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.     

Revisional Bariatric Surgery for Unsuccessful Weight Loss and Complications

Background

There are growing numbers of patients who require revisional bariatric surgery due to the undesirable results of their primary procedures. The aim of this study was to review our experience with bariatric patients undergoing revisional surgery.

Methods

We conducted a retrospective analysis to review the indications for revisional bariatric procedures and assess their postoperative outcomes.

Results

From 04/04 to 01/11, 2,918 patients underwent bariatric surgery at our institution. A total of 154 patients (5.3 %) of these cases were coded as revisional procedures. The mean age at revision was 49.1?±?11.3 and the mean BMI was 44.0?±?13.7 kg/m². Revisional surgery was performed laparoscopically in 121 patients (78.6 %). Laparoscopic revisions had less blood loss, shorter length of hospital stay, and fewer complications compared to open revisions. Two groups (A and B) were defined by the indication for revision: patients with unsuccessful weight loss (group A, n?=?106) and patients with complications of their primary procedures (group B, n?=?48). In group A, 74.5 % of the patients were revised to a bypass procedure and 25.5 % to a restrictive procedure. Mean excess weight loss was 53.7?±?29.3 % after revision of primary restrictive procedures and 37.6?±?35.1 % after revision of bypass procedures at >1-year follow-up (p?<?0.05). In group B, the complications prompting revision were effectively treated by revisional surgery.

Conclusions

Revisional bariatric surgery effectively treated the undesirable results from primary bariatric surgery. Laparoscopic revisional surgery can be performed after both failed open and laparoscopic bariatric procedures without a prohibitive complication rate. Carefully selected patients undergoing revision for weight regain have satisfactory additional weight loss.     

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.     

Revisional bariatric surgery: perioperative morbidity is determined by type of procedure

Background

Revisional bariatric procedures are on the rise. The higher complexity of these procedures has been reported to lead to increased risk of complications. The objective of our study was to compare the perioperative risk profile of revisional bariatric surgery with primary bariatric surgery in our experience.

Methods

A prospectively maintained database of all patients undergoing bariatric surgery by three fellowship-trained bariatric surgeons from June 2005 to January 2013 at a center of excellence was reviewed. Patient demographics, type of initial and revisional operation, number of prior gastric surgeries, indications for revision, postoperative morbidity and mortality, length of stay, 30-day readmissions, and reoperations were recorded. These outcomes were compared between revisional and primary procedures by the Mann–Whitney or Chi square tests.

Results

Of 1,556 patients undergoing bariatric surgery, 102 patients (6.5 %) underwent revisional procedures during the study period. Indications for revisions included inadequate weight loss in 67, failed fundoplications with recurrent gastroesophageal reflux disease in 29, and other in 6 cases. Revisional bariatric procedures belonged into four categories: band to sleeve gastrectomy (n = 23), band to Roux-en-Y gastric bypass (n = 25), fundoplication to bypass (n = 29), and other (n = 25). Revisional procedures were associated with higher rates of readmissions and overall morbidity but no differences in leak rates and mortality compared with primary procedures. Band revisions had similar length of stay with primary procedures and had fewer complications compared with other revisions. Patients undergoing fundoplication to bypass revisions were older, had a higher number of prior gastric procedures, and the highest morbidity (40 %) and reoperation (20 %) rates.

Conclusions

In experienced hands, many revisional bariatric procedures can be accomplished safely, with excellent perioperative outcomes that are similar to primary procedures. As the complexity of the revisional procedure and number of prior surgeries increases, however, so does the perioperative morbidity, with fundoplication revisions to gastric bypass representing the highest risk group.     

A two-decade spectrum of revisional bariatric surgery at a tertiary referral center.

BACKGROUND: Ineffective weight loss or complications of previous bariatric surgery often require revisional bariatric procedures. Our aim was to define the indications, operative approach, and outcomes of revisional bariatric procedures during 2 decades at a tertiary center. METHODS: From our prospective database (n = 1584), including 1985-2004, 218 patients (14%) underwent revisional bariatric procedures. Follow-up (mean 7 yr, range 1 mo to 19 yr) data obtained from patient records and questionnaires were current for 98%. Patients were grouped according to operative indications: group 1, unsatisfactory weight loss (n = 97); group 2, mechanical/symptomatic complications (n = 95); and group 3, severe nutritional/metabolic problems (n = 26). RESULTS: The operative mortality rate was 0.9% (1 case each of pulmonary embolus and cardiac arrest). The serious operative morbidity rate was 26% (wound infection in 13%, leak in 3%, pulmonary embolus in 2%, anemia/hemorrhage in 2%, pneumonia/prolonged ventilation in 2%, and other in 4%). Of the 218 patients, 94% underwent conversion to, or revision of, Roux-en-y gastric bypass. Group 1 achieved substantial weight reduction with a mean body mass index from 51 +/- 1 to 38 +/- 1 kg/m(2), the complications resolved in 88% of group 2, and the nutritional/metabolic problems resolved in 79% of group 3. Patients who underwent revisional surgery 1990 were more likely to present with mechanical/symptomatic/metabolic complications than for unsuccessful weight loss (P <.001). CONCLUSIONS: Revisional bariatric surgery is safe and effective in experienced centers. Complications (mechanical/symptomatic/nutritional) or unsatisfactory weight loss after primary bariatric procedures can be treated effectively with revision to Roux-en-y gastric bypass.     

Impact of technological advances on complications of revisional bariatric operations

BACKGROUND: Revisional bariatric operations are technically challenging and are associated with a high perioperative complication rate. Several parameters were analyzed to determine whether experience, coupled with technical innovation, reduced complications after these high-risk procedures. STUDY DESIGN: Outcomes of 215 consecutive revisional bariatric operations performed by 1 surgeon during the past 22 years were assessed before and after routine use of 6-row endostaplers and harmonic scalpel, which began in 2001. RESULTS: All but 3 operations were performed open, including 151 for weight loss failure (14 jejunoileal bypass, 71 gastroplasty or banding, 66 gastric bypass) and 64 for complications of the primary procedure (12 jejunoileal bypass, 11 gastroplasty or banding, 41 gastric bypass). Major perioperative complications occurred in 45 patients (21%): there were 15 leaks, 11 wound infections, 3 pulmonary embolisms, and 16 miscellaneous, including 3 deaths (1.4%). Morbidity after January 2001 was 6 of 73 (8.2%) versus 39 of 138 (28%) before 2001 (p < 0.0005). All deaths occurred before 2001. Complications occurred in 10 of 97 patients (10.3%) who had primary gastric restrictive operations (excluding banding) by the author versus 24 of 65 patients (36.9%) who had similar primary operations by other surgeons (p < 0.0001). Morbidity after second revisions was 70% versus 14.4% after first revisions (p < 0.0001). The 32 most recent patients were discharged in a mean of 3.0 days without complications. CONCLUSIONS: Incorporating the endostaplers and harmonic scalpel into open revisional operations significantly reduced postoperative complications. Because these 2 devices were introduced during the last 5 years of this study, it seems likely that cumulative experience also contributed to improved outcomes. Our results also suggest that surgeons perform their initial revisions on their own patients rather than on patients who had primary procedures elsewhere. Patients presenting as candidates for a second revision should be cautiously evaluated, anticipating a high morbidity rate.     

Outcome following resectional gastric bypass for failed bariatric surgery

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

Comparison of robotic revisional weight loss surgery and laparoscopic revisional weight loss surgery using the MBSAQIP database

BackgroundThe most common bariatric operation in the United States is sleeve gastrectomy. The second and third most common bariatric operations are gastric bypass and revisional bariatric surgery, respectively.ObjectiveThe objective of the study was to assess the differences between laparoscopic revisional weight loss surgery (LRWLS) and robotic revisional weight loss surgery (RRWLS).SettingUniversity hospital, United States.MethodsData were extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database spanning 2015 to 2016 to look at demographic characteristics, operative time, co-morbidities, and length of stay. Using the specified Current Procedural Terminology codes, patients who underwent bariatric procedures and required a revisional procedure were identified.ResultsA total of 354,865 patients were included in this study; 37,917 (11.9%) patients required revision after undergoing a bariatric procedure. Of these revisions, 94.9% (n = 35,988) were LRWLS, and 5.1% (n = 1929) were RRWLS. There were no differences in patient characteristics between the LRWLS and RRWLS groups. There was a significant difference between the RRWLS and the LRWLS groups in operative time, with the RRWLS group taking 167 minutes and the LRWLS group taking 103 minutes (P < .001). There was a statistically significant increase in length of stay for RRWLS, 2.3 days versus 1.7 for LRWLS (P < .005). In terms of postoperative complications, there were no significant differences between the 2 groups.ConclusionsRRWLS is as safe as LRWLS in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. There is an increase in operative times and length of stay for robotic cases.     

Revisional Bariatric Surgery

Background  Revisional surgery is required in a significant number of patients because of failure to lose weight, loss of quality of life, weight regain, or complications of the previous procedure. It has traditionally been associated with higher complication rates, and there appears to be no standardized surgical approach to revisional surgery. The aim of the study was to review the revisional procedures performed at St George Private Hospital and analyze the outcomes of the different types of revisional surgery. Methods   We performed a retrospective review of 75 patients who underwent revisional surgery between December 2003 and October 2007. Demographic, anthropometric, perioperative, and clinical follow-up data were collected, and statistical analyses were performed using SPSS version 14.0. Results  Sixty-six of the 75 patients were female. The mean age at the time of revision was 46.32 (22–68) years. Mean initial weight was 119.08 kg, and body mass index (BMI) was 43.42 kg/m². The lowest BMI and excess weight loss (EWL) recorded after primary surgery was 36.9% and 53.5%, respectively. At the time of revision, the mean EWL was 24.79. The EWL at 3 months and 6 months were 41.7% and 47.8%, respectively. Revision was performed laparoscopically in 51 patients and via laparotomy in 24 patients. There was no mortality in the cohort, but there were 17.3% minor and 4.0% major perioperative morbidities. Conclusion  Our study suggests that revision can be performed safely. Weight loss is satisfactory, and complications of the previous operations were all reversed. Furthermore, revisions may be done laparoscopically, including those who had previous open procedures.     

Revision of Failed Gastric Restrictive Operations to Roux-en-Y Gastric Bypass: Impact of Multiple Prior Bariatric Operations on Outcome

Background: Morbid obesity is now an epidemic with considerable associated morbidity for which bariatric surgery has been the only effective treatment. Despite its success, occasional patients require revision because of weight regain or mechanical complications. The impact of multiple prior bariatric operations on complications and weight loss after revision to Roux-en-Y gastric bypass (RYGBP) was evaluated. Methods: All patients undergoing revisional surgery to RYGBP by the senior author from 1997 through 2004 were retrospectively reviewed at a multi-center academic institution. Patients who had previously undergone multiple revisional operations (MR) were compared to patients who had undergone primary ("first-time") revision (PR). Demographics, indications for revision, complications, and weight loss were reviewed. Results: 66 patients underwent open revision to RYGBP after failed bariatric operations, with 12 in the MR group and 54 in the PR group. Mean preoperative BMI was 46.1 and 45.2 (P=0.8), respectively. Operative time (227 vs 162 min, P=0.07), blood loss (517 vs 313 ml, P=0.09) and hospital length of stay (11.5 vs 6.7 days, P=0.2) were higher in the MR group. Major perioperative complications occurred in 16.7% of MR patients compared to 9.3% of PR patients (P=0.6). Percent of excess weight loss (%EWL) has been 54.3% in the MR group and 60.6% in the PR group (P=0.6). Average follow-up is 26 and 23 months, respectively. Conclusion: Although operative times, blood loss, and LOS were greater in MR patients, RYGBP can be performed in patients with multiple previous bariatric operations with acceptable weight loss and complication rates.     

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.     

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.     

Surgical revision of loop ("mini") gastric bypass procedure: multicenter review of complications and conversions to Roux-en-Y gastric bypass.

BACKGROUND: The claim that the "mini"-gastric bypass (MGB) procedure with its loop gastrojejunostomy is safer and equally effective to the Roux-en-Y gastric bypass (RYGB) procedure has been promoted before validation. Rumors of unreported complications and the accuracy of follow-up are additional concerns. This study was undertaken to identify MGB patients who require or required revisional surgery at 5 hospitals within the region of the United States where the MGB procedure originated to assess the claim that revision to RYGB is rarely needed. METHODS: The databases of 5 medical centers were retrospectively searched to identify patients undergoing surgical revision after a MGB procedure, all of which had been done elsewhere. RESULTS: A total of 32 patients were identified who presented with complications after undergoing an MGB procedure and required or require revisional surgery. The complications included gastrojejunostomy leak in 3, bile reflux in 20, intractable marginal ulcer in 5, malabsorption/malnutrition in 8, and weight gain in 2. Of the 32 patients, 21 required conversion to RYGB and an additional 5 have planned revisions in the future. Also, 2 patients were treated with Braun enteroenterostomies and 4 required 1 or more abdominal explorations. CONCLUSIONS: The results of this preliminary review have confirmed that MGB does require revision in some patients and that conversion to RYGB is a common form of revision. A national registry to record the complications and number of revisions is proposed to gain insight into the need for revision after MGB and other nontraditional bariatric procedures.     

Adding malabsorption for weight loss failure after gastric bypass

Objective To present a technique of revisional RY gastric bypass in patients with unsatisfactory weight loss after primary gastric bariatric operations. Methods The Roux limb was lengthened by creating a 75–100 cm common channel below the enteroenterostomy with concomitant revision of the gastrojejunostomy. Results Fifty-four patients had this distal modification of RYGB including 47 patients who had primary gastric bypass and 7 patients who failed pure restrictive operations. Mean excess weight loss was 47.9% in patients followed for ≥1 year. Conclusions This distal modification of RYGB resulted in satisfactory weight loss for nearly half of the 54 patients in this series.     

修正手术在减重手术治疗失败及并发症中的应用

对于绝大多数病态性肥胖患者,手术治疗至今仍然是唯一被证明有效并保持体质量丢失的办法.目前公认减重效果良好、安全可靠且应用较广泛的术式为可调节胃束带手术（AGB）、袖状胃切除术（SG）和Roux-en-Y胃旁路术（RYGB）.随着减重手术需求的增加,由于初次减重手术治疗效果不理想而要求修正手术的患者数量也随之增多.减重失败和术后并发症是进行修正手术的两个最主要的原因.一系列数据说明,修正手术对于不成功的体质量和初次手术引起的并发症是有效的治疗措施.需要根据初次减重手术的方式和结果来选择合理的修正手术.修正手术对于大部分患者而言,其获益大于风险.     

Duodenal Switch is a Safe Operation for Patients who have Failed Other Bariatric Operations

Background: The incidence of morbid obesity and its surgical treatment have been increasing over the last few years. With this increase, there has been a rise in the number of patients who have had less than desirable outcome after bariatric operations. We perform the duodenal switch (DS) in patients for whom other weight loss surgical procedures have failed, because of inadequate weight loss, weight regain or significant complications, such as solid intolerance or dumping syndrome. Method: From November 1999 to March 2004, 46 revisional surgeries were performed at our institution. The data was prospectively collected and reviewed, based on a number of parameters. Operative details, perioperative morbidity, and results are reported. Results: 46 patients had their original bariatric surgical operation revised to DS. This resulted in complete resolution of their presenting complaints. The %EWL was 69% at the time of publication, with a mean lapsed time of 30 months. We had no mortality. Anastomotic leak occurred in 4 patients, 2 in our first 8 patients. We also noted that the majority of the patients were not aware of all the surgical procedures available to them at the time of their original operation. Conclusion: In patients in whom gastroplasty, gastric bypass or both have failed to provide adequate weight loss, or worse have resulted in complications, DS can be performed as a safe revisional operation. The revision of other failed bariatric operations to DS results in both weight loss and resolution of the complications.     

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.     

Laparoscopic revision of bariatric procedures: is it feasible?

Reoperative bariatric surgery is required in 10 per cent to 20 per cent of patients secondary to weight regain or complications of the previous procedure. This study evaluates the feasibility of performing the revision procedure laparoscopically. A retrospective review of all patients undergoing revision of a previous weight loss procedure between October 1998 and November 2003 was conducted. Demographics, indications for surgery, operative findings, and complications were reviewed. Thirty-nine revisions were performed in 37 patients. Indications for revision were failure to lose weight (22), gastric outlet stricture (10), refractory gastroesophageal reflux (GERD) (6), and blind loop syndrome (1). All 39 procedures were revised to Roux-en-Y gastric bypass (RYGBP), with 18 open revisions (OR) and 21 laparoscopic revisions (LR). Ten of the 21 LR (48%) were converted to an open procedure due to adhesions or unclear anatomy. Early complications requiring operation were noted in five procedures (two OR, three LR). Nine patients (seven OR, two LR) required surgery at least 3 months following their revision. One patient died (LR). The difference in body mass index (kg/m2) (BMI) pre- and post-op was 43.3+/-9.9 versus 37.4+/-9.2, P = 0.01 (follow-up 5 months), but no significant BMI differences between LR and OR patients were seen. Revisional bariatric surgery is associated with more complications requiring surgery early in the laparoscopic population versus more late complications in those approached open. Revisional bariatric surgery can be approached laparoscopically and with acceptable morbidity comparable to patients whose revision is approached open.     

Analysis of the risk factors for perioperative morbidity after laparoscopic revisional bariatric procedures: results from the multicenter Polish Revision Obesity Surgery Study

BackgroundThe growing number of primary bariatric operations has led to an increase in demand for revision surgeries. Higher numbers of revisional operations are also observed in Poland, yet their safety and efficacy remain controversial because of a lack of current recommendations and guidelines.ObjectiveTo review risk factors influencing perioperative morbidity.MethodsA retrospective study was conducted to analyze the results of surgical treatment among 12 Polish bariatric centers. Inclusion criteria were laparoscopic revisional bariatric surgeries and patients ≥18 years of age. The study included 795 patients, of whom 621 were female; the mean age was 47 years (range: 40–55 years).ResultsPerioperative morbidity occurred in 92 patients (11.6%) enrolled in the study, including 76 women (82.6%). The median age was 45 years (range: 39–54 years). Statistically significant risk factors in univariate logistic regression models for perioperative complications were the duration of obesity, revisional surgery after Roux-en-Y gastric bypass (RYGB) or adjustable gastric band (AGB), difference in body mass index before revisional surgery and the lowest achieved after primary surgery, and postoperative morbidity of the primary surgery as the cause for revisional bariatric surgery. These factors were included in the multivariate regression model. Revisional surgery after AGB (odds ratio [OR] = 2.18; 95% confidence interval [CI]: 1.28–3.69; P = .004), revisional surgery performed after RYGB (OR = 6.52; 95% CI: 1.98–21.49; P = .002), and revisions due to complication of the primary surgery (OR = 1.89; 95% CI: 1.06–3.34; P = .030) remained independent risk factors for perioperative morbidity.ConclusionRevisional operations after RYGB or AGB and those performed because of postoperative morbidity after primary surgery as the main cause for revisional surgery were associated with a significantly increased risk of postoperative morbidity.     

Revisional Surgery for Morbid Obesity - Conversion to the Lap-Band® System

Background:The safety and effectiveness of conversion to the Lap-Band? system‚ of patients who had failure of adequate weight loss and/or severe symptoms from prior bariatric procedures has been measured by prospective evaluation of a consecutive group of 50 patients. Methods:The patients were drawn as a subgroup of 713 patients who had placement of the Lap-Band system between July 1994 and May 2000.The preceding procedures were gastroplasty (35 patients), nonadjustable gastric banding (11), gastric bypass (2) and jejuno-ileal bypass (2). All operations were by open laparotomy. Initial reversal of the initial procedure was performed in 28 patients. M:F ratio was 6%/94%. Inadequate weight was the primary problem in 69%, and symptoms of obstruction were present in 31%. Results: Significant perioperative complications occurred more frequently than after primary placement (17% vs 1.1%). However, late complications were less frequent (2% vs 18%). In particular, there have been no occurrences of prolapse (slippage) of the stomach through the band or erosion of the band into the stomach in this group to date. Weight loss of 47% of excess weight had occurred at 3-year followup. This is not significantly different from the 53% EWL in the primary Lap-Band group. All symptoms of obstruction were relieved by the revision, and a number of comorbidities are seen to be markedly improved. Conclusions: We observe that, when compared to primary Lap-Band placement, revision of failed bariatric procedures to Lap-Band is associated with more perioperative adverse events but fewer late complications. Weight loss is equivalent and is associated with marked improvement in comorbidities and quality of life.The outcomes are better than have been achieved by revision to another form of gastric stapling and should be considered in those patients who have had an unsatisfactory outcome from other bariatric procedures.