gastrectomy and identify current best practices.

SETTING

International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) 2014, Fifth International Summit for Laparoscopic Sleeve Gastrectomy, Montréal, Canada.

METHODS

In August 2014, expert surgeons (based on having performed>1000 cases) completed an online anonymous survey. Identical survey questions were then administered to general surgeon attendees.

RESULTS

One hundred twenty bariatric surgeons completed the expert survey, along with 103 bariatric surgeons from IFSO 2014 general surgeon audience. The following indications were endorsed: as a stand-alone procedure (97.5%); in high-risk patients (92.4%); in kidney and liver transplant candidates (91.6%); in patients with metabolic syndrome (83.8%); body mass index 30-35 with associated co-morbidities (79.8%); in patients with inflammatory bowel disease (87.4%); and in the elderly (89.1%). Significant differences existed between the expert and general surgeons groups in endorsing several contraindications: Barrett's esophagus (80.0% versus 31.3% [P<.001]), gastroesophageal reflux disease (23.3% versus 52.5% [P<.001]), hiatal hernias (11.7% versus 54.0% [P<.001]), and body mass index>60 kg/m(2) (5.0% versus 28.0% [P<.001]). Average reported weight loss outcomes 5 years postoperative were significantly higher for the expert surgeons group (P = .005), as were reported stricture (P = .001) and leakage (P = .005) rates. The following significant differences exist between 2014 and 2011 expert surgeons: Patients with gastroesophageal reflux disease should have pH and manometry study pre-laparoscopic sleeve gastrectomy (32.8% versus 50.0%; P = .033); it is important to take down the vessels before resection (88.1% versus 81.8%; P = .025); it is acceptable to buttress (81.4% versus 77.3%; P<.001); the smaller the bougie size and tighter the sleeve, the higher the incidence of leaks (78.8% versus 65.2%; P = .006).

CONCLUSION

This study highlights areas of new and improved best practices on various aspects of laparoscopic sleeve gastrectomy performance among experts from 2011 and 2014 and among the current general surgeon population.

Laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy as revisional procedure after adjustable gastric band--a systematic review

The adjustable gastric band (L)AGB gained popularity as a weight loss procedure. However, long-term results are disappointing; many patients need revision to laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG). The purpose of this study was to assess morbidity, mortality, and results of these two revisional procedures. Fifteen LRYGB studies with a total of 588 patients and eight LSG studies with 286 patients were included. The reason for revision was insufficient weight loss or weight regain in 62.2 and 63.9% in LRYGB and LSG patients. Short-term complications occurred in 8.5 and 15.7% and long-term complications in 8.9 and 2.5%. Reoperation was performed in 6.5 and 3.5%. Revision to LRYGB or LSG after (L)AGB is feasible and relatively safe. Complication rate is higher than in primary procedures.

Comparison between laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding for morbid obesity: a meta-analysis

Bariatric surgery is now widely accepted for treatment of morbid obesity. This study compared the effects of laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) on excess weight loss (EWL) and type 2 diabetes mellitus (T2DM). PubMed and Embase were searched for publications concerning LAGB and LSG from 2000 to 2012, with the last search on August 17, 2012. EWL and T2DM improvement over 6 and 12 months were pooled and compared by meta-analysis. Odds ratios (ORs) and mean differences were calculated with 95 % confidence intervals (CIs). Eleven studies involving 1,004 patients met the inclusion criteria. Compared with LAGB, LSG achieved greater EWL. The mean percentage EWL for LAGB was 33.9 % after 6 months in six studies and 37.8 % after 12 months in four studies; for LSG, EWL was 50.6 % after 6 months and 51.8 % after 12 months in the same studies. LSG was also superior to LAGB in treating T2DM. In five studies, T2DM was improved in 42 of 68 (61.8 %) patients after LAGB and 66 of 80 (82.5 %) after LSG, representing a pooled OR of 0.34 (95 % CI 0.16–0.73) and pooled mean differences of −12.55 (95 % CI −15.66 to −9.43) and −4.97 (95 % CI −7.58 to −8.36), respectively. LSG is more effective than LAGB in morbid obesity, with higher percentage EWL and greater improvement in T2DM.

Comparison of laparoscopic sleeve gastrectomy leak rates in four staple-line reinforcement options: a systematic review

OBJECTIVE

The study compared laparoscopic sleeve gastrectomy (LSG) staple-line leak rates of 4 prevalent surgical options: no reinforcement, oversewing, nonabsorbable bovine pericardial strips (BPS), and absorbable polymer membrane (APM).

BACKGROUND

LSG is a multipurpose bariatric/metabolic procedure with effectiveness proven through the intermediate term. Staple-line leak is a severe complication of LSG for which no definitive method of prevention has been identified.

METHODS

The systematic review study design was employed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement screening guidelines. Inclusion criteria centered on variables potentially relevant to LSG leak: leak rate, age, gender, calibrating bougie size, distance between pylorus and gastric transection line, overall complication rate, and mortality. Analysis of variance models were used to explore differences in select demographic and surgical technique variables characterizing each reinforcement group. An omnibus χ(2) test followed by independent Fisher's exact tests were used to compare leak rates.

RESULTS

There were 659 articles identified; 41 duplicates removed. Of 618 remaining articles, 324 did not meet inclusion criteria. Of the 294 remaining articles, 206 were eliminated (kin studies, those not reporting staple-line or leak incidence, those reporting discontinued products). There were 88 papers included in the analysis. Statistically significant differences were found between groups across demographic and surgical variables studied (p<0.001). There were 191 leaks in 8,920 patients; overall leak rate 2.1%. Leak rates ranged from 1.09% (APM) to 3.3% (BPS); APM leak rate was significantly lower than other groups (p< 0.05).

CONCLUSION

Systematic review of 88 included studies representing 8,920 patients found that the leak rate in LSG was significantly lower using APM staple-line reinforcement than oversewing, BPS reinforcement, or no reinforcement.

Excessive weight loss after sleeve gastrectomy: a systematic review

BACKGROUND

The clinical significance of sleeve gastrectomy (SG) as a primary bariatric intervention is still under debate. This article aims to systematically analyze excessive weight loss (EWL) in patients after SG.

METHODS

A systematic literature search on SG from the period January 2003 to December 2010 was performed. Data described from systematic reviews dealing with gastric bypass procedures was used as comparator.

RESULTS

The final study included 123 papers describing 12,129 patients. Most of the papers describe EWL at 12 months (43.9% of all papers). For SG, the maximum EWL occurred 24 and 36 months postoperatively with a mean EWL of 64.3% (minimum 46.1%, maximum 75.0%) and 66.0% (minimum 60.0%, maximum 77.5%), respectively. At 12 months, the mean EWL in patients receiving SG was significantly lower when compared to patients who underwent gastric bypass (SG 56.1%, gastric bypass 68.3%; p < 0.01, two-sided Wilcoxon test). Although patients with gastric bypass still had higher EWL rates at 24 months compared to patients after SG, these differences were not significant (SG 61.3%, gastric bypass 69.6%; p = 0.09, two-sided Wilcoxon rank-sum test). Reoperations after SG are necessary in 6.8% (range 0.7-25%) of cases with patients receiving SG as a stand alone procedure and in 9.6-28.5% of cases with patients undergoing SG as a planned first stage procedure.

CONCLUSIONS

SG is an effective bariatric procedure with a lasting effect on EWL. Compared with gastric bypasses, there is no difference in EWL at the time point of 24 months.

Integrated bioabsorbable tissue reinforcement in laparoscopic sleeve gastrectomy

Division of the stomach in laparoscopic sleeve gastrectomy may be performed using bare stapler cartridges or cartridges fitted with tissue reinforcement strips, with or without oversewing. Many tissue reinforcement strips are after-market add-on products that must be fitted onto a stapler during surgery. A retrospective review was conducted of 85 consecutive patients undergoing laparoscopic sleeve gastrectomy using a novel integrated bioabsorbable polymer buttress pre-mounted on a single-use loading unit stapler. Mean preoperative body mass index (BMI) was 41.7 ± 5.2 kg/m(2). Morbidity and short-term outcomes were documented. Mean follow-up was 8.1 ± 3.6 months (range, 1.0-16.2 months). There were no mortalities or staple line leaks noted in this series with short-term follow up. The major complication rate (grade III and above) was 7.1% and included: reoperation for staple line bleeding (2.4%, n = 2), gastric sleeve stenosis requiring balloon dilation (2.4%, n = 2), choledocholithiasis 2 weeks after surgery (1.2%, n = 1), and reoperation without abnormality for suspected perioperative obstruction (1.2%, n = 1). Mean percent excess BMI loss at 3 (44.6 ± 11.3), 6 (57.9 ± 17.2), and 12 months (72.4 ± 27.5) was comparable to other published series. The use of an integrated absorbable synthetic polymer for stapled tissue reinforcement in laparoscopic sleeve gastrectomy appears to be feasible and safe, and yields results consistent with other published techniques.

International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is an emerging surgical approach, but 1 that has seen a surge in popularity because of its perceived technical simplicity, feasibility, and good outcomes. An international expert panel was convened in Coral Gables, Florida on March 25 and 26, 2011, with the purpose of providing best practice guidelines through consensus regarding the performance of LSG. The panel comprised 24 centers and represented 11 countries, spanning all major regions of the world and all 6 populated continents, with a collective experience of >12,000 cases. It was thought prudent to hold an expert consensus meeting of some of the surgeons across the globe who have performed the largest volume of cases to discuss and provide consensus on the indications, contraindications, and procedural aspects of LSG. The panel undertook this consensus effort to help the surgical community improve the efficacy, lower the complication rates, and move toward adoption of standardized techniques and measures. The meeting took place at on-site meeting facilities, Biltmore Hotel, Coral Gables, Florida.

METHODS

Expert panelists were invited to participate according to their publications, knowledge and experience, and identification as surgeons who had performed >500 cases. The topics for consensus encompassed patient selection, contraindications, surgical technique, and the prevention and management of complications. The responses were calculated and defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement).

RESULTS

Full consensus was obtained for the essential aspects of the indications and contraindications, surgical technique, management, and prevention of complications. Consensus was achieved for 69 key questions.

CONCLUSION

The present consensus report represents the best practice guidelines for the performance of LSG, with recommendations in the 3 aforementioned areas. This report and its findings support a first effort toward the standardization of techniques and adoption of working recommendations formulated according to expert experience.