Revision operation to one-anastomosis gastric bypass for failed sleeve gastrectomy

BackgroundThere are few publications on revising sleeve gastrectomy (SG) to one-anastomosis gastric bypass (OAGB).ObjectiveThis study was undertaken to determine outcomes in terms of weight loss and resolution of co-morbidities in patients who had SG revised to OAGB.SettingsA high-volume university–affiliated bariatric surgery center in India.MethodInformation was collected from patients identified in a prospectively maintained database of patients who had a revision from SG to OAGB. An analysis of outcomes in terms of weight loss and maintenance with up to 3-years follow-up is reported.ResultsThirty-two patients were revised from SG to OAGB. Of the 32 revised patients, 9 (28%) had type 2 diabetes, 15 (47%) had hypertension, and 2 (6%) had sleep apnea at the time of the initial SG. At the time of revision only 2 of 32 (6.25%) had type 2 diabetes, 3 (9.4%) had hypertension, and none had sleep apnea. The average initial weight in this study before SG was 118 kg and body mass index was 44.04 kg/m². The average weight at the nadir and at revision was 92.1 and 103.5 kg, respectively. Average weight was 93.5, 94.3, and 100.6 kg (P < .002) at 1-, 2-, and 3-year follow-up, respectively. There was reoccurrence of type 2 diabetes in 1 patient at 3 years after revision due to weight regain. There were no complications in this study.ConclusionIn this study, revision of SG to OAGB because of inadequate weight loss or significant weight regain was safe and effective at 2-year follow-up; however, there was a tendency toward weight regain at 3 years. Multicenter studies with larger series of patients and longer-term follow-up after SG revision to OAGB are needed.     

Roux-en-Y gastric bypass as a re-do procedure for failed restricive gastric surgery

Background Gastric restrictive procedures such as laparoscopic gastric banding or vertical banded gastroplasty show, at longer follow up, more and more failures and complications. This study focuses on the results of Roux-en-Y gastric bypass procedure (RYGBP) done as a re-do procedure, both after a technically failed restrictive procedure or when the restrictive procedure failed to obtain substantial weight loss. Methods We reviewed data concerning the postoperative complications and weight loss of 36 patients undergoing re-do surgery for failed restrictive procedures. Results Over a period of two years, 36 patients with a mean age of 40.9 years were converted to a RYGBP. Median time to conversion was 4.9 years, median follow up after conversion was 6.6 months. Early postoperative complications (less than 30 days postoperatively) were noted in 11 patients (30%). A greater number of early complications were noticed in group A (technical complications) compared to group B (insufficient weight loss) (39% vs. 22%). Late postoperative complications were seen in six patients (16%). In this relatively short follow up period we noticed a drop in body mass index (BMI) from a mean of 38.8kg/m² to 30.9 kg/m² with a mean excess body weight loss (EBWL) of 33.1% after the re-do procedure. Body mass index decreased from a mean preoperative value of 37.6kg/m² to 28.9 kg/m² in group A patients with an EBWL 36%, while group B patients had a change in BMI from 40.1kg/m² to 32.9 kg/m² with a mean EBWL of 30%. Conclusion Based on the literature, we can presume that restrictive surgery for morbidly obese patients will require many reoperations in the future. The standard operation of choice is RYGBP. In our study this procedure showed a higher, but not significantly early morbidity rate when the indication for re-do surgery was a technical complication of the initial procedure.     

Long-term follow-up in patients undergoing open gastric bypass as a revisional operation for previous failed restrictive procedures

BackgroundWe have previously described our early experience with Roux-en-Y gastric bypass (RYGB) as a revisional procedure. The favorable results have stimulated us to continue using RYGB as our standard operating procedure after failed bariatric surgery. Our objective was to evaluate the perioperative risks, weight result, and abdominal symptoms 5 years after revisional RYGB surgery at a university hospital in Sweden.MethodsWe studied 121 patients undergoing revisional open RYGB (age 42.0 yr, body mass index 37.7 kg/m², 101 women) 5 years after RYGB surgery. The patients underwent reoperation because of either intolerable side effects or inferior weight loss. The initial procedures were horizontal gastroplasty (n = 2), vertical banded gastroplasty (n = 34), gastric banding (n = 21), and silicone adjustable gastric banding (n = 64). The mean interval between the first surgery and revision was 5 years. The 5-year follow-up data were obtained annually using a questionnaire survey.ResultsThe average operating time was 162 minutes (range 75–355). In these 121 cases, 10 (8%) reoperations were performed in the first 30-day period (4 for leakage). No perioperative mortality occurred, and the 5-year follow-up rate was 91%. The mean body mass index was 30.7 kg/m². Seven patients (5.7%) had undergone subsequent surgery because of complications. At follow-up, 93% reported being very satisfied or satisfied with the revisional procedure. Disturbing abdominal symptoms after RYGB were rare.ConclusionThe perioperative risks of revisional RYGB are greater than those for primary RYGB. However, because the long-term weight results and patient satisfaction are very good, we believe that the 8% reoperative rate is acceptable. We consider RYGB to be a suitable procedure for patients in whom previous bariatric procedures have failed.     

Conversion to Roux-en-Y gastric bypass versus one-anastomosis gastric bypass after a failed primary gastric band: a matched nationwide study

BackgroundPrimary laparoscopic adjustable gastric band (LAGB) has high rates of patients not achieving the desired weight loss, and it remains unclear which bariatric conversion procedure gives better results.ObjectiveTo compare weight loss among patients undergoing conversion one-anastomosis gastric bypass (cOAGB) and conversion Roux-en-Y gastric bypass (cRYGB) after a failed LAGB.SettingNationwide population-based study including all 18 hospitals providing metabolic and bariatric surgery.MethodsPatients with a failed primary LAGB who underwent a cRYGB or cOAGB between January 1, 2015, and December 31, 2019, were selected from the Dutch Audit for Treatment of Obesity. The primary outcome was not achieving ≥20% total weight loss (TWL) at 1-year and up to 5-year follow-up. Secondary outcomes included postoperative complications, defined as Clavien-Dindo ≥III within 30 days, and co-morbidity remission. A propensity score matched logistic and Poisson regression model was used to estimate the difference in patients not achieving ≥20% TWL between cRYGB and cOAGB.ResultsA total of 615 (78.7%) patients underwent cRYGB, and 166 (21.3%) patients underwent cOAGB, with 163 patients successfully matched. Both groups had similar rates of patients not achieving ≥20% TWL at 1 year (odds ratio [OR] = .64, 95% confidence interval [CI]: .38–1.05). However, a sensitivity analysis showed that patients undergoing cOAGB had lower rates of patients not achieving ≥20% TWL up to 5-year follow-up (rate ratio = .69, 95% CI: .51–.95, P < .05). Patients undergoing cOAGB were less likely to achieve hypertension remission (OR = .22, 95% CI: .07–.66). There were no significant differences between groups in postoperative complications (OR = .39, 95% CI: .07–2.06, P > .05).ConclusionThis matched nationwide study suggests that the cOAGB has similar short-term weight loss outcomes but potentially better long-term weight loss results than cRYGB. Therefore, cOAGB could provide a reliable alternative but needs to be substantiated in future long-term studies.     

Conversion of proximal to distal gastric bypass for failed gastric bypass for superobesity

The purpose of this study was to analyze outcome following malabsorptive distal gastric bypass (D-GBP) in superobese patients who were reoperated for recurrent obesity comorbidity after a failed standard gastric bypass (S-GBP). Twenty-seven formerly superobese patients with a failed S-GBP converted to a D-GBP were studied. The small bowel was anastomosed 250 cm from the ileocecal valve to the disconnected Roux limb; the bypassed small intestine was connected to the ileum 50 cm from the ileocecal valve in five patients between 1985 and 1986 and 150 cm from the ileocecal valve in 22 patients thereafter. Comorbidity was reassessed yearly following conversion to D-GBP. Malnutrition occurred in all five patients with a 50 cm “common tract”; all required further revision and two died of hepatic failure. Three of 22 patients with a 150cm common tract were reoperated with bowel lengthening because of malnutrition. Initial body mass index was 57±2 kg/m² and fell from 46±2 kg/m² before revision to 37±2 kg/m² at 1 year and 32±2 kg/m² at 5 years after revision; the percentage of excess weight lost went from 30±4% to 61±4% at 1 year and 69±5% at 5 years after revision. Preoperative comorbidity in patients undergoing revision included 14 with insulin-dependent type II diabetes mellitus, 11 with sleep apnea, 14 with hypoventilation, 13 with hypertension, and two with venous stasis ulcers. Obesity comorbidity was corrected within 1 year in all but two patients with hypertension and remained stable in all patients followed for 5 years. Revision of a failed S-GBP to a 150 cm common tract D-GBP corrects failed weight loss and severe obesity comorbidity but requires nutritional support to prevent proteincalorie malnutrition, iron and fat-soluble vitamin deficiencies, and further revision in some patients to correct malnutrition. A 50 cm common tract has an unacceptable morbidity and mortality. Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the alimentary Tract, San Francisco., Calif., May 19–22, 1996.     

Salvage banding for failed Roux-en-Y gastric bypass

BackgroundAfter Roux-en-Y gastric bypass (RYGB), a substantial number of patients do not achieve successful long-term weight loss. In cases of loss of restriction, the application of an adjustable gastric band (“salvage banding”) over the gastric pouch, or gastrojejunostomy, could prevent weight regain or increase weight loss. The objective of this literature review is to provide an overview of the studies that report the effect of salvage banding after failed RYGB.MethodsA systemic literature search was conducted in PubMed, Google Scholar, Medline, the Cochrane Library, and the online websites of specific bariatric surgery journals to identify all relevant studies describing salvage banding after failed RYGB.ResultsSeven studies, with a total of 94 patients, were included for a systemic literature review. Inclusion criteria for salvage banding varied from unsuccessful weight loss to technical pouch failure. After salvage banding, all studies reported further weight loss, varying from 55.9%–94.2% excess body mass index loss (EBMIL) after 12–42 months of follow-up. In the included study group, 18% (17/94) of the patients developed long-term complications requiring a re-revision in 17% (16/94) of the cases.ConclusionThe results of all 9 studies that were included in this review report a further increase in weight loss after salvage banding for failed RYGB. In case of insufficient weight loss or technical pouch failure after RYGB, all reports suggest that salvage banding is a safe and feasible revisional procedure. Prospective studies are necessary to determine to the success of direct application of an adjustable gastric band in primary RYGB.     

Reoperation for failed gastric bypass procedures for obesity

Reoperation is worthwhile when there is an obvious defect in the gastric reduction operation that has failed to control weight. Reoperation occasionally is necessary to correct a complication of gastric bypass. Vertical banded gastroplasty is the operation of choice for reoperations, as it provides weight control while eliminating the problems of bypass. Conversion of a horizontal to a vertical pouch is safe but requires careful attention to the technique to avoid injury to the other organs in the area and preservation of blood supply to the stomach. The gastrogastrostomy across the old horizontal staple line in the vertical pouch can be constructed in a way that will minimize the risk of obstruction. Vertical banded gastroplasty is now the only operation in use at UIHC for the treatment of obesity and is used not only as the primary operation but in all reoperations. Bypass of the stomach and duodenum is not necessary for weight control and adds some risk of malabsorption and duodenal and stomal ulcer plus a lifetime of inaccessibility of the excluded areas for diagnostic and therapeutic measures.     

Large series examining laparoscopic adjustable gastric banding as a salvage solution for failed gastric bypass

Background

The Roux-en-Y gastric bypass (RYGB) has long been considered the gold standard of weight loss procedures. However, there is limited evidence on revisional options with both minimal risk and long-term weight loss results.

Modified vertical banded gastroplasty as revision of failed high gastric reduction for morbid obesity

Vertical banded gastroplasty is currently closest to the ideal gastric restrictive procedure for the surgical treatment of obesity. A modification of the technique of vertical banded gastroplasty can be successfully used to revise a failed high gastric reduction for morbid obesity.     

Laparoscopic revision of gastric band surgery

Aim: To identify the outcome of laparoscopic revision of gastric band surgery with respect to percentage of excess weight lost (%EWL). Methods: Analysis of a prospective database was then performed and %EWL was plotted with respect to time from initial procedure and also time from revision procedure. Results: All revision operations were performed laparoscopically. There were no patient deaths, but two serious complications. Percentage excess weight loss after replacement of the band because of prosthetic failure or dysphagia was 57% at an average follow‐up of 19 months. For repositioning of the band due to slippage, the %EWL was 72% at an average of 15 months follow‐up for those who had the existing band repositioned, and 42% at an average of 23 months follow‐up for those who had a new band repositioned. Conclusion: Revision laparoscopic gastric band surgery is a safe option for patients, and results in good %EWL at an average follow‐up period of 19 months.     

Conversion of failed laparoscopic gastric banding to gastric bypass as safe and effective as primary gastric bypass in morbidly obese patients

BackgroundTo determine whether the medium-term outcome of secondary gastric bypass (SGB) after laparoscopic adjustable gastric banding (LAGB) is comparable to the outcome of primary gastric bypass (PGB) in morbidly obese patients in terms of complications and weight loss. Controversy exists among bariatric surgeons regarding the choice of primary operation for morbid obesity. Some prefer to start with LAGB as a low-risk operation for all patients and perform revisional surgery in the case of failure. Others prefer to tailor the primary operation to the individual patient.MethodsA total of 55 patients who had undergone SGB after failed LAGB from 2002 to 2006 were compared with 81 patients who had undergone PGB for morbid obesity during the same period in our hospital by a single surgeon.ResultsThe mean operative time in the PGB group was shorter (73 ± 22 min, range 50–100) compared with the SGB group (99 ± 32 min, range 55–180; P <.001). The median length of admission did not differ significantly between the PGB and SGB groups (4 ± 6.6 d, range 3–55, versus 4 ± 2.9 d, range 3–16, respectively; P = .13). No significant differences were found in the occurrence of complications between the PGB and SGB groups (29.6% versus 30.9%, respectively, P = .87). No patient died. At 2 and 3 years postoperatively, no significant difference was found in percentage of patients treated with good or excellent outcomes using the criteria of MacLean (2 y, PGB 60.0% versus SGB 58.8%, P = .94; 3 y, PGB 75.0% versus SGB 72.7%, P = .91).ConclusionIn this series, gastric bypass as a secondary procedure after failed LAGB was as safe and effective as PGB. Conversion to gastric bypass appears to be the treatment of choice after failed LAGB.     

Laparoscopic gastric bypass as a reoperative bariatric surgery for failed open restrictive procedures

apd: 6 February 2001     

Gastric bypass in the operative revision of the failed jejunoileal bypass.

Fifty-five patients with failed jejunoileal bypasses underwent reanastomosis and gastric bypass at the same operation. One patient died of undetermined cause three months postoperatively. The 54 surviving patients were all relieved of their preoperative symptoms, and 40 patients achieved satisfactory weight control. Technical complications prevented weight loss in 13 patients: four were given pouches too large to be effective, and nine had late disruption of the staple line. Two patients gained weight despite the fact that their pouches were of appropriate size. Reanastomosis will reverse the side effects of jejunoileal bypass, and a properly performed gastric bypass at the same operation will afford protection against subsequent weight gain.     

Outcome following resectional gastric bypass for failed bariatric surgery

PurposeAn increasing number of patients who have failed a primary bariatric procedure are presenting for revisional surgery. There are few studies examining the outcome following any revisional surgery, and none examining resectional gastric bypass (RGB) in this role. We examine the indications, outcome, and patient satisfaction following conversion of a prior bariatric procedure to the RGB.MethodsFrom May 1992 to May 1998, 38 patients underwent RGB as a conversion from prior bariatric operations. Weight loss, indications, and complications were reviewed. A patient survey was used to examine patient satisfaction.ResultsMean body mass index decreased from 46 to 33 kg/m² following revision to RGB. Median weight loss after revision to RGB was 34 kg. From the time of the initial bariatric procedure to post-RGB, mean body mass index decreased from 52 to 33 kg/m². Patients with pre-RGB Visick scores of 3 or 4 improved following RGB. Ninety-five percent of respondents were satisfied with the RGB, and 85% thought it improved their lives. Constant nausea and vomiting and failure of weight control were the most common indications for revision.ConclusionsResectional gastric bypass is a safe and effective revisional procedure for patients who have had failed or complicated bariatric surgery.     

Gastric pouch resizing for Roux-en-Y gastric bypass failure in patients with a dilated pouch

BackgroundInsufficient weight loss or weight regain a few years after laparoscopic Roux-en-Y gastric bypass is becoming a serious problem given the large diffusion of this procedure. In the present study, we analyzed the feasibility and safety of pouch resizing for Roux-en-Y gastric bypass failure in a consecutive series of 20 patients at a university hospital.MethodsA prospectively maintained database was queried regarding patient demographics, the indication for revision morbidity, the percentage of excess weight loss, and the evolution of co-morbidities.ResultsA total of 20 patients, 18 women and 2 men, with a mean age of 44 years and mean body mass index of 45.8 kg/m², underwent pouch resizing. No patients died; 6 patients (30%) developed complications, including acute abdomen due to volvulus of the small bowel in 1, intra-abdominal abscess in 3, and pulmonary embolus in 2. At a mean follow-up of 20 months, the percentage of excess weight loss was an average of 69.1% and persistent co-morbidities had improved or resolved.ConclusionPouch resizing has been shown to be a valuable option in the short term for weight loss failure or regain in patients who have undergone laparoscopic Roux-en-Y gastric bypass and have a dilated gastric pouch. However, the long-term efficacy of this procedure needs to be determined.