Feasibility of laparoscopic sleeve gastrectomy as a revision procedure for prior laparoscopic gastric banding

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.

Improvement of Lipid Profile after One-Anastomosis Gastric Bypass Compared to Sleeve Gastrectomy

Fewer studies compared the improvement of plasma lipid levels after different types of surgery, in particular compared to one-anastomosis gastric bypass (OAGB). The aim of our study was to investigate how laparoscopic sleeve gastrectomy (LSG) and OAGB impact on weight loss and lipid profile 18 months after surgery, in patients with severe obesity. Forty-six patients treated with OAGB were matched to eighty-eight patients submitted to LSG. Weight loss after OAGB (33.2%) was more evident than after LSG (29.6%) (p = 0.024). The difference in the prevalence of dyslipidemia showed a statistically significant reduction only after OAGB (61% versus 22%, p < 0.001). After adjustment for delta body mass index (BMI), age and sex, we demonstrated a statistically significant decrease of the differences between the changes before and after (delta Δ) the two surgery procedures: Δ total cholesterol values (p < 0.001), Δ low density lipoprotein-cholesterol values (p < 0.001) and Δ triglycerides values (p = 0.007). Patients with severe obesity undergoing to OAGB presented a better improvement of lipid plasma values than LSG patients. The reduction of lipid plasma levels was independent of the significant decrease of BMI after surgery, of age and of sex.

Assessment of Protein Intake in the First Three Months after Sleeve Gastrectomy in Patients with Severe Obesity

An adequate protein intake prevents the loss of fat-free mass during weight loss. Laparoscopic sleeve gastrectomy (SG) jeopardizes protein intake due to post-operative dietary restriction and intolerance to protein-rich foods. The purpose of this study is to evaluate protein intake in the first three months after SG. We evaluated, 1 month and 3 months after surgery, 47 consecutive patients treated with SG. Protein intake, both from foods and from protein supplementation, was assessed through a weekly dietary record. Patients consumed 30.0 ± 10.2 g of protein/day on average from foods in the first month, with a significant increase to 34.9 ± 4.8 g of protein/day in the third month (p = 0.003). The use of protein supplementation significantly increased total protein intake to 42.3 ± 15.9 g protein/day (p < 0.001) in the first month and to 39.6 ± 14.2 g of protein/day (p = 0.002) in the third one. Compliance with supplement consumption was 63.8% in the first month and only 21.3% in the third month. In conclusion, both one and three months after SG, protein intake from foods was not sufficient. The use of modular supplements seems to have a significant impact on protein intake, but nevertheless it remains lower than recommended.

Revisional bariatric surgery to single-anastomosis gastric bypass: a large multi-institutional series

BACKGROUND

Reoperation is often required after bariatric procedures. Single-anastomosis gastric bypass (SAGB) is increasingly utilized as a primary bariatric procedure. Few series document SAGB as a revisional bariatric procedure.

OBJECTIVES

To describe our short-term experience with revisional SAGB, focusing on weight loss and reflux symptom outcomes.

SETTING

Three hospitals in Australia with both private and public (government funded) patients.

METHODS

We reviewed all revisional SAGB cases from 2012 to 2019 at. Complications were considered significant if they were Clavien-Dindo grade 3a or higher. A phone survey was conducted to assess weight loss outcomes, patient satisfaction, reflux symptoms, and other complications.

RESULTS

We identified 254 patients who had a revisional bariatric procedure to SAGB (21 previous sleeve gastrectomies and 233 previous adjustable bands), with a mean follow-up of 22 ± 15.6 months (range, 1-55 mo). The mean percentage of excess weight loss was 77% (183 patients, 72%), and the number of patients with follow-ups at 1 and 4 years was 184 (73%) and 35 patients (14%). Within 30 days, there were 29 patients (11%) who required reinterventions (21 endoscopies, 1 interventional radiology procedure, and 7 reoperations) with no deaths. Beyond 30 days, 27 patients (11%) required rerevision to Roux-en-Y gastric bypass for reflux symptoms and 10 (4%) required a laparotomy or laparoscopy for another reason (e.g., bowel obstruction). At a median follow-up of 36.6 months, 87 patients (34%) completed a phone survey, 45 (52%) of whom were taking proton pump inhibitors and 66 patients (76%) of whom were satisfied with their experience.

CONCLUSION

In our series, revision to SAGB was safe, with low short-term morbidity and favorable weight loss outcomes. However, beyond 1 year, a large proportion of patients experienced severe reflux symptoms and required rerevision.

Food Tolerance After Laparoscopic Sleeve Gastrectomy with Total Antral Resection

BACKGROUND

Among the controversial points in laparoscopic sleeve gastrectomy (LSG) is how much of the antrum to be resected. This study aimed to evaluate food tolerance after preservation or resection of the antrum during LSG.

METHODS

Prospective randomized study included 50 patients scheduled for LSG. Participants were randomly allocated into one of two groups. In antral resection (AR-LSG) group (n = 25), resection started 2 cm from the pylorus. In antral sparing (AS-LSG) group (n = 25), it started 6 cm from the pylorus. Percentage of excess weight loss (%EWL) and percentage of excess BMI loss (%EBL) were evaluated after 3 and 6 months. Quality of life (QOL) was evaluated by using the Bariatric Analysis and Reporting Outcome System (BAROS). Food tolerance was assessed using the Quality of Alimentation questionnaire. Primary outcome measure was food tolerance and %EWL.

RESULTS

Food tolerance was significantly better in the antral sparing group compared to the antral resection group after 3 and 6 months. The two groups were comparable in %EWL and BMI change after 3 and 6 months. Six months after surgery, the majority of patients had a very good quality of life, with no significant difference between the two groups (p = 0.877). There was no significant difference between the two groups in operative time, intraoperative blood loss, and hospital stay.

CONCLUSIONS

Preservation of the pyloric antrum during LSG is associated with significantly better food tolerance and comparable effect of weight loss up to 6 months postoperatively when compared with total antral resection.

Efficiency of Laparoscopic One-Step Revision of Failed Adjusted Gastric Banding to Gastric Sleeve: a Retrospective Review of 101 Consecutive Patients

BACKGROUND

Until recently, laparoscopic adjustable gastric banding (LAGB) was one of the most commonly performed bariatric surgeries worldwide. Today, its high rate of complications and failure rates up to 70% requires revisional surgery. The one-stage conversion from LAGB to laparoscopic sleeve gastrectomy (LSG) has been shown to be safe, although there are some concerns on efficacy and long-term weight loss.

OBJECTIVES

To demonstrate that one-step revision of LAGB to another restrictive procedure, such as LSG, might have efficient long-term outcomes.

METHODS

The charts from 133 revisional LSGs for failed or complicated LAGB were retrospectively reviewed for the period between January 2010 and August 2017. Thirty-two patients were excluded for loss to follow-up. Demographics, complications, and percentage of excess weight loss (%EWL) were determined.

RESULTS

One hundred one patients were included (85 women and 16 men), with a mean age of 48.5 years, and a mean body mass index of 47.1 kg/m². During the follow-up, 15 patients (15%) underwent a second revisional surgery for weight loss failure (8 Roux-en-Y gastric bypass (RYGBP), 3 biliopancreatic diversion, 3 single anastomosis duodenal-ileal bypass, 1 revisional LSG). Ten patients (10%) had long-term complications (8 severe reflux and 2 stenosis) during this period and underwent a second revisional surgery (10 RYGBP). The remaining 76 had a mean follow-up of 4.3 years and a mean %EWL of 53.2%.

CONCLUSION

Single-stage conversion to LSG is a safe and appropriate solution for failed or complicated LAGB with good long-term weight loss.

SCCA-IgM as a Potential Biomarker of Non-Alcoholic Fatty Liver Disease in Patients with Obesity, Prediabetes and Diabetes Undergoing Sleeve Gastrectomy

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) has a high prevalence in obesity and its presence should be screened. Laparoscopic sleeve gastrectomy (LSG) is an effective treatment for obesity, but its effects on NAFLD are still to be firmly established. The diagnosis of non-alcoholic steatohepatitis (NASH) is currently performed by liver biopsy, a costly and invasive procedure. Squamous cell carcinoma antigen-IgM (SCCA-IgM) is a biomarker of viral hepatitis to hepatocellular carcinoma development and its role in NAFLD to NASH progression has not yet been investigated.

OBJECTIVE

The aim of this study was to evaluate SCCA-IgM as a non-invasive biomarker of NAFLD/NASH in patients with different degrees of metabolic-complicated obesity before and after LSG.

METHOD

Fifty-six patients with obesity were studied before and 12 months after LSG; anthropometric, biochemical, clinical, and imaging data were collected.

RESULTS

At baseline steatosis was strongly associated with the glycaemic profile (p = 0.016) and was already present in prediabetic patients with obesity (82%). Only 3 patients had an SCCA-IgM level above the normal cut-off. SCCA-IgM titre did not change according to glycaemic profile or steatosis. Metabolic and inflammatory factors and transaminases significantly reduced after LSG-induced weight loss, except for SCCA-IgM. The ALT/AST ratio decreased post-LSG correlated with BMI (r = 0.297, p = 0.031), insulin (r = 0.354, p = 0.014), and triglycerides (r = 0.355, p = 0.009) reduction.

CONCLUSIONS

Our results confirm the tight link between NAFLD and metabolic complications, suggesting prediabetes as a new risk factor of steatosis. SCCA-IgM does not seem to have a role in the identification and prognosis of NAFLD.

Incidence and Predictors of Hypoglycemia 1 Year After Laparoscopic Sleeve Gastrectomy

INTRODUCTION

Hypoglycemia is a known adverse event following gastric bypass. The incidence of hypoglycemia after laparoscopic sleeve gastrectomy (LSG) is still under investigation. The aim of our study was to verify the presence of oral glucose tolerance test (OGTT)-related hypoglycemia after LSG and to identify any baseline predictors of its occurrence.

METHODS

We analyzed 197 consecutive non-diabetic morbid obese patients that underwent LSG. All patients were studied before and 12 months after LSG. Evaluation included anthropometric parameters, 3-h OGTT for blood glucose (BG), insulin and c-peptide, lipid profile, interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), highly sensitive C-reactive protein (hsCRP), and leptin. Hypoglycemia was defined as BG ≤ 2.7 mmol/l.

RESULTS

After surgery, 180 patients completed the OGTT. Eleven patients did not complete the test for gastric intolerance, and in six patients, the test was stopped earlier for the onset of severe symptomatic hypoglycemia. Of the patients, 61/186 (32.8%) had at least one OGTT-related hypoglycemia. The highest frequency of hypoglycemic events occurred 150' after glucose load (20.2%). At baseline, patients with hypoglycemic events after surgery (Hypo) were younger (40 ± 11 vs 46 ± 10 years; p < 0.001), less obese (BMI 46 ± 5.7 vs 48.4 ± 7.9 kg/m²; p < 0.05), and had a worse lipid profile as compared to patients without hypoglycemic events (N-Hypo). Moreover, after LSG, Hypo patients compared with N-Hypo presented a higher weight loss (%EBMIL 80 ± 20 vs 62 ± 21%; p < 0.001). Low age, low fasting glucose, and high triglyceride levels before LSG were independent predictors of hypoglycemia development after surgery (r ² = 0.131).

CONCLUSION

These findings confirm the high incidence of post-prandial hypoglycemia 1 year after LSG. Hypoglycemia is more frequent in younger patients with lower fasting glucose and higher triglyceride levels before surgery.

Revisional Laparoscopic Sleeve Gastrectomy in failed gastric banding and effects of exercise and frequent sweet-eating on its outcome

Objective:

To find out effectiveness of revisional laparoscopic sleeve gastrectomy (RLSG) in the patients who had laparoscopic adjustable gastric banding (LAGB) and failed to reduce or regained the weight and effectiveness of sweet abstaining and exercise on postoperative weight loss.

Methods:

This retrospective observational study was conducted at AlMoosa Hospital, Al-Ahsa, Kingdom of Saudi Arabia from December 2011 to November 2016. The patients who failed to reduce, regained the weight or had complications after LAGB, were performed RLSG. They were followed-up at three, six, twelve and twenty-four months intervals. Their weight, percent excess weight loss (%EWL) and body mass index (BMI) at pre-RLSG were compared with post-RLSG. The data was recorded in SPSS 22 and analyzed.

Results:

Thirty-six patients with male/female ratio of 1:5 underwent RLSG. Twelve (33.3%) were frequent sweet-eaters and twenty-four (66.7%) were not. Fourteen (38.88%) did not have exercise, while twenty-two (61.11%) had daily regular exercise. Their mean pre-RLSG weight, percent excess weight loss (%EWL)and BMI were compared with post-RLSG at the period of three, six, twelve and twenty-four months. Their mean weight reduced from 111.69 kilograms to 96.94, 87.25, 79.56 and 76.11 kilograms respectively. Their mean of the percent excess weight loss (%EWL) reduced to 22.08, 45.75, 59.64 and 66.42 kilograms respectively. Their mean pre-RLSG BMI was 43.50 kg.m^-2, which reduced to the mean of 37.79, 34.02, 30.97 and 29.70 respectively. There were no post-operative complications in thirty (83.3%), mild like wound infection and seroma in four (11.1%) and bleeding in two (5.6%) patients. None of the patients had leakage. The patients who kept themselves abstained from sweet consumption and performed regular postoperative exercise had better results. They also had considerable reduction in appetite after RLSG.

Conclusion:

RLSG is an effective procedure after failed LAGB in terms of weight loss having minimal rate of complications. Moreover, abstaining from sweet consumption and continuing exercise postoperatively has better results.

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.

Analysis of Morbidity Data of 308 Cases of Laparoscopic Sleeve Gastrectomy--the Soroka Experience

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) became a prevalent bariatric procedure in Israel, while laparoscopic adjustable gastric banding (LAGB) was losing ground, due to high failure rates (40 % at 10 years). Many patients after LAGB failure choose LSG as a further bariatric surgery (secondary LSG). However, LAGB often impairs upper stomach anatomy and physiology, which may contribute to complications increased risk after secondary LSG, in comparison to surgery-naive obese patients choosing LSG (primary LSG).

METHODS

A retrospective cohort study was conducted on a prospective database, looking at morbidly obese patients for LSG surgery. All procedures were done by a single surgeon at the Soroka Medical Center between January 2008 and March 2013. Data were collected from hospitalization charts on demographics, biometric and bariatric status, medical and bariatric surgical history, post-LSG morbidity, and mortality.

RESULTS

Three hundred eight patients underwent LSG during the study period, 181 (58.8 %) had a primary LSG while 127 (41.2 %) had a secondary LSG. No mortality occurred in both groups. Odds ratio for major complication (leak, stenosis) was 3.12 [CI 0.90-10.75] among the secondary LSG group, compared to the primary LSG (p = 0.071). The risk for major complication was doubled (OR = 2, 95 % CI [1.36-3.06]) for each one of previous bariatric procedure underwent (p = 0.001). Significant differences were found between the two groups regarding number and length of readmissions and number of imaging tests (p value = 0.027, 0.022, and 0.049, respectively).

CONCLUSIONS

Primary LSG is a safe and efficient bariatric procedure. After failed LAGB, secondary LSG should be carefully considered, because of a potentially higher risk of complications.

A Study on Role of Laparoscopic Sleeve Gastrectomy in the Management of Morbid Obesity

Obesity has assumed a pandemic and is responsible for serious medical, social, psychological, and economic implications, affecting all ages and socioeconomic groups. Hence, this prospective study was carried out to study the surgical benefits in such patients. A Prospective interventional study was carried out from June 2010 to November 2012 at IGGMC Nagpur performing laparoscopic sleeve gastrectomy (LSG) in morbidly obese patients, and its efficacy was determined. A total of 56 patients were studied. 26 (46.42 %) being males and 30 (53.57 %) females. The maximum number of patient's, i.e., 32 (57.14 %) were in the range of BMI 40-44.99 kg/m(2) with mean BMI-43.25 kg/m(2). Mean weight was 117 kg (range 92-180 kg). Common comorbidities observed were hypertension in 43 (76.78 %), bronchial asthma in 31 (55.35 %), and diabetes in 21 (37.5 %). All patients treated with LSG had a mean operative time of 154.9 min (range 110-310 min) with 0 % leak, one conversion to open, and no mortality. Postoperative hospital stay was 3.54 days (range 3-7). Complications were minimal with prolonged vomiting seen significantly in 28 (50 %) patients. Follow up at 24 months showed mean weight 74.72 kg (68-81 kg) with mean excess weight loss of 67.71 % (62.79-71.05 %) causing a mean BMI of 28.42 kg/m(2) (26.56-30.44 kg/m(2)). It also reduced mean BP to 120.36 mmHg (110-144 mmHg) and mean fasting blood sugar to 100.63 mg/dl (80-146 mg/dl). Surgery for obesity is definitely an answer for this gift of modernization, and LSG is a safe and effective technique for achieving weight loss. Quality of life improves astonishingly and adds confidence to this mentally traumatic entity called "OBESITY".

The effect of residual gastric antrum size on the outcome of laparoscopic sleeve gastrectomy: a prospective randomized trial

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is gaining popularity worldwide as a definitive bariatric procedure. However, there are still some controversial issues associated with the technique, one of which is the size of the residual antrum.

OBJECTIVES

The aim of this prospective randomized trial is to study the effect of the size of the residual gastric antrum on the outcome of LSG.

SETTINGS

University-affiliated hospital.

METHODS

Between November 2009 and August 2013, 113 morbidly obese patients submitted for LSG were randomized into 2 groups, namely antral preserving-LSG (AP-LSG) and antral resecting-LSG (AR-LSG), depending on the distance from the pylorus at which gastric division begins. In the AP-LSG group, the distance was 6 cm from the pylorus and included 58 patients, whereas the distance was 2 cm in the AR-LSG group and included 55 patients. The follow-up period was at least 12 months. Baseline and 6 and 12 month outcomes were analyzed including assessments of the percent excess weight lost (%EWL), reduction in BMI, morbidity, mortality, reoperations, quality of life, and co-morbidities.

RESULTS

Both groups were comparable regarding age, gender, body mass index (BMI), and co-morbidities. There was one 30-day mortality, and there was no significant difference in the complication rate or early reoperations between the 2 groups. Weight loss was significant in both groups at 6 and 12 months. At 12 months, weight loss was greater in the AR-LSG than in the AP-LSG group, but with was no significant difference between the 2 groups at 12 months (%EWL was 64.2% in the AP-LSG group and 67.6% in the AR-LSG group; p>.05). The resolution/improvement of co-morbidities, quality of life outcome and the overall prevalence of co-morbidities were similar.

CONCLUSIONS

LSG with or without antral preservation produces significant weight loss after surgery. The 2 procedures are equally effective regarding %EWL, morbidity, quality of life, and amelioration of co-morbidities.

Revisions after failed gastric band: sleeve gastrectomy and Roux-en-Y gastric bypass

INTRODUCTION

Laparoscopic gastric band is an appealing bariatric operation due to its simplicity and good short-term outcomes; however, it is associated with complications (slippage, erosion, prolapse) and failure in reaching target weight loss. This study describes our experience with failed gastric bands that required a revisional procedure.

MATERIALS AND METHODS

This single-center retrospective analysis includes all consecutive patients who underwent a gastric band removal and revisional surgery in our hospital from January 2008 to June 2014. A total of 81 patients were identified and divided in three groups: Group one included patients who just had the gastric band removed (43), group two consisted of patients who underwent a conversion to sleeve gastrectomy (SG) (26), and group three included patients who required a conversion to Roux-en Y gastric bypass (RYGB) (12). Patient demographics, date of gastric band placement, indications for revision, postoperative morbidity and mortality, operating time, blood loss, length of stay, and % excess weight loss (%EWL) were recorded. Perioperative and clinical outcomes were compared between conversions to SG and RYGB.

RESULTS

In group two (n = 26), 21 conversions to SG were performed in concurrence with the band removal as a one-stage operation, while five procedures were performed in two-stages. There were no complications and no case was converted to open. Patients who underwent a one-stage procedure had a longer operative time, although it did not reach statistical significance. In group three, 12 patients underwent a conversion to RYGB as a revisional operation; 11 were performed as a one-stage procedure and only one patient underwent a two-stage procedure.

CONCLUSIONS

SG and RYGB are safe options to revise a failed gastric band. Both groups who received either a SG or RYGB had a low complication rate and acceptable %EWL with no statistical difference between the two.

Sustained weight loss after gastric banding revision for pouch-related problems

OBJECTIVE

To assess the impact of revisional surgery after laparoscopic adjustable gastric banding (LAGB) on weight loss at 12 and 24 months.

BACKGROUND

There is no uniform consensus as to the optimal procedure for patients requiring revision after LAGB. Few studies address the issue of weight loss after band salvage procedures, despite this being a critical factor in deciding which reoperative procedure to choose.

METHODS

A retrospective analysis was conducted of adult patients who underwent LAGB from January 1, 2001 to June 30, 2009 at a single institution. Patients who required revision for pouch-related problems including band slippage, pouch dilation, and hiatal hernia were studied. Demographic data, body mass index (BMI), percentage excess weight loss (% EWL), and operative details were recorded. Weights were recorded at 12 and 24 months after revision. These were compared with initial weight, weight before revision, and weight in patients who did not have a reoperation.

RESULTS

Of 3876 patients, 390 patients were included in analysis of weight outcomes after revision. The procedure-related mortality was 0%. Early (30-day) complications occurred in 0.5%, late complications (erosion) in 0.5%, and 29 patients (7.4%) required a second revision. For patients undergoing revision, the initial weight was 124.06 ± 21.28 kg and BMI was 44.80 ± 6.12 kg/m. At reoperation, weight was 89.18 ± 20.51 kg, BMI was 32.25 ± 6.50 kg/m and, %EWL was 54.13 ± 21.80%. Twelve months postrevision, weight was 92.24 ± 20.22 kg, BMI was 33.32 ± 6.41 kg/m, and %EWL was 48.81 ± 22.71%. Weight was 92.42 ± 19.91 kg, BMI was 33.53 ± 6.25 kg/m, and %EWL was 47.50 ± 22.91% twenty-four months postrevision.

CONCLUSIONS

Reoperation for pouch-related problems after LAGB is safe and effective. Weight loss is maintained after reoperation.

Laparoscopic sleeve gastrectomy as revisional surgery for adjustable gastric band erosion

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has been increasingly adopted as a revisional surgery for failed gastric banding. However, little information is available regarding the outcome of revisional LSG for band erosion.

MATERIALS AND METHODS

A retrospective database analysis was performed to study LSG as revisional surgery for band erosion. For staged revision, we waited a minimum of 3 months after band removal, and for single-stage revision, the band was removed by gastrotomy, and sleeve gastrectomy was performed at the same time. Main outcome measures were success rates of therapeutic strategies, morbidity, and mortality rates, length of stay, and body mass index (BMI) (percentage excess weight loss [%EWL]) before and after revision.

RESULTS

From March 2011 to February 2013, 9 female patients underwent revisional LSG. Average age was 34.7 years. Six patients underwent a staged procedure, and the other 3 underwent a single-stage revision. Among the 6 staged patients, eroded bands had been removed by laparoscopy in 4 and by endoscopy in 2 without complications. Their LSGs were performed at a median of 4.4 months after band removal. Another 2 patients underwent single-stage revision. In the last patient, band erosion was incidentally found during a revisional LSG for insufficient weight loss. No mortality occurred. There were one stenosis and two proximal leaks. Two patients with leak underwent total gastrectomy and fistulojejunostomy. After a mean follow-up of 19.1 months, all 9 patients exhibited weight loss. The mean (±standard deviation [SD]) pre- and post-LSG BMIs were 34.0±4.4 and 25.6±2.1 kg/m(2), respectively, and their mean (±SD) %EWL from prebanding was 86.8±10.1%. Revisional LSG resulted in a further median %EWL of 28.0% (range, 7.9%-68.9%) versus weight at time of band removal.

CONCLUSIONS

Revisional LSG after band erosion was found to be feasible and effective. However, it is prone to severe complication. In selected cases of band erosion, LSG can be performed at the time of band removal in a single stage.

Laparoscopic sleeve gastrectomy as a revisional procedure for failed gastric banding: lessons from 300 consecutive cases

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) is a common bariatric procedure associated with a high rate of weight loss failure and/or complications in the long term. The objective of this study was to test the hypothesis that the conversion of failed LAGB into laparoscopic sleeve gastrectomy (LSG) is not associated with an increased risk of postoperative complications and leads to weight loss results that are comparable to those obtained with a primary LSG.

METHODS

We retrospectively analyzed the results of a prospective series of 1360 LSG regarding patient demographics, the indication for revision morbidity, the percentage of excess weight loss, and the rate of postoperative complications.

RESULTS

The primary LSG group contained 1060 patients and the LAGB to LSG group contained 300 patients. The rate of postoperative complications was 4.5% in the primary LSG group and 2% in the LAGB to LSG group. Two patients died in the LSG group (1 pulmonary embolus, 1 myocardial infarction). There was no significant difference with respect to the rate of leak, which was 1% in the LAGB to LSG group and 1.6% in the primary LSG group. There was a greater weight loss after primary LSG, mean % excess weight loss of 75.9%±21.4 at a mean interval of 29±19.8 months, versus 62.6%±22.2 at a mean interval of 35±24 months after LAGB to LSG (P = .008). There were 72.1% and 59.2% of patients available for follow-up after primary LSG at 24 and 60 months respectively, versus 69.3% and 55.4% after LAGB to LSG.

CONCLUSION

This study indicates that the risk of leak after LSG was not increased after conversion failed LAGB into LSG when performed as a 2-step procedure.

Is nasogastric decompression useful in prevention of leaks after laparoscopic sleeve gastrectomy? A randomized trial

INTRODUCTION

Although its excellent results, laparoscopic sleeve gastrectomy (LSG) presents major complications ranging from 0% to 29%. Among them, the staple line leak presents an incidence varying from 0% to 7%. Many trials debated about different solutions in order to reduce leaks' incidence. No author has investigated the role of gastric decompression in the prevention of this complication. Aim of our work is to evaluate if this procedure can play a role in avoiding the occurrence of staple line leaks after LSG.

MATERIALS AND METHODS

Between January 2008 and November 2012, 145 patients were prospectively and randomly included in the study. Seventy patients composed the group A, whose operations were completed with placement of nasogastric tube; the other 75 patients were included in the group B, in which no nasogastric tube was placed.

RESULTS

No statistical differences were observed between group A and group B regarding gender distribution, age, weight, and BMI. No intraoperative complications and no conversion occurred in both groups. Intraoperative blood loss (50.1 ± 42.3 vs. 52.5 ± 37.6 ml, respectively) and operative time (65.4 ± 25.5 vs. 62.6 ± 27.8 min, respectively) were comparable between the two groups (p: NS). One staple line leak (1.4%) occurred on 6th postoperative day in group A patients. No leak was observed in group B patients. Postoperative hospital stay was significantly longer in group A vs. group B patients (7.6 ± 3.4 vs. 6.2 ± 3.1 days, respectively, p: 0.04).

CONCLUSIONS

Routine placement of nasogastric tube in patients operated of LSG seems not useful in reducing leaks' incidence.

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.

Laparoscopic sleeve gastrectomy as a revisional procedure for failed laparoscopic gastric banding with a "2-step approach": a multicenter study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has been proposed as an alternative revisional procedure for failed/complicated gastric banding. This is a retrospective cohort study of a prospectively maintained database of revisional LSG after band removal for insufficient weight loss and/or band-related complications, using a 2-step approach. The outcomes were compared with a control group of primary LSG. The study was conducted at a university hospital (Sapienza University of Rome-Polo Pontino, Icot, Latina, Italy) and 2 community general hospitals (Hospital Andosilla Civita Castellana, Viterbo, Italy and Hospital Villa D'Agri, Potenza, Italy).

METHODS

A total of 76 revisional LSG procedures was recorded; a control group of 279 LSG patients was selected. The primary endpoint was to compare the perioperative complication rate between the revisional versus the control group. Secondary endpoints were operative time, conversion rate, postoperative length of stay and percentage excess weight loss (%EWL) at 6, 12, and 24 months.

RESULTS

The indications for band removal were inadequate weight loss (47 patients), slippage (10 patients), erosion (7 patients), and pouch dilation (12 patients). All procedures were completed laparoscopically. The median operative time was 78 minutes for the revision LSG and 65 minutes for the control LSG (P<.05). In the revision group, the overall complication rate was 17.1%, and the median postoperative length of stay was 4 days; in the control group, the overall complication rate was 10.7%, and the median postoperative length of stay was 3. No complications requiring reoperation or readmission occurred in the revision group. In the control group, there were 5 cases of major complications. All the patients completed the follow-up. A total of 56 patients in the revision group and 184 patients in the control group were followed-up for at least 24 months. The %EWL at 6, 12, and 24 months was 46.5%, 66.4%, and 78.5%, respectively, in the revision group, and 49.8%, 78.2%, and 78%, respectively, in the control group.

CONCLUSION

Results confirmed that LSG, performed in 2 steps, is an effective revision procedure for failed or complicated laparoscopic adjustable gastric banding with good perioperative outcomes and 2-year weight loss.

Erosions after laparoscopic adjustable gastric banding: diagnosis and management

OBJECTIVE

To define the changing prevalence of erosion after Laparoscopic Adjustable Gastric Banding (LAGB), describing the range of clinical presentations, the approaches to treatment and the outcomes from these approaches over a 15-year study period.

BACKGROUND

A recent systematic review of the literature of erosion after LAGB identified 25 relevant studies and reported a total of 231 erosions in 15,775 patients giving an overall incidence of 1.46%. The review highlighted a broad variation of incidence from 0.2% to 33%. The review was unable to identify either common presentations or an optimal pattern of management.

METHODS

Patients who underwent a primary LAGB operation between September 1994 and January 2010 by 2 surgeons (P.O.B. and W.B.) were identified in a prospectively maintained database. Those patients who had an erosion of their LAGB were identified. Presentation, operative details, demographics, body mass index, weight history, and perioperative problems were analyzed.

RESULTS

In total, 2986 patients were identified. All bands placed were Lap-Bands (Allergan, CA). Hundred erosions were experienced by 85 patients (2.85%) at a median time of 33 months from initial surgery to the erosion (range: 11-170 months). The rate of erosion was highest when the band was placed by the perigastric approach at 6.77%. Since the adoption of the pars flaccida approach, the rate of erosion has dropped to 1.07%. The majority of patients who had experienced an erosion (71 patients; 83.5%) experienced only 1 erosion, 13 patients (15.3%) had 2 erosions, and 1 patient had 3 erosions. The most common presentation was loss of satiety. The band has been successfully replaced in 56 patients. It has been explanted in 27 patients and 2 patients were converted to other bariatric procedures. The weight loss in patients who had a LAGB reinserted after erosion was not significantly different to the background cohort.

CONCLUSIONS

Erosion of LAGB is uncommon and its clinical course is benign. It is best treated with a staged surgical approach; initially, with removal and repair followed later by replacement. With this approach, weight loss is maintained and reerosion is uncommon.

Simultaneous gastric band removal and sleeve gastrectomy: a comparison with front-line sleeve gastrectomy

The placement of a gastric band (GB) prior to a sleeve gastrectomy (LSG) would increase postoperative complications, whether it is withdrawn or not at the time of the LSG. The purpose of this retrospective study was to evaluate and compare postoperative morbidity and outcome weight for simultaneous GB removal (RGB) and LSG (the RGB + LSG group) and front-line LSG only (the LSG group) after unsuccessful GB. From May 2005 to May 2009, 305 patients underwent first- or second-line LSG at Amiens University Hospital. The primary endpoint was the postoperative complication rate (according to the Clavien classification) in the RGB + LSG and LSG groups. The secondary endpoints were intra-operative data, postoperative data, and weight loss over a period of 2 years (body mass index, percentage of excess weight loss, and percentage of excess body mass index (BMI) loss). Univariate and multivariate propensity score analyses were used to search for independent risk factors for postoperative complications. The RGB + LSG group (n = 46) had a mean age of 42 and a mean BMI of 44 kg/m(2). The indication for surgery was renewed weight gain or insufficient weight loss in 68 % of these cases. The LSG group (n = 259) had a mean age of 41 and a mean BMI of 49.2 kg/m(2). All procedures were performed laparoscopically. The complication rate was 8.6 % in the RGB + LSG group and 8 % in the SG group (p = 0.42). The fistula rates in the two groups were 4.3 and 3.4 %, respectively (p = 0.56), and the mean BMI at 2 years was 33.4 kg/m(2) (RGB + LSG group) and 34.4 kg/m(2), respectively (p = 0.83). The operating time for LSG (after subtracting the time associated with RGB for a combined procedure) averaged 107 min, whereas the operating time for front-line LSG was 89 min (p = 0.011). The propensity score analysis failed to find independent risk factors for postoperative complications. The performance of RGB + LSG is feasible and does not increase the postoperative morbidity rate. Weight loss after RGB + LSG validates the concept of "restrictive surgery after restrictive surgery". We did not find any independent risk factors that would have justified the avoidance of RGB + SG.

Revisional surgery after failed laparoscopic adjustable gastric banding: a systematic review

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) has emerged as one of the most commonly performed bariatric procedures worldwide. Unfortunately, revisional surgery is required in 20-30 % of cases. Several revisional strategies have been proposed, but there is no consensus regarding the best surgical option. This systematic review was designed to determine which revisional surgery (laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, or laparoscopic biliopancreatic diversion with duodenal switch) is best suited to enhance weight loss following failed LAGB due to complications or inadequate weight loss.

METHODS

EMBASE, MEDLINE, PsycINFO, and Cochrane Clinical Trials were searched using the most comprehensive timeline for each database. A total of 24 relevant articles were identified. Two investigators independently extracted data, and differences were resolved by consensus. The weighted means were calculated for weight loss measurements.

RESULTS

A total of 106, 514, and 71 patients underwent conversion from LAGB to laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), and laparoscopic biliopancreatic diversion and duodenal switch (BPDDS), respectively. Before revisional surgery, the weighted mean body mass index (BMI) was 38.8 (6.9), 43.3 (8.1), and 41.3 (7.2) kg/m(2) for the LSG, LRYGB, and BPDDS groups, respectively. The majority of data was reported at 12-24 months follow-up. The mean BMI within this interval was 28 (10.5), 32.2 (6.4), and 33 (5.7) kg/m(2) for the LSG, LRYGB, and BPDDS groups, respectively. In addition, the mean excess weight loss (EWL) was 22 % (2.8), 57.8 % (11.7), 47.1 % (14) for the LSG, LRYGB, and BPDDS groups, respectively. The EWL reached 78.4 % (35) in the BPPDS group after 2-year follow-up.

CONCLUSIONS

Failed LAGB is best managed with conversion to another bariatric procedure. Stable weight loss occurs with salvage LRYGB. Although results for revisional BPPDS appear promising, additional research, with higher methodological quality, is needed.

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.

Staple-line reinforcement during laparoscopic sleeve gastrectomy using three different techniques: a randomized trial

BACKGROUND

The main drawback of laparoscopic sleeve gastrectomy (LSG) is the severity of postoperative complications. Staple line reinforcement (SLR) is strongly advocated. The purpose of this study was to compare prospectively and randomly three different techniques of SLR during LSG.

METHODS

From April 2010 to April 2011, patients submitted to LSG were randomly selected for the following three different techniques of SLR: oversewing (group A); buttressed transection with a polyglycolide acid and trimethylene carbonate (group B); and staple-line roofing with a gelatin fibrin matrix (group C). Primary endpoints were reinforcement operative time, incidence of postoperative staple-line bleeding, and leaks. Operative time was calculated as follows: oversewing time in group A; positioning of polyglycolide acid and trimethylene carbonate over the stapler in group B; and roofing of the entire staple line in group C.

RESULTS

A total of 120 patients were enrolled in the study (82 women and 38 men). Mean age was 44.6 ± 9.2 (range, 28-64) years. Mean preoperative body mass index was 47.2 ± 6.6 (range, 40-66) kg/m². Mean time for SLR was longer in group A (14.2 ± 4.2 (range, 8-18) minutes) compared with group B (2.4 ± 1.8 (range, 1-4) minutes) and group C (4.4 ± 1.6 (range, 3-6) minutes; P < 0.01). Four major complications were observed (3.3 %): one leak and one bleeding in group A; one bleeding in group B; and one leak in group C, with no significant differences between the groups. No mortality was observed.

CONCLUSIONS

SLR with either polyglycolide acid with trimethylene carbonate or gelatin fibrin matrix is faster compared with oversewing. No significant differences were observed regarding postoperative staple-line complications.

Our 1-year experience in laparoscopic sleeve gastrectomy

Sleeve gastrectomy was conceived in 1988 both as a first step to the duodenal switch procedure and as an extension of anti-reflux surgery where patients lost significant weight. It is now a stand-alone laparoscopic bariatric procedure worldwide with two international consensus summits identifying it as a safe and feasible restrictive and appetite-suppressing procedure. In our centre, it is a key component in the surgical armamentarium and used as a first-line and revisional procedure for morbid obesity. The procedure is performed using standard five port technique. One year results are reviewed for its feasibility in our Asian patients. Twenty of 48 laparoscopic sleeve gastrectomies have a 1-year follow-up with four of them a revisional procedure for bands with complications. There were 11 males and 9 females (average age 43.6) and a representation of all four major ethnic groups. Average weight and BMI improved from 116.3 to 90.2 kg and 42.5 to 33.1 kg m(-2) after 1 year, respectively. Average weight loss was 26.1 kg and excess weight loss (in percent) was 49.6%. There was an improvement in diabetes mellitus, hypertension, obstructive sleep apnoea and asthma and three complications including two leaks and a gastro-oesophageal spasm/stricture. Laparoscopic sleeve gastrectomy is safe and feasible as first-line surgery for morbid obesity and revisional procedures for band-related complications in the short term. Further studies are required to elucidate the exact mechanisms of weight loss in the sleeve gastrectomy to answer the appropriateness of the variations in the technique and long-term weight loss and morbidity.

Laparoscopic sleeve gastrectomy--radiological assessment of fundus size and sleeve voiding

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is now considered an effective bariatric procedure (American Society for Metabolic and Bariatric Surgery statement). We attempted to assess the size of the gastric fundus remaining after LSG and gastric voiding rate (fast/slow) by radiological upper gastrointestinal series (UGS) with a water-soluble contrast medium (CM). The findings were compared with weight loss data.

METHODS

Seventy-four obese patients underwent LSG. Radiological UGS were used to measure the remaining fundus size in 28 of 74 patients 24-72 h after the procedure, with the aid of Matlab software and a library image processing toolbox (MathWorks®). Sleeve voiding was measured in 57 of 74 patients, based on the patients' radiological reports.

RESULTS

The mean volume of the remaining fundus was 17.56 ml (range 1.00-77.03 ml). The mean percent excess BMI loss (%EBL) was 39.5%, 53.7%, and 60.8%, respectively, 3, 6, and 12 months after LSG. Sleeve voiding was fast in 49 of 57 patients (85.96%) and slow in eight (14.03%).

CONCLUSIONS

No correlation was found between the estimated volume of the remaining gastric fundus and weight loss (%EBL) after LSG. Patients showing a rapid gastroduodenal transit of the CM achieved a better weight loss than patients with a slow voiding rate.

Laparoscopic sleeve gastrectomy: our first 100 patients

Laparoscopic sleeve gastrectomy appears to be a safe, reproducible method to manage morbidly obese patients.

Background:

Laparoscopic sleeve gastrectomy is becoming a popular procedure for the morbidly obese patient. Its utilization as a standalone procedure has good results with weight loss in short- and midterm reports. The aim of this study was to assess our technique and whether it warranted any modifications in the early postoperative period.

Methods:

Our first 100 consecutive patients undergoing laparoscopic sleeve gastrectomy were retrospectively reviewed. Data analysis was conducted at 3 and 6 months to assess the percentage of excess body weight loss and comorbidity status change.

Results:

The percentage of excess body weight loss at the 3- and 6-month marks was 34.2% and 49.1%, respectively. Comorbidities were also improved at the 3- and 6-month marks. Hypertension resolved in 38%, hyperlipidemia resolved in 19%, and diabetes in 46%. Complication rate during the first 6 months was 10%. Major complications included 2 patients with postoperative bleeding, 2 patients with acute renal failure from dehydration, and 1 postoperative bleeding patient who developed a gastric fistula. No surgical reintervention was required for any complication.

Conclusion:

Our technique is a safe method that is easily reproducible and does not require any modification. Laparoscopic sleeve gastrectomy is an excellent surgical option with a low complication rate.

Conversion of failed gastric banding into four different bariatric procedures

BACKGROUND

The most common bariatric operation in Europe, laparoscopic adjustable gastric banding (LAGB), is reported to have a high incidence of long-term complications. Also, insufficient weight loss is reported. The optimal conversion technique is unknown. Our objective was to report our experience in the conversions of failed laparoscopic gastric banding procedures to 4 different bariatric procedures at a university hospital.

METHODS

From March 2006 to December 2010, 630 bariatric operations were performed. Of these patients, 45 underwent conversion of failed LAGB (n = 38) and nonadjustable gastric banding (n = 7). Using a prospectively collected database, we analyzed these procedures.

RESULTS

The 45 patients underwent laparoscopic conversion of failed LAGB (n = 38) and nonadjustable gastric banding (n = 7) to 4 different procedures. Of the 45 patients, 18 underwent conversion to laparoscopic sleeve gastrectomy, 18 to laparoscopic Roux-en-Y gastric bypass, 7 to laparoscopic biliopancreatic diversion with duodenal switch, and 2 to laparoscopic biliopancreatic diversion. All conversions but 1 were completed laparoscopically. The mean operating time and hospital stay for laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, laparoscopic biliopancreatic diversion with duodenal switch, and biliopancreatic diversion was 111 ± 28 minutes and 4.3 ± 1.4 days, 195 ± 59 minutes and 3.9 ± 1.5 days, 248 ± 113 minutes, and 5.9 ± 2.6 days, and 203 minutes and 6.5 days, respectively. No patient died. Perioperative complications occurred in 4 patients (9.8%). The mean body mass index decreased from 41.5 ± 8 kg/m(2) to 31.3 ± 6.8 kg/m(2) during a mean follow-up period of 13.7 ± 9.6 months. Although laparoscopic biliopancreatic diversion with and without duodenal switch had the greatest preoperative body mass index, they achieved the greatest excess weight loss.

CONCLUSION

Conversion of LAGB or nonadjustable gastric banding to laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic biliopancreatic diversion with or without duodenal switch is feasible and effective to treat the complications of LAGB and to further reduce the weight of morbidly obese patients.

Laparoscopic sleeve gastrectomy as a revisional option after gastric band failure

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) is an effective bariatric procedure with low morbidity and mortality. Unfortunately, it is fraught with high failure rates in long-term follow-up. Laparoscopic sleeve gastrectomy (LSG) is an emerging procedure, quickly gaining momentum in the arsenal of bariatric practice as a first step toward gastric bypass/biliopancreatic diversion or as a stand-alone operation. Recently, it has been described as a revisional option for previous bariatric surgery failures. We report our early experience with LSG as a revisional procedure for failed LAGB.

METHODS

From January 2007 to April 2010, 46 patients, who had undergone LAGB, underwent LSG. Patient demographics, reason for band removal, interval between removal and LSG, operative times, estimated blood loss, complications, length of hospital stay, and percent of excess weight loss were collected.

RESULTS

Of the 46 patients, 20 (43%) had their bands removed before LSG (median time interval, 2 years; range, 2 months to 9 years); the rest had concomitant band removal and LSG. Twelve patients were men (26%). Mean age and BMI were 40 (range, 20-60) years and 43.1 kg/m(2) (range, 33-57), respectively. In two cases, surgery was converted to an open procedure due to extensive adhesions related to previous surgeries. Median operative time, estimated blood loss, and length of hospital stay were 118 (range, 70-250) minutes, 41 (range, 5-600) ml, and 3 (range, 1-100) days, respectively. Major morbidity was encountered in three patients (6%; leak in 2 and bleeding in 1). There were no mortalities. Mean follow-up time for our cohort is 17 (range, 1-39) months. Percent of excess weight loss at 2, 6, 12, 24, and 36 months was 24, 37, 53, 51, and 48%, respectively.

CONCLUSIONS

Our results suggest that LSG is safe, feasible, and effective as a revisional procedure for failed LAGB and can be considered as an appealing option in these cases. Larger series and longer follow-up are needed to confirm this.

Surgical treatment of morbid obesity and type 2 diabetes mellitus: current situation and future prospects

Along with social progress and life style transformation, morbid obesity, type 2 diabetes mellitus, and metabolic syndrome are increasingly becoming a great threat to human health. Because conventional conservative treatment has little effect on these diseases, they were considered incurable before. However, surgery shows good results in the treatment of these diseases and has therefore revolutionized their treatment. This review aims to elucidate the therapeutic mechanisms of surgery for morbid obesity and 2 diabetes mellitus and to discuss the current situation and future prospects of surgical treatment of these diseases.

Safety and short-term outcomes of laparoscopic sleeve gastrectomy as a revisional approach for failed laparoscopic adjustable gastric banding in the treatment of morbid obesity

Laparoscopic sleeve gastrectomy (LSG) has been used as a first step of a two-stage approach in bariatric surgery for high-risk patients. Recently, LSG is being utilized as a primary and final procedure for morbid obesity with acceptable short-term results. The aim of this study is to investigate the effectiveness of LSG as a revisional procedure for patients with unsatisfactory outcomes after laparoscopic adjustable gastric band (LAGB). A retrospective review of a prospectively maintained database was performed. Data were reviewed for all patients undergoing revision from LAGB to LSG during the period May 2005 and May 2009. Data collected included demographics, indication for revision, operative time, length of stay, postoperative complications, and degree of weight reduction. Fifteen patients (three males and 12 females) had revisional surgery converting a LAGB to a LSG. The indication in four patients (26.66%) was weight regains and in five patients (33.33%) was poor weight loss; four patients (26.66%) had a band slippage and symptoms of gastroesophageal reflux, and one patient (6.66%) had poor weight loss, band slippage, and reflux. In one patient (6.66%), the indication was slippage and duodenal fistula. One-step revision procedure was done in 13 patients (86.66%), while two-step procedure was done in two patients (13.33%). Mean preoperative weight and BMI were 233.02 (181.4-300) lb and 38.66 (29.7-49.3) kg/m2, respectively. Mean weight loss at 2, 6, 12, 18, and 24 months postoperatively was 20.7, 48.3, 57.2, 60.1, and 13.5 lb, respectively. Mean % excess BMI loss was 28.9%, 64.2%, 65.3%, 65.7%, and 22.25% at 2, 6, 12, 18, and 24 months, respectively. There was one major complication (staple line leak) and one postoperative acute gastric outlet obstruction. We had no mortality. Thirteen patients were followed up postoperatively. The number decreased as follow-up time progressed. LSG could provide short-term weight loss after previously failed LABG, but prone to more complications compared to an initial LSG without a prior bariatric procedure.

Sleeve gastrectomy as revisional procedure for failed gastric banding or gastroplasty

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is considered an effective multipurpose operation for morbid obesity, although long-term results are still lacking. Also, the best procedure to be offered in the case of failed restrictive procedures is still debated. We here reported our results of LSG as a revisional procedure for inadequate weight loss and/or complications after adjustable gastric banding or gastroplasty.

METHODS

Since April 2005, 57 patients (20 men and 37 women), with a mean age of 49.9 +/- 11.9 years, underwent revisional LSG, 52 after laparoscopic adjustable gastric banding/adjustable gastric banding and 5 after vertical banded gastroplasty at our institution. The mean interval from the primary procedure to LSG was 7.54 +/- 4.8 years. The LSG was created using a 34F bougie with an endostapler, after removing the laparoscopic adjustable gastric band or the anterior portion of the band in those who had undergone vertical banded gastroplasty. An upper gastrointestinal contrast study was performed within 3 days after surgery and, if the findings were negative, a soft diet was promptly started.

RESULTS

A total of 41 patients had undergone concurrent band removal and LSG and 16 had undergone band removal followed by an interval LSG. Three cases required conversion to open surgery because of a large incisional hernia. The mean operative time was 120 minutes (range 90-180). One patient died of multiple organ failure from septic shock. Three patients (5.7%) developed a perigastric hematoma, 3 (5.7%) had leaks, and 1 had mid-gastric short stenosis. The median hospital stay was 5 days. The mean body mass index at revisional LSG was 45.7 +/- 10.8 kg/m(2) and had decreased to 39 +/- 8.5 kg/m(2) after 2 years, with a mean percentage of the estimated excess body mass index lost of 41.6% +/- 24.4%. Two patients required a duodenal switch for insufficient weight loss.

CONCLUSION

LSG seems to be effective as revisional procedure for failed LAGB/vertical banded gastroplasty, although with greater complication rates than the primary procedures. Larger series and longer follow-up are needed to confirm these promising results.