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.     

Long-Term Results of Bariatric Restrictive Procedures: A Prospective Study

Laparoscopic adjustable gastric banding (LAGB) and vertical-banded gastroplasty (VBG) are surgical treatment modalities for morbid obesity. This prospective study describes the long-term results of LAGB and VBG. One hundred patients were included in the study. Fifty patients underwent LAGB and 50 patients, open VBG. Study parameters were weight loss, changes in obesity-related comorbidities, long-term complications, re-operations including conversions to other bariatric procedures and laboratory parameters including vitamin status. From 91 patients (91%), data were obtained with a mean follow-up duration of 84 months (7 years). Weight loss [percent excess weight loss (EWL)] was significantly more after VBG compared with LAGB, 66% versus 54%, respectively. All comorbidities significantly decreased in both groups. Long-term complications after VBG were mainly staple line disruption (54%) and incisional hernia (27%). After LAGB, the most frequent complications were pouch dilatation (21%) and anterior slippage (17%). Major re-operations after VBG were performed in 60% of patients. All re-operations following were conversions to Roux-en-Y gastric bypass (RYGB). In the LAGB group, 33% of patients had a refixation or replacement of the band, and 11% underwent conversion to another bariatric procedure. There were no significant differences in weight loss between patients with or without re-interventions. No vitamin deficiencies were present after 7 years, although supplement usage was inconsistent. This long-term follow-up study confirms the high occurrence of late complications after restrictive bariatric surgery. The failure rate of 65% after VBG is too high, and this procedure is not performed anymore in our institution. The re-operation rate after LAGB is decreasing as a result of new techniques and materials. Results of the re-operations are good with sustained weight loss and reduction in comorbidities. However, in order to achieve these results, a durable and complete follow-up after restrictive procedures is imperative.     

Modification of the education system for organ procurement coordinators in Japan after the revision of the Japanese Organ Transplantation Act

Background

From October 1997 to July 2010, only 86 brain-dead (BD) organ donations were obtained and no organs were retrieved from children under 15 years of age because of the strict Japan Organ Transplantation Act. The Act was revised on July 17, 2010, allowing organs to be donated after BD with family consent.

Objective

To manage the increased donations after the revision, the Japan Organ Transplant Network (JOT) employed 10 organ procurement coordinators (OPCs) and modified its education systems. We retrospectively reviewed the modified education programs to evaluate whether they were effective and whether the processes of organ donation were promptly performed after the revision of the Act.

Methods

The modifications of education program were: changing OPC to guideline manuals to correspond to the revised Transplant Act; OPCs were taught the new organ procurement system; and a special education program was provided for the 10 newcomers for 2 months.

Results

After 12 months of the revision, 58 BD organ donations were accomplished, whereas they had averaged 6.6 in a year before the revision. Two pediatric BD organ donations were accomplished without problem. One priority organ donation to a relative was performed uneventfully. After applying the modified education program, skilled JOT OPCs and leader JOT OPCs increased.

Conclusions

To manage increased organ donations after the revision of the Act, the educational system was modified and 58 brain dead organ donations were performed safely.     

Prophylactic mesh to prevent incisional hernia: A note of caution

Background

Ventral hernia is a common complication of open Roux-en-Y gastric bypass (RYGB). The aim of this study was to determine whether prophylactic mesh placement during RYGB would reduce the incidence of postoperative hernias.

Methods

Obese patients undergoing RYGB by a single surgeon had prosthetic mesh placed in a subfascial location at the conclusion of the procedure. The incidences of recurrent hernia and morbidity associated with the placement of mesh were assessed.

Results

Sixteen patients underwent RYGB with prophylactic mesh placement over 6 months. The average preoperative body mass index was 46.6 kg/m². Half of the patients were diabetics. None were smokers. During mean follow-up of 6 months, 4 patients (25%) required mesh excision, 3 for infection and 1 for a persistently symptomatic seroma. One patient was explanted incidentally in the course of reexploration for intractable nausea and vomiting. Another developed an incisional hernia despite prophylactic mesh.

Conclusions

In the investigators' experience, the use of prophylactic new-generation mesh at the time of open RYGB led to an unacceptable rate of local complications. They caution against this technique in patients undergoing open RYGB.     

Long-Term Follow-up after Gastric Surgery for Morbid Obesity: Preoperative Weight Loss Improves the Long-Term Control of Morbid Obesity after Vertical Banded Gastroplasty

Background: Gastric restrictive surgery in a large non-university teaching hospital has been combined with preoperative weight loss by diet. The aims of preoperative dieting were to test patient motivation, to reduce perioperative morbidity, to accustom patients to the restriction of food intake after surgery, and to increase total weight loss. This study was performed to investigate the long-term results of this approach. Methods: 200 morbidly obese persons were operated on between 1978 and 1986 after they had lost more than 50% of their excess weight by diet. 100 Roux-en-Y gastric bypasses (RYGB) and, after 1983, 100 vertical banded gastroplasties (VBG) were performed. Data from medical records and data concerning present weight, complaints, food intolerance, nutritional deficiencies, and medical follow-up visits were obtained by questionnaire. Results: The lowest body weight was obtained 1 year after operation with an average excess weight loss (EWL) of 78% after RYGB and 75% after VBG. Body weight gradually increased, and 7 years after surgery the average EWL was 67% after RYGB and 63% after VBG. Ten patients had died (three postoperatively after RYGB). Preoperative dieting did not decrease perioperative morbidity and mortality in comparison with other reports. Conclusions: After combined preoperative dieting and VBG, weight loss is greater than after surgery alone. No additional weight loss after preoperative dieting was observed in RYGB patients. Most patients who underwent bariatric surgery still experience nutritional, physical, and cosmetic problems 7 years after surgery.     

Laparoscopic adjustable gastric banding in adolescents: short-term results

Purpose

Children and adolescents who fail to lose weight through diet and exercise programs have been offered weight loss surgery for several years. We report our early results on laparoscopic adjustable gastric banding (LAGB) in 100 teenagers.

Methods

Candidates for surgery underwent rigorous assessment for medical eligibility, compliance, and psychological well-being. Patients who met criteria and were approved by our team were offered LAGB. Postoperatively, patients were followed monthly until steady weight loss was achieved, then every 3 months thereafter.

Results

One hundred patients aged 14 to 19 years underwent LAGB. Preoperative average weight was 136.7 kg, and median body mass index was 48.7. Comorbid medical conditions were common. Five reoperations were performed for port site bleeding, hiatal hernia repair, possible intestinal obstruction, and port slippage. Eighty-seven patients were followed for a minimum of 6 months. Average weight loss at 6 months was 12.4 (range, 33.2 to 16.2) kg, and average change in body mass index was 4.4 (range, 11.8 to −5.6).

Conclusion

Laparoscopic adjustable gastric banding may be performed safely in adolescents, and short-term results suggest that LAGB may serve as an important tool to help them lose weight.     

A five year Canadian laparoscopic adjustable gastric band experience

Background

The aim of this study was to review 5 years of laparoscopic adjustable gastric band (LAGB) procedures in which low-pressure bands were used.

Methods

All LAGB cases at the authors' center were retrospectively analyzed. A survey of these patients was conducted in 2008 and 2009.

Results

Of 90 LAGB patients, 86 were surveyed. Follow-up averaged 17.5 months. Weight loss averaged 24.8 ± 19.4 kg. Weight loss averaged 2.7 kg/mo and did not significantly drop over the last 10.7 months (2.7 vs 1.5 kg/mo, P = .16). Excess body weight loss was 27.5%, 39.1%, and 67.2% in the first, second, and following years, respectively. Patients averaged 4.14 adjustments of their bands and vomited 2.13 times per week. The mortality rate was 0%. No band slippages or band erosion occurred. Resolution or improvement occurred in most obesity-related illness. Gastroesophageal reflux disease symptoms worsened in 25% of patients.

Conclusions

These results replicate world LAGB literature. Low complication rates result either from the authors' band or their techniques.     

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.     

Revisional bariatric surgery is more effective for improving obesity-related co-morbidities than it is for reinducing major weight loss

BackgroundPatients having previous bariatric surgery are at risk for weight regain and return of co-morbidities. If an anatomic basis for the failure is identified, many surgeons advocate revision or conversion to a Roux-en-Y gastric bypass. The aim of this study was to determine whether revisional bariatric surgery leads to sufficient weight loss and co-morbidity remission.Patients and MethodsFrom 2005-2012, patients undergoing revision were entered into a prospectively maintained database. Perioperative outcomes, including complications, weight loss, and co-morbidity remission, were examined for all patients with a history of a previous vertical banded gastroplasty (VBG) or Roux-en-Y gastric bypass (RYGB).ResultsTwenty-two patients with a history of RYGB and 56 with a history of VBG were identified. Following the revisional procedure, the RYGB group experienced 35.8% excess weight loss (%EWL) and a 31.8% morbidity rate. For the VBG group, patients experienced a 46.2% %EWL from their weight before the revisional operation with a 51.8% morbidity rate. Co-morbidity remission rate was excellent. Diabetes (VBG:100%, RYGB: 85.7%), gastroesophageal reflux disease (VBG: 94.4%, RYGB: 80%), and hypertension (VBG: 74.2%, RYGB:60%) demonstrated significant improvement.ConclusionRevision of a failed RYGB or conversion of a VBG to a RYGB provides less weight loss and a higher complication rate than primary RYGB but provides an excellent opportunity for co-morbidity remission.     

Rate of revisions or conversion after bariatric surgery over 10 years in the state of New York

Background

A primary measure of the success of a procedure is the whether or not additional surgery may be necessary. Multi-institutional studies regarding the need for reoperation after bariatric surgery are scarce.

Incidence of cholecystectomy after bariatric surgery

Background

Bariatric surgery predisposes patients to development of cholelithiasis, and therefore the need of a subsequent cholecystectomy; however, the incidence of cholecystectomy after bariatric surgery is debated.

Long-term infection rates in diabetic patients implanted with antibiotic-impregnated versus nonimpregnated inflatable penile prostheses: 7-year outcomes

Background

Diabetic patients may be more prone to penile-implant infections than other men.

Objective

We sought to determine whether revision surgeries due to infection were less common in diabetic men after implantation of an inflatable penile prosthesis (IPP) impregnated with minocycline and rifampin (M/R) versus a nonimpregnated prosthesis.

Design, setting, and participants

Infection-related revisions for M/R-impregnated and nonimpregnated implants were compared during a retrospective review of patient-implant and removal data recorded in the manufacturer's database. The data set included men with diabetes as an etiology of erectile dysfunction and who were implanted with their first IPPs between 2001 and 2008.

Intervention

All men received three-piece IPPs.

Measurements

The number of first revisions due to infection reported at any time during the study period were summarized for each group. Freedom from infection-related revisions for initial M/R-impregnated implants were compared to nonimpregnated implants with ≤84 mo of follow-up using life-table survival analysis. Infection-free survival was also compared for diabetics versus nondiabetics.

Results and limitations

Mean age was 59.1 yr for the 6071 diabetic men in the M/R-impregnated group. The nonimpregnated group included 624 diabetics with a mean age of 57.6 yr. Initial revisions due to infection were reported for 1.47% of M/R-impregnated versus 4.17% of nonimpregnated implants. At 7 yr, the rate of infection-related revisions was significantly lower for M/R-impregnated (1.62%) than for nonimpregnated implants (4.24%; log-rank p < 0.0001). Diabetic men had a significantly higher rate of revisions due to infection at 7 yr (1.88%) than men without diabetes (1.53%; log-rank p = 0.0052).

Conclusions

This long-term evidence from the largest known database of diabetic IPP recipients establishes that the use of an antibiotic-impregnated IPP can decrease revisions due to infection. Reducing the incidence of this devastating complication represents a significant medical advance in erectile restoration for diabetic patients.     

Should bariatric revisional surgery be avoided secondary to increased morbidity and mortality?

Background

Revisional bariatric surgery may be necessary due to inadequate weight loss or postoperative complications of the primary operation. We sought to identify the reasons for revision, characteristics of the surgery, and outcomes. We hypothesize that revisional surgery, although technically challenging, can produce desirable outcomes.

Methods

Patients undergoing bariatric surgery at our institution between 1998 and 2007 were reviewed from a prospective database. Patients who had revisional surgery were compared to those who had primary surgery.

Results

We have identified 46 of 1,038 patients who underwent revisional surgery. Twenty of 46 had a primary Roux-en-Y gastric bypass. The most common indication for revisions is inadequate weight loss secondary to gastrogastric fistula (15/20). Leaks occurred more frequently following revisional surgeries (11% vs 1.2%), but intensive care unit (ICU) utilization was less (11% vs 4.4%) and mortality was lower (0% vs .3%) with bariatric revision surgery.

Conclusions

Although we saw a 9-fold increase in leaks, a 2-5 fold increase in ICU utilization, and 1.5-fold increase in length of stay, our mortality rate was zero. In experienced hands, bariatric revision surgery can be performed to produce desirable outcomes.     

Six thousand three hundred sixty-one pediatric inguinal hernias: a 35-year review

Purpose

This study, by its mere size and uniformity (1 pediatric surgeon), aims to corroborate or refute the teachings and myths of the pediatric inguinal hernia.

Methods

From July 1969 to January 2004, 6361 infants and children with inguinal hernias were seen, operated on, and followed by the senior author. A retrospective survey of their charts was carried out to evaluate the demographics and clinical aspects of these patients. The hospital's research ethics board approved of this study.

Results

The ages ranged from premature to 18 years (mean age, 3.3 years) with a male-to female ratio of 5:1. There were 59% right, 29% left, and 12% bilateral hernias (almost all indirect). Hydroceles were found in 19%. Incarceration occurred in 12%. A modified Ferguson repair was used. An opposite-side hernia developed in 5%, 95% within the first 5 years, and was not sex or age specific. There were 1.2% recurrences, 96% within 5 years. Thirteen percent had ventriculo-peritoneal shunts, 1.2% wound infections, and 0.3% testicular atrophy. There were no postoperative deaths. One percent had a documented hernia disappearance.

Conclusions

Three of our results have not corresponded with previous teachings and myths: (1) a hernia of a premature baby should be fixed sooner than later; (2) routine contralateral groin exploration is not indicated in any situation; and (3) teenage recurrence rate is 4 times greater than the overall series.     

Aerobic Exercise is Associated with Improved Weight Loss after Laparoscopic Adjustable Gastric Banding

Background

Laparoscopic adjustable gastric banding (LAGB) is a common surgical treatment for obesity. Evidence for and against the association of aerobic exercise (AE) and weight loss after LAGB exists. We hypothesize that aerobic exercise is associated with improved weight loss and resolution of comorbidities after LAGB.

Methods

A review of a prospectively collected database identified patients who underwent LAGB over a 3-year period at a single institution. Body mass index (BMI), comorbidities, frequency, and duration of exercise were collected preoperatively and at 6, 12, 24, and 36 months postoperatively. Excess weight loss (EWL) was calculated. Groups were analyzed using Fisher’s exact test and ANOVA.

Results

Of the 145 LAGB patients, 120 had adequate data for analysis. AE had no association with weight loss at 6 months. At 12, 24, and 36 months following LAGB, patients who reported 150 min or more per week of exercise had an EWL of 35.5, 47.3, and 54.1 %, respectively, while those reporting 0–59 min per week of AE had an EWL of 25.3, 32.1, and 33.0 % (p?=?0.03, 0.03, and 0.02, respectively). BMI and age was not statistically different among groups. Diabetes and obstructive sleep apnea were significantly improved in patients exercising at least 60 min per week as compared to those exercising 0–59 min.

Conclusions

AE is significantly associated with weight loss and comorbidity resolution after LAGB. We propose that patients who perform more AE will have higher levels of EWL.     

Gastric band conversion to Roux-en-Y gastric bypass shows greater weight loss than conversion to sleeve gastrectomy: 5-year outcomes

Background

Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are often used as revisional surgeries for a failed laparoscopic adjustable gastric band (LAGB). There is debate over which procedure provides better long-term weight loss.

Electrogastrography in the management of pediatric functional dyspepsia and motility disorder

Purpose

Electrogastrography (EGG) is a noninvasive investigation for recording gastric myoelectrical activity. We hypothesize that children with functional dyspepsia (FD) and gastrointestinal (GI) motility disorder have abnormal gastric myoelectrical activity. We aim to study the dyspepsia symptom scores and EGG of these children and compare them with those of the normal population.

Methods

Seventeen children aged 6 to 18 years with persistent dyspepsia symptoms but with normal investigations were recruited as the FD group. Nine children with same age as the FD group with known upper GI motility disorder were recruited as the GI group. Eight normal healthy children were recruited as controls (CL). Dyspepsia symptom score (0-18) was charted, and all had EGG performed. Gastric slow wave frequency of 2 to 4 cycles per minute is defined as normogastria. Electrogastrography is regarded as abnormal when normogastria occurs in less than 70% of recorded time. Wilcoxon rank sum test and Fisher's Exact test were performed with statistical significance at P value equal to .05.

Results

Mean dyspepsia symptom score was significantly different in comparing FD and GI with CL groups (FD, 6.71; GI, 5.54; CL, 0.25; P < .001). Abnormal EGG patterns occur more often in FD than in CL (FD, 58.9%; CL, 12.5%; P = .042). Abnormal EGG patterns were found in 55.6% of GI and 12.5% of CL (P = .131).

Conclusions

Electrogastrography is a useful and noninvasive armamentarium for evaluating the abnormal myoelectrical activity in children with FD and GI motility disorder.     

Long-term results for gastric banding as salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass

Background

Studies reporting revisionary options for weight loss failure after Roux-en-Y gastric bypass (RYGB) have been underpowered and lacking long-term data. We have previously shown that short-term (12 mo) and midterm (24 mo) weight loss is achievable with laparoscopic adjustable gastric banding (LAGB) for failed RYGB. The present study represents the largest published series with longest postoperative follow-up of patients receiving salvage LAGB after RYGB failure.

Laparoscopic conversion of adjustable gastric banding and vertical banded gastroplasty to duodenal switch

BackgroundThe aim of this retrospective consecutive study was to evaluate the feasibility, safety, and efficacy of the conversion of laparoscopic adjustable gastric banding (LAGB) and open vertical banded gastroplasty (VBG) into duodenal switch (DS) by laparoscopy.MethodsFrom November 2003 to February 2007, laparoscopic conversion into DS was performed in 1-step in 43 patients, 31 after LAGB and 12 after VBG. The reason for conversion was weight loss issues, such as insufficient excess weight loss (EWL) or weight regain. The mean interval from LAGB and VBG to conversion to the DS was 42.7 ± 28.7 months and 172.2 ± 86.9 months, respectively. The mean %EWL at conversion was 8.3% ± 19.3% after LAGB and 20.8% ± 30% after VBG.ResultsThe mean operative time was 205.8 ± 44.8 minutes for LAGB and 210.9 ± 53.7 minutes for VBG. No conversions to open surgery occurred. One patient in the LAGB group died on the third postoperative day of sudden death syndrome, as shown by the postmortem examination. Major complications occurred in 6.4% of patients with LAGB (1 hemoperitoneum and 1 ileoileostomy leak) and in 50% with VBG (1 sleeve gastrectomy leak with subsequent duodenoileostomy leak, 3 duodenoileostomy leaks, 1 pancreatitis, and 1 respiratory insufficiency). The mean hospital stay was 5.5 ± 5 days for the LAGB group and 34.5 ± 50.3 days for the VBG group. After a mean follow-up of 28 ± 15.7 months for LAGB to DS and 43.5 ± 6 months for VBG to DS, reoperations for late complications were required in 6 patients (20.6%) in the LAGB to DS group and in 5 patients (62.5%) in the VBG to DS group. Three patients (25%) died within 8 months after conversion of VBG. The 29 surviving patients (LAGB to DS) showed a mean %EWL and percentage of excess body mass index loss of (%EBMIL) 78.4% ± 24.9% and 77.8% ± 23.7%, respectively. The 8 surviving patients (VBG to DS) had a mean %EWL and %EBMIL of 85.1% ± 20% and 85.8% ± 18.7%, respectively.ConclusionAccording to these results, laparoscopic conversion of LAGB to DS seems feasible and effective, despite the 1 death. However, in our hands, laparoscopic conversion of VBG to DS had an unacceptable rate of complications and deaths.     

Laparoscopic adjustable gastric banding in adolescent: safety and efficacy

Background

Obesity prevalence is rapidly increasing among children and adolescents worldwide. It is considered one of the most alarming public health issues facing the world today. The adult experience has demonstrated that surgery is the only effective means of achieving persistent weight loss in obese patients. However, little is known about bariatric surgery in children and adolescents. The aim of this study is to evaluate the safety and efficacy of laparoscopic adjustable gastric banding (LAGB) in this group of patients.

Methods

A retrospective review included all children and adolescents who underwent LAGB from January 2003 to December 2005.

Results

Fifty-one patients underwent LAGB. The mean age was 16.8 years (range, 9-19), and the mean body mass index was 49.9 kg/m² (range, 38-63). Mean excess weight loss was 42% at 6 months and 60% at 1 year follow-up. The most prevalent comorbidities were obstructive sleep apnea, limited physical activities, hypertension, and diabetes mellitus. Band adjustments were performed under fluoroscopic guidance in 5 patients and direct access as a clinic procedure in the remaining. One patient required port repositioning under fluoroscopic guidance. The mean follow-up was 16 months (range, 3-34). There was no mortality or significant postoperative complications.

Conclusion

The absence of significant nutritional deficiency, the continued adjustability, and potential reversibility of LAGB make it the safest, least invasive, and most effective bariatric surgery that can be offered to the young and adolescent population.