Comparison of rates of resolution of diabetes mellitus after gastric banding, gastric bypass, and biliopancreatic diversion

BACKGROUND: Bariatric operation is the most effective treatment for diabetes mellitus in the morbidly obese. The purpose of this study is to compare the rate of resolution of diabetes mellitus after three common laparoscopic bariatric procedures: laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with or without duodenal switch (BPD/DS). STUDY DESIGN: All data were prospectively collected and entered into an electronic registry. Characteristics evaluated for this study included preoperative age, body mass index, duration of diabetes, race, gender, operative time, length of stay, percent excess weight loss, oral hypoglycemic requirements, and insulin requirements. RESULTS: A total of 282 bariatric patients with diabetes mellitus were analyzed (218 LAGB, 53 RYGB, and 11 BPD/DS). Preoperative age (46 to 50 years), body mass index (46 to 50; calculated as kg/m(2)), race and gender breakdown, and baseline oral hypoglycemic (82% to 87%) and insulin requirements (18% to 28%) were comparable among the three groups (p = NS). Percent excess weight loss at 1, 2, and 3 years was: 43%, 50%, and 45% for LAGB; 66%, 68%, and 66% for RYGB; and 68%, 77%, and 82% for BPD/DS (p < 0.01 LAGB versus RYGB and LAGB versus BPD/DS at all time intervals). At 1 and 2 years, the proportion of patients requiring oral hypoglycemics postoperatively was 39% and 34% for LAGB; 22% and 13% for RYGB; and 11% and 13% for BPD/DS (p = NS). At 1 and 2 years, the proportion of patients requiring insulin postoperatively was 14% and 18% for LAGB; 7% and 13% for RYGB; and 11% and 13% for BPD/DS (p = NS). CONCLUSIONS: Despite the disparity in percent excess weight loss between LAGB, RYGB, and BPD/DS, the rate of resolution of diabetes mellitus is equivalent.     

Laparoscopic adjustable gastric banding in the treatment of obesity: a systematic literature review

BACKGROUND: We attempted to compare the safety and efficacy of laparoscopic adjustable gastric banding with vertical-banded gastroplasty and gastric bypass. Morbid obesity presents a serious health issue for Western countries, with a rising incidence and a strong association with increased mortality and serious comorbidities, such as diabetes, hyperlipidemia, and cardiovascular disease. Unfortunately, conservative treatment options have proven ineffective. Surgical interventions, such as vertical-banded gastroplasty (stomach stapling), Roux-en-Y gastric bypass, and, more recently, laparoscopic gastric banding have been developed with the aim of providing a laparoscopically placed device that is safe and effective in generating substantial weight loss. METHODS: Electronic databases were systematically searched for references relating to obesity surgery by (1) laparoscopic adjustable gastric banding (LAGB), (2) vertical banded gastroplasty (VBG), and (3) Roux-en-Y gastric bypass (RYGB). RESULTS: Only 6 studies reported comparative results for laparoscopic gastric banding and other surgical procedures. One study reported comparative results for all 3 surgical procedures, and this study was only of moderate quality. In total, 64 studies were found that reported results for LAGB and 57 studies reported results on the comparative procedures. LAGB was associated with a mean short-term mortality rate of approximately 0.05% and an overall median morbidity rate of approximately 11.3%, compared with 0.50% and 23.6% for RYGB, and 0.31% and 25.7% for VBG. Overall, all 3 procedures produced considerable weight loss in patients up to 4 years in the case of LAGB (the maximum follow-up available at the time of the review), and more than 10 years in the case of the comparator procedures. CONCLUSIONS: The Australian Safety and Efficacy Register of New Interventional Procedures-Surgical Review Group concluded that the evidence base was of average quality up to 4 years for LAGB. Laparoscopic gastric banding is safer than VBG and RYGB, in terms of short-term mortality rates. LAGB is effective, at least up to 4 years, as are the comparator procedures. Up to 2 years, LAGB results in less weight loss than RYGB; from 2 to 4 years there is no significant difference between LAGB and RYGB, but the quality of data is only moderate. The long-term efficacy of LAGB remains unproven, and evaluation by randomized controlled trials is recommended to define its merits relative to the comparator procedures.     

Laparoscopic Gastric Bypass versus Laparoscopic Adjustable Gastric Banding in the Super-obese: A Comparative Study of 290 Patients

Background: Controversy exists regarding the best surgical treatment for super-obesity (BMI >50 kg/m 2 ). The two most common bariatric procedures performed worldwide are laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGBP). We undertook a retrospective single-center study to compare the safety and efficacy of these two operations in super-obese patients. Methods: 290 super-obese patients underwent laparoscopic bariatric surgery: 179 LAGB and 111 LRYGBP. Results: There were one death in both groups. The early complication rate was higher in the LAGB group (10% vs 2.8%, P<0.01). Late complication rate was higher in the LAGB group (26% vs 15.3%, P<0.05). Operating time and hospital stay were significantly higher in the LRYGBP group. LRYGBP had significantly better excess weight loss than LAGB (63% vs 41% at 1 year, and 73% vs 46% at 2 years), as well as lower BMI than LAGB (35 vs 41 at 18 months). Conclusion: LRYGBP results in significantly greater weight loss than LAGB in super-obese patients, but is associated with a higher early complication rate.     

A one-step conversion from gastric banding to laparoscopic Roux-en-Y gastric bypass is as safe as a two-step conversion: A comparative analysis of 885 patients

Aims: To achieve additional weight loss or to resolve band-related problems, a laparoscopic adjustable gastric banding (LAGB) can be converted to a laparoscopic Roux-en-Y gastric bypass (RYGB). There is limited data on the feasibility and safety of routinely performing a single-step conversion. We assessed the efficacy of this revisional approach in a large cohort of patients operated in a high-volume bariatric institution.

Methods: Between October 2004 and December 2015, a total of 885 patients who underwent LAGB removal with RYGB were identified from a prospectively collected database. In all cases, a single-stage conversion procedure was planned. The feasibility of this approach and peri-operative outcomes of these patients were evaluated and analyzed.

Results: A single-step approach was successfully achieved in 738 (83.4%) of the 885 patients. During the study period, there was a significant increase in performing the conversion from LAGB to RYGB single-staged. No mortality or anastomotic leakage was observed in both groups. Only 45 patients (5.1%) had a 30-d complication: most commonly hemorrhage (N?=?20/45), with no significant difference between the groups.

Conclusion: Converting a LAGB to RYGB can be performed with a very low morbidity and zero-mortality in a high-volume revisional bariatric center. With increasing experience and full standardization of the conversion, the vast majority of operations can be performed as a single-stage procedure. Only a migrated band remains a formal contraindication for a one-step approach.     

Roux-en-Y gastric bypass as revisional procedure after gastric banding: leaving the band in place

BackgroundRoux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) are frequently used bariatric procedures. With both techniques, LAGB more than RYGB, failures occur. After years of experience with both techniques, we present a series of patients who underwent RYGB after failed LAGB. The band was kept in place. Our objective was to evaluate the safety and short-term effectiveness of RYGB after failed LAGB, without removing the band. The setting was a large teaching hospital in Heerlen, The Netherlands.MethodsWe first retrospectively considered the efficacy and complication rate of adding an adjustable band to RYGB. This was safe and effective. The patients lost a median of 7.6 kg within a median period of 21 months. The complication rate was low. Observing the positive results in this group, we began to leave the band in place when converting patients from LAGB to RYGB.ResultsA total of 12 patients underwent revision of LAGB to RYGB. There was no mortality. The complication rate and severity were low. During a median period of 16 months, the patients lost a median of 23 kg or 8 points in the body mass index. Also, additional improvement in co-morbidities was observed.ConclusionOur results suggest that performing RYGB after LAGB and leaving the band in place is feasible, safe, and effective in the short term.     

Laparoscopic adjustable gastric band versus laparoscopic Roux-en-Y gastric bypass

Background In the United States, the most frequently performed bariatric procedure is the Roux-en-Y gastric bypass (RYGB). Worldwide, the most common operation performed is the laparoscopic adjustable gastric band (LAGB). The expanding use of LAGB is probably driven by the encouraging data on its safety and effectiveness, in contrast to the disappointing morbidity and mortality rates reported for RYGB. The aim of this study was to evaluate the results of LAGB versus RYGB at a single institution. Methods Between November 2000 and July 2004, 590 bariatric procedures were performed. Of these, 120 patients (20%) had laparoscopic RYGB and 470 patients (80%) had LAGB. A retrospective review was performed. Results In the LAGB group, 376 patients (80%) were female, and the mean age was 41 years (range, 17–65). In the RYGB group, 110 patients (91%) were female, and the mean age was 41 years (range, 20–61). Preoperative body mass index was 47 ± 8 and 46 ± 5, respectively (p = not significant). Operative time and hospitalization were significantly shorter in LAGB patients (p < 0.001). Complications and the need for reoperation were comparable in both groups. Weight loss at 12, 18, 24, and 36 months for LAGB and RYGB was 39 ± 21 versus 65 ± 13, 39 ± 20 versus 62 ± 17, 45 ± 25 versus 67 ± 8, and 55 ± 20 versus 63 ± 9, respectively. Conclusions The current study demonstrates that LAGB is a simpler, less invasive, and safer procedure than RYGB. Although mean percentage excess body weight loss (%EBWL) in RYGB patients increased rapidly during the first postoperative year, it remained nearly unchanged at 3 years. In contrast, in LAGB patients weight loss was slower but steady, achieving satisfactory %EBWL at 3 years. Therefore, we believe that LAGB should be considered the initial approach since it is safer than RYGB and is very effective at achieving weight loss.     

Evolution and Outcomes of a Canadian Pediatric Bariatric Surgery Program

PurposeAn interdisciplinary obesity management program was established in 2007 at our quaternary hospital, including bariatric surgery for selected adolescent patients. We report the evolution of surgical management within the program and outcomes following bariatric surgery.MethodsThis was a retrospective review of adolescents who underwent bariatric surgery between 2007 and 2017. All cases were performed by a pediatric surgeon and an adult bariatric surgeon. Baseline demographics, BMI, co-morbidities, and post-operative outcomes were recorded.ResultsThirty-eight patients underwent bariatric surgery. Median age at entrance into the program was 16.5 (range, 12.1–17.4) years and at time of surgery was 17.4 (range, 13.6–18.8) years. Eight patients had laparoscopic adjustable gastric banding (LAGB) from 2007 to 10. Between 2011 and 2017, 18 had laparoscopic sleeve gastrectomy (LSG), and 12 had laparoscopic Roux-en-Y gastric bypass (RYGB). There were no intraoperative complications or conversions. Postoperative complications included wound infection, bleeding requiring transfusion and re-exploration, and internal hernia. Of patients who had LAGB, 2 required surgical revision, and 3 underwent subsequent removal.ConclusionsAdolescent bariatric surgery in the context of a multidisciplinary obesity management program is safe and effective. RYGB and sleeve gastrectomy are associated with superior weight loss in the immediate post-operative period and at most recent follow-up and lower reoperation rates than gastric banding.Level of EvidenceIII.     

Conversion of failed gastric banding into four different bariatric procedures

BackgroundThe 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.MethodsFrom 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.ResultsThe 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/m² to 31.3 ± 6.8 kg/m² 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.ConclusionConversion 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.     

A Comparison of Laparoscopic Adjustable Gastric Banding and Biliopancreatic Diversion in Superobesity

Background: Controversy exists regarding the best surgical treatment for superobesity (BMI >50 kg/m²), and a comparison of the 2 most commonly performed procedures in Europe, namely biliopancreatic diversion (BPD) and laparoscopic adjustable gastric banding (LAGB), has not yet been reported. Methods: BPD has been performed in 134 morbidly obese patients since 1996, and as the primary bariatric procedure in 23 superobese patients. 23 sex-matched patients who most closely resembled the age and BMI of the 23 BPD patients were chosen from 1,319 patients who had undergone LAGB since 1996. These groups were compared using appropriate statistical tests. Results: BPD was performed laparoscopically in 12 patients. Median excess weight loss at 24 months was 64.4% following BPD and 48.4% following LAGB. Hospital stay and complication rate were significantly greater with BPD, although the majority of complications were related to the laparotomy wound in patients undergoing open BPD. Rate of resolution of obstructive sleep apnea, hypertension and diabetes mellitus following LAGB was similar to BPD. Conclusion: BPD results in significantly greater weight loss than LAGB in superobese patients, but is associated with a longer hospital stay and a higher complication rate in patients undergoing open BPD.     

Cost-effectiveness analysis of laparoscopic gastric bypass, adjustable gastric banding, and nonoperative weight loss interventions

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the two most commonly performed bariatric procedures. Although both procedures likely reduce healthcare expenditures related to the resolution of co-morbid conditions, they have different rates of perioperative risks and different rates of associated weight loss. We designed a model to evaluate the incremental cost-effectiveness of these procedures compared with nonoperative weight loss interventions and with each other. METHODS: We used a deterministic, payer-perspective model comparing the lifetime expected costs and outcomes of LAGB, LRYGB, and nonoperative treatment. The major endpoints were survival, health-related quality of life, and weight loss. Life expectancy and lifetime medical costs were calculated across age, gender, and body mass index (BMI) strata using previously published data. RESULTS: For both men and women, LRYGB and LAGB were cost-effective at <$25,000/quality-adjusted life-year (QALY) even when evaluating the full range of baseline BMI and estimates of adverse outcomes, weight loss, and costs. For base-case scenarios in men (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $11,604/QALY for LAGB compared with $18,543/QALY for LRYGB. For base-case scenarios in women (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $8878/QALY for LAGB compared with $14,680/QALY for LRYGB. CONCLUSION: The modeled cost-effectiveness analysis showed that both operative interventions for morbid obesity, LAGB and RYGB, were cost-effective at <$25,000 and that LAGB was more cost-effective than RYGB for all base-case scenarios.     

Impact of Patient Follow-Up on Weight Loss after Bariatric Surgery

Background: Postoperative follow-up after bariatric surgery is important. Because of the need for adjustments, follow-up after gastric banding may have a greater impact on weight loss than after Roux-en-Y gastric bypass.We reviewed all patients at 1 year after these two operations. Methods: During the first year after surgery, laparoscopic adjustable gastric banding (LAGB) patients were followed every 4 weeks and Roux-en-Y gastric bypass (RYGBP) patients were followed at 3 weeks postoperatively and then every 3 months.The number of follow-up visits for each patient was calculated, and 50% compliance for follow-up and weight loss was compared. Results: Between October 2000 and September 2002, 216 LAGB and 139 RYGBP operations were performed. Of these patients, 186 LAGB patients and 115 RYGBP patients were available for 1-year follow-up. Age and BMI were similar for each group. Overall excess weight loss (EWL) after LAGB was 44.5%. 130 (70%) returned 6 or less times in the first year and achieved 42% EWL. 56 patients (30%) returned more than 6 times and had 50% EWL (P=0.005). Overall %EWL after RYGBP was 66.1%. 53 patients (46%) returned 3 or less times in the first year, achieving 66.1% EWL. 62 patients (54%) returned more than 3 times after surgery and achieved 67.6% EWL (P=NS). Conclusion: Patient follow-up plays a significant role in the amount of weight lost after LAGB, but not after RYGBP. Patient motivation and surgeon commitment for long-term follow-up is critical for successful weight loss after LAGB surgery.     

Current Attitudes to the Laparoscopic Bariatric Operations among European Surgeons

Background: The current attitudes among European bariatric surgeons toward the laparoscopic bariatric operations were examined. Methods: 150 questionnaires were sent to recognized bariatric surgeons in Europe, and 60% responded. Results: 47% of respondents perform laparoscopic Roux-en-Y gastric bypass (LRYGBP), 81% laparoscopic adjustable gastric banding (LAGB), and 29% laparoscopic biliopancreatic diversion with or without duodenal switch (L-BPD/BPDDS). For BMI <40, 57% of respondents would only perform LAGB, 7% LRYGBP, 2% vertical banded gastroplasty (VBG), 3% L-BPD/BPDDS, and 2% intra-gastric balloon. For BMI 40-50, 43% of respondents prefer LAGB, 11% LRYGBP, 8% VBG, 5% L-BPD/BPDDS, and 33% contemplate several operations. For BMI 50-60, 30% prefer LAGB, 23% LRYGBP, 5% VBG, 16% L-BPD/BPDDS, and 26% tailor each patient's treatment. For BMI >60, 20% prefer LAGB, 24% LRYGBP, 37% L-BPD/BPDDS, 2% VBG, and 17% consider more than one operation. Although important, BMI and patient eating habits are not significant in choosing an operation for 25% of respondents. Interestingly, 39% of the surgeons offer laparoscopic bariatric surgery to so-called pediatric patients (<18). Of these, 76% favor LAGB, 8% LRYGBP, 8% L-BPD and 4% other procedures. Conclusions: The overall body of respondents prefers laparoscopic procedures. The responses suggest that at lower BMI there is a higher trend for restrictive operations. However, as BMI increases, combined and malabsorptive operations are preferred. At least one-third of surgeons offer bariatric surgery to patients with age <18 years, and here LAGB is greatly preferred.     

Biliopancreatic diversion with duodenal switch or gastric bypass for failed gastric banding: retrospective study from two institutions with preliminary results.

BACKGROUND: Of patients who have undergone gastric banding, 11-25% will require a major reoperation with band removal and conversion to another bariatric procedure after they have failed to lose sufficient weight or have developed dysphagia or reflux. The aim of this study was to evaluate the respective benefits of Roux-en-Y gastric band (RYGB) or biliopancreatic diversion with duodenal switch (BPD-DS) after failed gastric banding and whether 1 of the 2 procedures might be a better procedure for such cases. METHODS: RYGB or BPD-DS was performed according to the institutional protocols with synchronous band removal, irrespective of the reason for failure. RESULTS: Of the 53 patients, 32 underwent laparoscopic RYGB for a body mass index (BMI) of 43.1 +/- 6.4 kg/m(2) (BMI 45.8 +/- 6.4 kg/m(2) before laparoscopic adjustable gastric banding) and 21 underwent BPD-DS for a BMI of 46.0 +/- 5.5 kg/m(2) (BMI 49.6 +/- 5.2 kg/m(2) before laparoscopic adjustable gastric banding). BPD-DS required significantly longer operative times (239.7 +/- 55.8 versus 135 +/- 26.7 minutes) and resulted in more complications (62% versus 12.5%; P <.002). No patients died postoperatively. The 2 groups of patients had a similar BMI at 12 and 18 months after revision (BMI 33.4 +/- 5.6 kg/m(2) and 31.4 +/- 3.5 kg/m(2)). The weight loss was greater after BPD-DS than after RYGB compared with the prerevision weight loss (66.2% versus 58.8% excess weight loss) or initial weight (73% versus 61.8%), although this was not significant. CONCLUSION: Despite an excessive rate of complications that were, in part, related to the learning curve in this series, BPD-DS resulted in greater weight loss compared with RYGB. However, both procedures were successful after failed gastric banding. A more accurate definition of failure could help to determine the respective indications for revisional surgery.     

Revisional versus primary Roux-en-Y gastric bypass: a case-matched analysis

Background

Laparoscopic adjustable gastric banding (LAGB) has been a widely performed bariatric procedure. Unfortunately, revisional surgery is required in 20–30 % of cases. Data comparing revisional and primary gastric bypass procedures are scarce. This study compared revisional malabsorptive laparoscopic very very long limb (VVLL) Roux-en-Y gastric bypass (RYGB) with primary VVLL RYGB and tested the hypothesis that one-stage revisional laparoscopic VVLL RYGB is an effective procedure after failed LAGB.

Methods

In this study, 48 revisional VVLL RYGBs were matched one-to-one with 48 primary VVLL RYGBs. The outcome measures were operating time, conversion to open surgery, excess weight loss (EWL), and early and late morbidity.

Results

Surgical and medical morbidities did not differ significantly. No conversions occurred. The revisional group showed an EWL of 41.8 % after 12 months of follow-up evaluation and 45.1 % after 24 months based on the pre-revisional weight. The total EWL based on the weight before the LAGB was calculated to be 54.3 % after 12 months and 57.2 % after 24 months. The EWL in the primary RYGB group was significantly higher for both types of calculation: 41.8 %/54.3 % versus 64.1 % (p < 0.001 and <0.01) after 12 months and 45.1 %/57.2 % versus 70.4 % (p < 0.001 and <0.002) after 24 months.

Conclusions

Revisional laproscopic VVLL RYGB can be performed as a one-stage procedure by experienced bariatric surgeons but shows less effective EWL than primary RYGB procedures.     

The Improvement of Gastroesophageal Reflux Disease and Barrett’s after Bariatric Surgery

Obesity and gastroesophageal reflux disease (GERD) are prevalent in Western populations. In obese patients, high-resolution manometry often shows altered gastroesophageal pressure gradients, promoting retrograde gastric content flow into the esophagus and esophagogastric junction disruption, leading to a hiatal hernia. Hernia recurrence is higher in the obese, and recurrence is seen regardless of the operative approach used. Bariatric surgery is the gold-standard treatment for GERD in obese patients, and symptom improvement varies depending on the specific bariatric procedure performed, Roux-en-Y (RYGB), laparoscopic adjustable gastric banding (LAGB), or sleeve gastrectomy (SG). Studies have shown these surgeries significantly improve GERD, but RYGB had the greatest effect. Limited data is available examining the progression or regression of Barrett’s following bariatric surgery. We currently recommend RYGB for morbidly obese patients with Barrett’s esophagus.     

One Year Improvements in Cardiovascular Risk Factors: a Comparative Trial of Laparoscopic Roux-en-Y Gastric Bypass vs. Adjustable Gastric Banding

Background  

Coronary artery disease (CAD) is the leading cause of death in the industrialized world with obesity as a leading preventable risk factor. Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) have been shown to improve certain biochemical cardiovascular risk factors (BCRFs) at 1 year post-op, however no study has directly compared the 12-month BCRF improvements of RYGB vs. LAGB.     

Revisional surgery after failed gastric banding: results of one-stage conversion to RYGB in 195 patients

BackgroundThe most performed restrictive bariatric procedure is the laparoscopic adjustable gastric band (LAGB). With many patients still receiving a LAGB in Europe and the United States, inevitably, the number of complications also increases. For many complications revisional bariatric surgery is necessary. In this study, the outcomes of one-stage LAGB conversion to a Roux-en-Y gastric bypass (RYGB) at our institution are presented. The objective of this study was to investigate the safety and efficiency of RYGB performed as a one-stage procedure after failed LAGB.MethodsPatients were retrospectively selected using a prospectively collected database. The gastric band had to be in situ for at least 1 year and minimum postoperative follow-up was 12 months. The revisional RYGB had to be performed as a 1-step procedure.ResultsA total of 195 patients were included while 3 were lost to follow up. Overall, 178 (91%) procedures were performed without perioperative complications, and only 8 (4%) patients required reoperation within 30 days. The mean follow-up was 40 months (±24) after RYGB. Mean excess weight loss (EWL) increased from 25% (±26/-50- 120%) to 60% (±21.2/0- 130), 65% (±23.5/0- 131), 63% (±24.2/2- 132), 60% (±24.1/0- 111) and 53% (±28.7/-39- 109) in the first 5 postoperative years.ConclusionConverting a gastric band to a RYGB in a one-stage procedure is safe and feasible, with acceptable complication rates when performed in a specialized institution. The RYGB conversion results in a good EWL of 65% after 2 years. However, proper patient selection is of the utmost importance.     

Revision of Failed Laparoscopic Adjustable Gastric Banding to Roux-en-Y Gastric Bypass

Background: The most common bariatric surgical 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. We investigated whether revision to Roux-en-Y gastric bypass (RYGBP) is a safe and effective therapy for failed LAGB and for further weight loss. Methods: From Jan 1999 to May 2004, 613 patients underwent LAGB. Of these, 47 underwent later revisional Roux-en-Y gastric bypass (RYGBP). Using a prospectively collected database, we analyzed these revisions. All procedures were done by two surgeons with extensive experience in bariatric surgery. Results: All patients were treated with laparoscopic (n=26) or open (n=21) RYGBP after failed LAGB. Total follow-up after LAGB was 5.5±2.0 years. For the RYGBP, mean operating time was 161±53 minutes, estimated blood loss was 219±329 ml, and hospital stay was 6.7±4.5 days. There has been no mortality. Early complications occurred in 17%. There was only one late complication (2%) – a ventral hernia. The mean BMI prior to any form of bariatric surgery was 49.2±9.3 kg/m², and decreased to 45.8±8.9 kg/m² after LAGB and was again reduced to 37.7±8.7 kg/m² after RYGBP within our follow-up period. Conclusion: Conversion of LAGB to RYGBP is effective to treat complications of LAGB and to further reduce the weight to healthier levels in morbidly obese patients.     

Preoperative thiamine deficiency in obese population undergoing laparoscopic bariatric surgery

BACKGROUND: Nutritional deficiencies are a recognized complication of bariatric surgery. Thiamine deficiency has been reported as a possible consequence of both restrictive and malabsorptive bariatric procedures. Most of the reported cases occurred after Roux-en-Y gastric bypass (RYGB) surgery; fewer were described after biliopancreatic diversion, vertical banded gastroplasty, or duodenal switch. Adults who have a high carbohydrate intake derived mainly from refined sugars and milled rice are at greater risk of developing thiamine deficiency, because thiamine is absent from fats, oils, and refined sugars. Currently, no reports have evaluated the preoperative thiamine status of bariatric patients. The aim of this study was to evaluate the degree of thiamine deficiency in obese patients before bariatric surgery at our institution. METHODS: The medical records of consecutive patients who underwent laparoscopic RYGB or laparoscopic adjustable gastric banding at our institution between March 2003 and February 2004 were retrospectively reviewed. Patients were selected for this study on the basis of predetermined criteria. Preoperative thiamine levels were retrospectively recorded. Excluded from this study were patients who had been taking multivitamins or other nutritional supplements before surgical intervention, had a history of frequent alcohol consumption, any malabsorptive diseases, or previous restrictive-malabsorptive surgical interventions, such as RYGB, biliopancreatic diversion, or adjustable gastric banding, according to the initial evaluation and questionnaire. RESULTS: Of 437 consecutive patients who underwent laparoscopic RYGB or laparoscopic adjustable gastric banding, 303 were included in the study. Forty-seven patients (15.5%) presented with low preoperative thiamine levels. The mean age and body mass index of these patients was 46 years and 60 kg/m(2), respectively. Male patients presented with greater mean preoperative thiamine levels (3.2 microg /dL) than female patients (2.4 microg/dL). CONCLUSION: Obese patients undergoing bariatric surgery may have significant thiamine deficiency before surgery.     

Revisional bariatric surgery at a single institution

Background

Bariatric surgery, although safe, can have long-term complications that require revision. Our series illustrates the spectrum of primary procedures, indications for surgery, and strategies for revision.

Methods

The study was a retrospective chart review. Sixty-three patients were identified. Of specific interest were complications and percentage of excess weight loss (EWL) during the follow-up period.

Results

Eighteen patients had a previous vertical banded gastroplasty (VBG), 26 had a Roux-en-Y gastric bypass (RYGB), 18 had a laparoscopic adjustable gastric banding (LAGB), and 1 had a jejunal-ileal bypass. All VBG patients were revised to RYGB. Seventeen RYGB patients were revised with RYGB. Eight LAGB patients were revised with RYGB. Eight RYGB patients had placement of LAGB. Two LAGB patients were revised with LAGB because of a slipped band. Eight LAGB patients had the band removed. The morbidity rate was 30% with a major morbidity rate of 11%. There were 2 leaks, neither required reoperation. Other major complications included 3 pneumonias, 2 reoperations, and 2 intra-abdominal abscesses. There were no mortalities. In the 15 patients who had conversion of VBG to RYGB, the mean EWL was 50%, with 60% of patients achieving more than 50% EWL. In the 10 patients who had revision of their RYGB, the mean EWL was 51%, with 60% of patients achieving more than 50%. In the 6 patients who had revision of LAGB to RYGB, the mean EWL was 39%, with 33% of patients achieving more than 50% EWL. In the 8 patients who had LAGB after RYGB the mean EWL was −2%, with 0% of patients achieving more than 50%.

Conclusions

Revisional surgery is effective, although complication rates are higher than primary bariatric surgery. The type of initial and revisional procedure affects EWL.