Revisional Surgery After Failed Vertical Banded Gastroplasty: Restoration of Vertical Banded Gastroplasty or Conversion to Gastric Bypass

Background: An increasing number of patients with a failed primary bariatric procedure present themselves for secondary treatment. Only a few studies have investigated critically the success of revisional surgery. In the present study, the effectiveness of revisional surgery for failed vertical banded gastroplasty (VBG) is analyzed: restoration of the VBG (reVBG) is compared to conversion to a Roux-en-Y gastric bypass (RYGB). Patients and Methods: From 1980 to 1996, 136 consecutive morbidly obese patients underwent primary RYGB (n = 20) or VBG (n = 16). Weight loss, indications and complications after revisional surgery were registered. The rate of revisional surgery after primary and secondary bariatric procedures was estimated by means of a Kaplan-Meier analysis. Results: Kaplan-Meier analysis revealed that 56% of the patients will eventually require revisional surgery after initial VBG over a 12-year period compared to 12% after initial RYGB (P < 0.01). After reVBG 68% will need revisional surgery over a 5-year period, while no further revisional surgery was required after conversion to a RYGB (P < 0.05). Body mass index dropped significantly after reVBG or conversion to RYGB for insufficient weight loss (P < 0.05), however, more revisional surgery was necessary after reVBG to achieve this result. The complication rate was comparable between reVBG and conversion to RYGB (33%). Conclusion: Conversion of a failed VBG to a RYGB is more effective than a reVBG, because conversion to RYGB provides satisfactory weight loss without requiring further revisional surgery.     

Long-term results after revisions of failed primary vertical banded gastroplasty

AIM: To compare the results after revision of primary vertical banded gastroplasty(Re-VBG) and conversion to sleeve gastrectomy(cS G) or gastric bypass(cR YGB).METHODS: In this retrospective single-center study, all patients with a failed VBG who underwent revisional surgery were included. Medical charts were reviewed and additional postal questionnaires were sent to update follow-up. Weight loss, postoperative complications and long-term outcome were assessed. RESULTS: A total 152 patients were included in this study, of which 21 underwent Re-VBG, 16 underwent c SG and 115 patients underwent c RYGB. Sixteen patients necessitated a second revisional procedure. No patients were lost-to-follow-up. Two patients deceased during the follow-up period, 23 patients did not return the questionnaire. Main reasons for revision were dysphagia/vomiting, weight regain and insufficient weight loss. Excess weight loss(%EWL) after Re-VBG, cS G and cR YGB was, respectively, 45%, 57% and 72%. Eighteen patients(11.8%) reported postoperative complications and 27% reported long-term complaints. CONCLUSION: In terms of additional weight loss, postoperative complaints and reintervention rate, Rouxen-Y gastric bypass seems feasible as a revision for a failed VBG.     

Perioperative and 1-year outcomes of bariatric surgery in septuagenarians: implications for patient selection

BackgroundAlthough bariatric surgery is an effective treatment for obesity, utilization of bariatric procedures in older adults remains low. Previous work reported higher morbidity in older patients undergoing bariatric surgery. However, the generalizability of these data to contemporary septuagenarians is unclear.ObjectivesWe sought to evaluate differences in 30-day outcomes, 1-year weight loss, and co-morbidity remission after bariatric surgery among 3 age groups as follows: <45 years, 45–69 years, and ≥70 years.SettingStatewide quality improvement collaborative.MethodsUsing a large quality improvement collaborative, we identified patients undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between 2006 and 2018. We used multivariable logistic regression models to evaluate the association between age cohorts and 30-day outcomes, 1-year weight loss, and co-morbidity remission.ResultsWe identified 641 septuagenarians who underwent SG (68.5%) or RYGB (31.5%). Compared with 45–69 year olds, septuagenarians had higher rates of hemorrhage (5.1% versus 3.1%; P = .045) after RYGB and higher rates of leak/perforation (.9% versus .3%; P = .044) after SG. Compared with younger patients, septuagenarians lost less of their excess weight, losing 64.8% after RYGB and 53.8% after SG. Remission rates for diabetes and obstructive sleep were similar for patients aged ≥70 years and 45–69 years.ConclusionsBariatric surgery in septuagenarians results in substantial weight loss and co-morbidity remission with an acceptable safety profile. Surgeons with self-imposed age limits should consider broadening their selection criteria to include patients ≥70 years old.     

Laparoscopic revisional surgery after Roux-en-Y gastric bypass and sleeve gastrectomy

BackgroundFailure of primary bariatric surgery is frequently due to weight recidivism, intractable gastric reflux, gastrojejunal strictures, fistulas, and malnutrition. Of these patients, 10–60% will undergo reoperative bariatric surgery, depending on the primary procedure performed. Open reoperative approaches for revision to Roux-en-Y gastric bypass (RYGB) have traditionally been advocated secondary to the perceived difficulty and safety with laparoscopic techniques. Few studies have addressed revisions after RYGB. The aim of the present study was to provide our experience regarding the safety, efficacy, and weight loss results of laparoscopic revisional surgery after previous RYGB and sleeve gastrectomy procedures.MethodsA retrospective analysis of patients who underwent laparoscopic revisional bariatric surgery for complications after previous RYGB and sleeve gastrectomy from November 2005 to May 2007 was performed. Technical revisions included isolation and transection of gastrogastric fistulas with partial gastrectomy, sleeve gastrectomy conversion to RYGB, and revision of RYGB. The data collected included the pre- and postoperative body mass index, operative time, blood loss, length of hospital stay, and intraoperative and postoperative complications.ResultsA total of 26 patients underwent laparoscopic revisional surgery. The primary operations had consisted of RYGB and sleeve gastrectomy. The complications from primary operations included gastrogastric fistulas, refractory gastroesophageal reflux disease, weight recidivism, and gastric outlet obstruction. The mean prerevision body mass index was 42 ± 10 kg/m². The average follow-up was 240 days (range 11–476). The average body mass index during follow-up was 37 ± 8 kg/m². Laparoscopic revision was successful in all but 1 patient, who required conversion to laparotomy for staple line leak. The average operating room time and estimated blood loss was 131 ± 66 minutes and 70 mL, respectively. The average hospital stay was 6 days. Three patients required surgical exploration for hemorrhage, staple line leak, and an incarcerated hernia. The overall complication rate was 23%, with a major complication rate of 11.5%. No patients died.ConclusionLaparoscopic revisional bariatric surgery after previous RYGB and sleeve gastrectomy is technically challenging but compared well in safety and efficacy with the results from open revisional procedures. Intraoperative endoscopy is a key component in performing these procedures.     

Laparoscopic Sleeve Gastrectomy as Revisional Procedure for Failed Gastric Banding and Vertical Banded Gastroplasty

Background  The problem of revision of failed gastric banding (GB) and vertical banded gastroplasty (VBG) procedures has become a common situation in bariatric surgery. Laparoscopic sleeve gastrectomy (LSG) has been recently used to revise failed restrictive procedures. The objective of this study is to evaluate the results of LSG as revisional procedure for failed GB and VBG. Methods  A prospective held database was questioned regarding patients' demographic, indication for revision, conversion to open surgery, morbidity, percentage of excess weight loss (%EWL), evolution of comorbidities, and need for a second procedure after LSG. Results  Forty-one patients, 34 women and seven men with a mean age of 42 years (range 19 to 63 years) and a mean body mass index at 49.9 kg/m² (range 35.9–63 kg/m²), underwent laparoscopic conversion of GB (36 patients) and VBG (five patients) into LSG. Indication for revisional surgery was insufficient weight loss in all the cases. All procedures were completed laparoscopically. There was no mortality and five patients (12.2%) developed complications (high leak, one patient; intra-abdominal abscess, three patients; and complicated incisional hernia, one patient). At a mean follow-up of 13.4 months, %EWL is on average 42.7% (range 4–76.1%). Six patients had a second procedure (four had laparoscopic duodenal switch, one had laparoscopic Roux-en-Y gastric bypass, and one had laparoscopic biliopancreatic diversion). Conclusion  Conversion of GB and VBG into LSG is feasible and safe. LSG is effective in the short term with a mean %EWL of 42.7% at 13.4 months. Long-term results of LSG as revisional procedure are awaited to establish its efficacy in the long term.     

Short- and Long-Term Outcomes of Vertical Banded Gastroplasty Converted to Roux-en-Y Gastric Bypass

Background

Vertical banded gastroplasty (VBG) often necessitates revisional surgery for weight regain or symptoms related to gastric outlet obstruction. Roux-en-Y gastric bypass (RYGB) is considered as the revisional procedure of choice. However, revisional bariatric surgery is associated with relatively higher rates of complications. The aim of the current study is to analyse our single-centre experience with patients requiring revisional RYGB following primary VBG.

Methods

Retrospective review of the prospectively collected database identified 153 patients who underwent RYGB as a revisional procedure after VBG from Feb 2004–Feb 2011. Early and late complications, weight data and resolution of symptoms related to gastric outlet obstruction were analysed.

Results

One hundred twenty-three females and 30 males underwent revisional RYGB post VBG. Mean age was 44.4 (15–74) years with a mean pre-operative body mass index (BMI) of 34.2 (23.5–65.5) kg/m². Mean hospital stay was 4.3 days. Early complication rate was 3.9 % with a 30-day re-operation rate of 1.3 %. Mortality and leak rate were zero. After a mean follow-up of 48 months, the mean BMI decreased significantly to 28.8 kg/m² and a complete resolution of the obstructive symptoms was achieved in nearly all patients. Late complications developed in 11 (7.7 %) of the patients of which seven (4.9 %) required surgery.

Conclusions

Revisional RYGB following VBG is technically challenging but safe with low rates of morbidity and mortality, comparable to primary RYGB. It produces a significant reduction in body weight and in symptoms resolution. We recommend RYGB as the procedure of choice in patients requiring revisional surgery following VBG.     

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.     

Adjustable gastric band placed around gastric bypass pouch as revision operation for failed gastric bypass

BackgroundThe failure rate after gastric bypass surgery for weight loss has been reported at 10–20%. To date, no reliably safe and effective salvage operation is available. This pilot study was conducted to determine whether restriction of the Roux-en-Y gastric bypass (RYGB) pouch using the adjustable gastric band (AGB) is an effective revision operation.MethodsA prospectively accrued group of patients who underwent revisional surgery using the AGB placed around the RYGB pouch by our bariatric surgical group from October 2004 to October 2006 was analyzed.ResultsOf the 10 patients accrued during this period, 2 were lost to follow-up, leaving 8 patients for analysis. Of the 8 patients, 1 was a man and 7 were women. The mean prerevision weight was 135.75 kg (range 105–165), and the body mass index was 48.42 kg/m² (range 38.92–55). The mean weight loss at 1 year of follow-up was 17.03 kg (range 0.2–42), with a mean percentage of excess weight loss of 24.29% (range 0.2–49.2%). The mean weight loss of the 5 patients with 2 years of follow-up was 36.4 kg (range 20–58), with a mean percentage of excess weight loss of 48.7% (range 21.8–98.1%). One patient with 3 years of follow-up had a weight loss of 56 kg and a percentage of excess weight loss of 66.2%. Three minor complications developed: 2 AGB port-related complications requiring port revision and 1 postoperative wound hematoma requiring evacuation. No band erosions or band slippages occurred, and no major complications developed.ConclusionIn our study, an AGB placed around the RYGB pouch was a safe and effective revision operation for a failed RYGB operation.     

Operative technique for converting a failed vertical banded gastroplasty to Roux-en-Y gastric bypass

BACKGROUND: Bariatric surgeons are increasingly encountering patients with failed weight-loss operations. Conversion from vertical banded gastroplasty (VBG) to Roux-en-Y gastric bypass (RYGB) is the most common revisional operation in our practice. We reviewed our experience in converting from VBG to RYGB using a basic five-step surgical technique. STUDY DESIGN: We reviewed data on all patients undergoing revisional surgery for failed VBG, defined as patients with body mass index >/=35 kg/m(2), weight gain, poor control of comorbidities, staple-line dehiscence, or band-specific complications. The five basic steps include identification of the band, delineation of the extent of the pouch, division of the stomach, preparation of the Roux limb, and completion of the cardiojejunostomy. RESULTS: We have undertaken 28 conversions from VBG to RYGB. Median age was 51 years (range 27 to 65 years), preoperative body mass index was 40 kg/m(2) (range 20 to 58 kg/m(2)), and 25 patients (89%) were women. Indications for revision were band-related complications (13 patients), staple-line disruption (9 patients), and inadequate weight loss (6 patients). Median operative time was 185 minutes (range 105 to 465 minutes), estimated blood loss was 450 mL (range 100 to 2,500 mL), postoperative complications occurred in 6 patients (21%), and length of hospitalization was 5 days (range 3 to 69 days). Median postoperative body mass index was 32 kg/m(2) (range 20 to 41 kg/m(2)) at a followup time of 16 months (range 1 to 32 months). CONCLUSIONS: The technique described facilitates the operative approach to patients with failed VBG, providing guidelines for safe dissection and division of the gastric pouch for conversion to RYGB. Revisional bariatric operations are technically difficult and are associated with relatively higher complication rates than those reported for primary operations.     

Bariatric revisional surgery for gastrogastric fistula following Roux-en-Y gastric bypass positively impacts weight loss

BackgroundGastrogastric fistula (GGF) is a rare complication from Roux-en-Y gastric bypass (RYGB). It is a known risk factor associated with weight recidivism and an indication for Bariatric Revisional Surgery (BRS).ObjectivesThe primary outcome of this study is to evaluate perioperative outcomes and the long-term total body weight loss (TBWL) outcomes following revision.SettingSingle Academic Institution, Center of Bariatric Excellence.MethodsWe selected patients who had primary bariatric surgery and BRS from 2003 to 2020, followed by BRS for GGF. Patients’ demographics, perioperative outcomes, and TBWL were analyzed.ResultsOne hundred five patients underwent BRS for GGF. Mean body mass index (BMI) at index operation and revision was 51.6 ± 10.1, and 42.4 ± 11.2 respectively. Ninety percent of patients had open primary RYGB, and 69% had open revisional surgery. The median length of stay after BRS was 3 days. The 30-day reintervention rate was 19%. The 30-day readmission rate was 34%. Of the 77 patients included for weight loss analysis, the mean %TBWL after primary RYGB was 34% ± 14. The total mean %TBWL at the time of revision was 18.8%, translating into a weight regain of 13.6% ± 9.5. The total mean %TBWL after revision was 37.6% ± 11.4, translating into TBWL of 18.8% ± 9.4 after revision when compared to TBWL at revision time.ConclusionsOur results demonstrate that revision for GGF can be safely performed, however is associated with higher morbidity than primary bariatric surgery. Revision for GGF results in significant long-term weight loss.     

Revision of Mason’s procedure (vertical banded gastroplasty) to Roux-en-Y gastric bypass: role of an associated fundectomy in weight loss outcomes

BackgroundVertical banded gastroplasty (VBG) presents a significant rate of long-term complications, and revisions are often necessary. Conversion to Roux-en-Y gastric bypass (RYGB) seems to be preferred, but literature data remain limited.ObjectivesTo analyze the indications, safety, results of conversions from VBG to RYGB, and to identify predictive factors of success or failure.SettingTwo specialized centers of bariatric surgery.MethodsThis bicentric retrospective study included all the patients who benefited from a conversion from VBG to RYGB between 2008 and January 2020. Demographic characteristics, indications, preoperative workups, intraoperative data, complications, and weight loss results were analyzed.ResultsDuring the study period, 85 patients underwent a conversion to RYGB. The mean body mass index (BMI_ before conversion was 40.6 kg/m². 82.3% of the patients were converted because of weight loss failure and 17.6% because of a complication of their VBG. The global rate of complications was 25%. After an average follow-up of 35 months and a rate of loss to follow-up of 33%, the mean BMI was 33.5 kg/m. The weight loss success rate according to Reinhold’s criteria was 64.7%, and resolution of complications was obtained in 89.1%. The association of a fundectomy was a predictive factor of weight loss (odds ratio, .27; P = .04), whereas primary failure of the VBG was a predictive factor of failure.ConclusionConversion from VBG to RYGB remains the procedure of choice to achieve satisfying weight loss and resolution of functional complications. The addition of a fundectomy appeared to have a significant positive impact on weight loss outcomes.     

Revision of Failed Vertical Banded Gastroplasty to Non-resectional Scopinaro Biliopancreatic Diversion: Early Experience

Background: The most commonly performed revision operation following failed vertical banded gastroplasty (VBG) is Roux-en-Y gastric bypass, although revision to biliopancreatic diversion (BPD) with duodenal switch is now another common option. We describe the surgical technique for revision of a failed VBG to a non-resectional Scopinaro BPD in a series of patients, as well as the outcome in terms of complications and mean % excess weight loss (%EWL). Methods: A retrospective review was conducted on all patients who underwent revision to BPD at Mercy Bariatrics, Western Australia, between June 2001 and April 2005. This yielded 20 patients who had revision to BPD, 9 of whom had VBG as their initial operation. The mean %EWL was measured at regular intervals postoperatively (3, 6, 12, and 24 months). Results: Mean %EWL at 12 and 24 months was 69.5 and 76.7, respectively. These results are comparable to %EWL after a primary BPD. Nutritional manifestations were found to be the most common of the minor complications. Conclusion: Our technique for revision of a failed restrictive operation to a non-resectional Scopinaro BPD is described. The preliminary results in terms of %EWL and complications are comparable to other revisional malabsorptive operations. Prospective randomized controlled trials are needed to further evaluate effects of revision to a non-resectional Scopinaro BPD and to ensure that the results (in terms of %EWL) are reproducible.     

Revisional Surgery for Failed Vertical-Banded Gastroplasty

Vertical-banded gastroplasty (VBG) was once a common bariatric procedure. It has fallen out of favor due to the emergence of the adjustable gastric band and late complications including band erosion and stenosis. Options for revision include conversion to a Roux-en-Y gastric bypass (RYGB) or VBG reversal via gastrogastrostomy. Patients undergoing revision of a previous VBG were identified. VBG reversal was performed laparoscopically. Conversion to RYGB was performed by both laparotomy and laparoscopy. Perioperative outcomes and long-term weight loss were evaluated. A total of 34 patients with a previous open VBG underwent revision over a nearly 8-year period (January 2003 to September 2010). Conversion to RYGB was performed in 25 (four laparoscopically) and VBG reversal in nine patients. Mean age for all patients was 56.3 years (range 36–70), and VBG had been performed 23 years previously (range 16–30). Patients to undergo VBG reversal were more likely to be male and less likely to be morbidly obese at the time of revision. Operative time and length of stay were shorter for laparoscopic procedures. Complication rates did not differ based on technique or procedure. Patients with a previous VBG may present with complications and obesity decades after the primary procedure. Revisional surgery can be accomplished laparoscopically. Following VBG reversal, most patients gain weight and many become morbidly obese again. Conversion to RYGB is associated with weight loss and resolution of morbid obesity in most patients. When feasible, laparoscopic conversion to RYGB may offer the best outcomes.     

One-year weight loss after primary or revisional Roux-en-Y gastric bypass for failed adjustable gastric banding

BackgroundAdjustable gastric banding has been widely used in Europe, but recently gastric bypass (Roux-en-Y gastric bypass [RYGB]) has become the procedure of choice. With a gastric banding failure rate of nearly 40% at 5 years, the need for revisional surgery is increasing. The effect of a failed previous bariatric surgery on the weight loss curve after RYGB is still a controversial issue.MethodsA total of 259 patients underwent RYGB from 2003 to 2007, 58 after failed gastric banding and 201 as primary surgery. All the procedures were laparoscopically performed by the same surgeon at a single institution. The postoperative course and the percentage of excess weight loss were compared between the 2 groups.ResultsThe 2 groups were similar in age and initial body mass index (46.3 ± 7.2 kg/m² for revision versus 47.7 ± 6.7 kg/m² for primary RYGB). In contrast, the prerevision body mass index was 43.2 ± 7.0 kg/m². Revisional RYGB required a significantly longer operative time (128.3 ± 25.9 minutes versus 89.0 ± 14.7 minutes, P <.0001) and the morbidity was greater (8.6% versus 5.5%), but no patient died in the postoperative period after revision. As determined from the initial body mass index, the 1-year percentage of excess weight loss was comparable between the 2 groups (66.1% ± 26.8% and 70.4% ± 18.9%).ConclusionWhen RYGB is performed after an adjustable gastric band failure to restore weight loss or because of a complication, the weight loss curve is similar to that after primary RYGB. Therefore, the strategy of adjustable gastric banding first is an option that does not seem to preclude satisfactory weight loss after revision to RYGB.     

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.     

Revisional bariatric surgery for failed restrictive procedures

BackgroundRevisional bariatric surgery is increasing in frequency, but the morbidity and efficacy have not been well defined. The primary aim of this study was to determine the clinical efficacy with respect to weight loss, and associated morbidity, of revisional bariatric surgery in an academic university hospital bariatric surgery program.MethodsA retrospective review of all patients who underwent revisional bariatric surgery for failed primary restrictive procedures, including gastroplasty and gastric bypass, but not including gastric banding or malabsorptive procedures, during a 10-year period at a single university hospital was performed. The perioperative morbidity and long-term weight loss and clinical results were determined from the medical charts.ResultsA total of 41 patients met the inclusion criteria. The primary bariatric procedures included vertical banded gastroplasty in 20 and Roux-en-Y gastric bypass in 21. The indications for revisional surgery included poor weight loss, weight regain, and various technical problems, including anastomotic stenosis and ulcer. The major morbidity rate was 17%. No patients died. The weight loss results varied depending on the indication for the revisional surgery and reoperative solution applied. The resolution of technical problems was achieved in all patients.ConclusionRevisional bariatric surgery can be performed with minimal mortality, albeit significant morbidity. The efficacy with respect to weight loss appeared acceptable, although the results were not as good as those after primary bariatric surgery. The analysis of patient subsets stratified by surgical history and revisional strategy provided important insights into the mechanisms of failure and efficacy of different revisional strategies.     

Conversion from one-anastomosis gastric bypass to Roux-en-Y gastric bypass: when and why—a single-center experience of all consecutive OAGB procedures

BackgroundOne-anastomosis gastric bypass (OAGB) is a well-established treatment method in patients with morbid obesity. Its long-term impact on de novo reflux, anastomotic complications, and malnutrition needs further evaluation. Roux-en-Y gastric bypass (RYGB) is a technically feasible procedure in revisional bariatric surgery. This study presents our institutional data on conversion from OAGB to RYGB.ObjectiveTo determine the reasons for conversion, preoperative endoscopic findings, and feasibility of revisional bariatric surgery after OAGB.SettingUniversity hospital in AustriaMethodsRetrospective analysis of a prospectively fed database. All patients undergoing OAGB between January 2012 and December 2019 were included. Screening was carried out for all patients needing conversion to RYGB. Percent total weight loss, percent excess weight loss, time to conversion, postoperative complications, and reasons for conversion were assessed.ResultsEighty-two of 1,025 patients who underwent OAGB were converted laparoscopically to RYGB. Seven patients were converted early because of anastomotic/gastric tube leakage. Median time to late conversion was 29.1 ± 24.3 months, mean percent excess weight loss was 86.6% ± 33.1% and percent total weight loss was 35.1% ± 13.5%. Forty-two patients were converted because of reflux, 11 because of persistent marginal ulcers, 10 because of anastomotic stenosis, 9 because of malnutrition, and 3 because of weight regain. Seven patients showed Barrett’s metaplasia in biopsies at the gastroesophageal junction before conversion.ConclusionLaparoscopic conversion from OAGB to RYGB is technically feasible with a moderate rate of postoperative complications. Severe (bile) reflux is a serious long-term complication after OAGB, with 4.1% of patients needing conversion to RYGB. Endoscopy after OAGB in patients showing clinical symptoms of gastroesophageal reflux disease is strongly advised to detect underlying pathologic changes.     

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

BackgroundLaparoscopic sleeve gastrectomy (SG) is one of the most commonly performed bariatric procedure worldwide. There is currently no consensus on which revisional procedure is best after an initial SG.ObjectivesTo compare the efficacy and safety between single-anastomosis duodeno-ileal bypass (SADI) or biliopancreatic diversion with duodenal switch (BPD-DS) versus Roux-en-Y gastric bypass (RYGB) as a revisional procedure for SG.SettingUniversity Hospital, Canada.MethodsMEDLINE, Embase, Cochrane Central Register of Controlled Trials, and PubMed were searched up to August 2018. Studies were eligible for inclusion if they compared SADI or BPD-DS with RYGB as a revisional bariatric procedure for SG. Primary outcome was absolute percentage of total weight loss. Secondary outcomes were length of stay, adverse events, and improvement or resolution of co-morbidities (diabetes, hypertension, or hypercholesterolemia). Pooled mean differences were calculated using random effects meta-analysis.ResultsSix retrospective cohort studies involving 377 patients met the inclusion criteria. The SADI/BPD-DS group achieved a significantly higher percentage of total weight loss compared with RYGB by 10.22% (95% confidence interval, ?17.46 to ?2.97; P = .006). However, there was significant baseline equivalence bias with 4 studies reporting higher initial body mass index (BMI) in the SADI/BPD-DS group. There were no significant differences in length of stay, adverse events, or improvement of co-morbidities between the 2 groups.ConclusionSADI, BPD-DS, and RYGB are safe and efficacious revisional surgeries for SG. Both SADI and RYGB are efficacious in lowering initial BMI but there is more evidence for excellent weight loss outcomes with the conversion to BPD-DS when the starting BMI is high. Further randomized trials are required for definitive conclusions.     

Results of Bariatric Surgery for Morbid Obesity in Patients Older than 50 Years

Background: Surgery is increasingly used for weight loss in morbidly obese patients. The authors evaluated the safety and efficacy of bariatric surgery in patients older than 50 years. Methods: Prospective data on 62 consecutive patients (Male = 13, Female = 49) undergoing bariatric procedures between 1985-1994 were reviewed. Mean followup was 30 ± 2 months (3-48 months). All data are mean ± sem. Results: Age was 57 ± 1 year (range 50-71 years). Patients had a mean preoperative weight of 125 ± 4 kg (275 ± 9 lb) and 119 ± 6% excess body weight. A total of 68 procedures were performed: vertical banded gastroplasty (VBG = 23), Roux-en-Y gastric bypass (RYGB = 43), and biliopancreatic diversion (BPD = 2). Six patients were converted to RYGB (5) and BPD (1) after failed VBG. Hospital mortality was nil. Complications were wound infection (5), pulmonary (4), gastric leak (2), abscess (1) and others (4). Mean weight loss at 3 years was 55 ± 7 and 33 ± 6% of percent excess body weight for RYGB and VBG, respectively. Postoperative use of medications for arthritis, diabetes mellitus and asthma was reduced by 23%, 62% and 100%, respectively. Satisfaction with the outcome of treatment and weight loss was reported by 81% of patients. Six patients that were converted from jejunoileal bypass (metabolic complications) to VBG gained weight. Conclusions: Bariatric surgery is safe and well tolerated in morbidly obese patients older than 50 years. Weight loss parallels that of younger populations and is greater in patients treated with RYGB in this subgroup. Age should not be a contraindication to bariatric surgery provided the patient has obesity-related medical morbidity. Control of obesity-related co-morbid conditions is improved by weight loss.     

Vertical Banded Gastroplasty Versus Standard or Distal Roux-en-Y Gastric Bypass Based on Specific Selection Criteria in the Morbidly Obese: Preliminary Results

Background: Predicting successful outcomes after bariatric surgical procedures has been difficult, and the establishment of specific selection criteria has been a subject of ongoing research. In an effort to choose the most appropriate surgical procedure for each patient, we have established a specific set of selection criteria for each procedure based on degree of obesity, preoperative dietary habits, eating behavior, and various metabolic features. Methods: From June 1994 to December 1998, 90 bariatric surgical procedures were performed at the authors' institution by a single surgeon (F.K.) based on specific selection criteria. Vertical banded gastroplasty (VBG) was performed in 35 patients, standard Roux-en-Y gastric bypass (RYGB) in 38 patients, and distal RYGB in 17 patients. All patients were monitored postoperatively 1, 3, 6, and 12 months and once per year thereafter, with an additional visit at 18 months in distal RYGB patients. Results: Early postoperative morbidity (<30 days) did not differ significantly between the three groups and averaged 9% of total patients. Long-term postoperative morbidity (>30 days) included 9 incisional hernias (2 in the VBG group, 5 after RYGB, and 2 in the distal RYGB group). There were 6 cases of staple-line disruption, 4 after VBG and 2 after standard RYGB, 1 of which resulted in stomal ulcer. Early postoperative mortality was 0%, and long-term mortality was 1.1%, which was due to pulmonary embolism in 1 standard RYGB patient on the 65th postoperative day. Average percentage of excess weight loss (%EWL) was 62% the first year, 61% the second year, and 50% the third year in VBG patients, and 63.6%, 65%, and 63.3%, respectively, in standard RYGB patients. In distal RYGB patients, where the patient number was significantly smaller, the %EWL at 1 and 2 years, respectively, was 51% and 53%. The most significant metabolic/nutritional complication was the appearance of hypoproteinemia (hypoalbuminemia) in 1 distal RYGB patient 20 months after surgery, which was corrected by total parenteral nutrition and subsequent increase in dietary protein intake. Significant improvement or resolution of pre-existing comorbid conditions was observed in all patient groups. The postoperative quality of eating, as evaluated by variety of food intake and frequency of vomiting, was significantly better in RYGB patients. Conclusions: These results show that selection of the bariatric surgical procedure to be performed in each patient based on specific criteria leads to acceptable weight loss, improvement in preexisting comorbid conditions, and a high degree of patient satisfaction in most patients. On the basis of our own observations as well as those of others, our selection criteria have become more strict over time and our selection of VBG as the operation of choice increasingly infrequent.