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.     

Systematic Review of Medium-Term Weight Loss after Bariatric Operations

Background: Although bariatric surgery is known to be effective in the short term, the durability of that effect has not been convincingly demonstrated over the medium term (>3 years) and the long term (>10 years). The authors studied the durability of weight loss after bariatric surgery based on a systematic review of the published literature. Methods: All reports published up to September, 2005 were included if they were full papers in refereed journals published in English, of outcomes after Roux-en-Y gastric bypass (RYGBP), and its hybrid procedures of banded bypass (Banded RYGBP) and longlimb bypass (LL-RYGBP), biliopancreatic diversion with or without duodenal switch (BPD±DS) or laparoscopic adjustable gastric banding (LAGB). All reports that had at least 100 patients at commencement, and provided ≥3 years of follow-up data were included. Results: From a total of 1,703 reports extracted, 43 reports fulfilled the entry criteria (18 RYGBP; 18 LAGB; 7 BPD). Pooled data from all the bariatric operations showed effective and durable weight loss to 10 years. Mean %EWL for standard RYGBP was higher than for LAGB at years 1 and 2 (67 vs 42; 67 vs 53) but not different at 3, 4, 5, 6 or 7 years (62 vs 55; 58 vs 55; 58 vs 55; 53 vs 50; and 55 vs 51). There was 59 %EWL for LAGB at 8 years, and 52 %EWL for RYGBP at 10 years. Both the BPD±DS and the Banded RYGBP appeared to show better weight loss than standard RYGBP and LAGB, but with statistically significant differences present at year 5 alone. The LL-RYGBP was not associated with improved %EWL. Important limitations include lack of data on loss to follow-up, failure to identify numbers of patients measured at each data point and lack of data beyond 10 years. Conclusions: All current bariatric operations lead to major weight loss in the medium term. BPD and Banded RYGBP appear to be more effective than both RYGBP and LAGB which are equal in the medium term.     

Adjustable Gastric Banding as a Revisional Bariatric Procedure after Failed Gastric Bypass

Background: Inadequate weight loss after proximal gastric bypass presents a clinical challenge to bariatric surgeons. Pouch size, stoma size and limb length are the variables that can be surgically altered. Aside from conversion to distal bypass, which may have significant negative nutritional sequelae, revisional surgery for this group of patients has not often been reported. The addition of adjustable silicone gastric banding (ASGB) to Roux-en-Y gastric bypass (RYGBP) may be a useful revision strategy because it has potential safety benefits over other revisional approaches. Materials and Methods: We report on 8 patients who presented with inadequate weight loss or significant weight regain after proximal gastric bypass. All patients underwent revision with the placement of an ASGB around the proximal gastric pouch. Bands were adjusted at 6 weeks postoperatively and beyond as needed. Complications and weight loss at the most recent follow-up visit were evaluated. Results: Mean age and body mass index (BMI) at the time of revision were 39 ± 9.9 years and 44.0 ± 4.5 kg/m² respectively. No patients were lost to follow-up, and they lost an average of 38.1 ± 10.4% and 44.0 ± 36.3% of excess weight and 49.1 ± 20.9% and 52.0 ± 46.0% of excess BMI in 12 and 24 months respectively. Patients lost an average of 62.0 ± 20.5% of excess weight from the combined surgeries in 67 (48–84) months. The only complication was the development of a seroma overlying the area of the port adjustment in one patient. There have been no erosions or band slippages to date. Conclusions: These results indicate that the addition of an ASGB causes significant weight loss in patients with poor weight loss outcome after RYGBP. The fact that no anastomosis or change in absorption is required may make this an attractive revisional strategy. Long- term evaluation in a larger population is warranted.     

The Decrease in Plasma Ghrelin Concentrations following Bariatric Surgery Depends on the Functional Integrity of the Fundus

Background: Gastric bypass surgery, which involves the production of a reduced stomach pouch,has been shown to markedly suppress circulating ghrelin concentrations. Since bypassing the ghrelin-producing cell population may be relevant to the disruption of fundic-derived factors participating in food intake signaling, the effect of weight loss induced by either adjustable gastric banding (AGB), Roux-en-Y gastric bypass (RYGBP) or biliopancreatic diversion (BPD) was studied. Methods: 16 matched obese patients [35.0 + 2.4 years; initial body weight 124.8 ± 5.7 kg; body mass index (BMI) 47.1 ± 2.2 kg/m²] in whom similar weight loss had been achieved by either AGB (n=7), RYGBP (n=6) or BPD (n=3) were studied. Blood was obtained for biochemical and hormonal analyses. Body composition was assessed by air-displacement-plethysmography. Results: Comparable weight loss (AGB: 26.1 ± 5.1 kg; RYGBP: 32.1 ± 5.0; BPD: 31.7 ± 6.1; P=NS) and decrease in percentage body fat (AGB: 10.0 ± 1.5%; RYGBP: 14.2 ± 2.8; BPD: 10.3 ± 1.0; P=NS) induced by bariatric surgery exerted significantly different (P=0.004) effects on plasma ghrelin concentrations, depending on the surgical procedure applied (AGB: 480 ± 78 pg/ml; RYGBP: 117 ± 34; BPD: 406 ± 86). Without significant differences in BMI, body fat, glucose, triglycerides, cholesterol, insulin and leptin levels, patients who had undergone the RYGBP exhibited statistically significant diminished circulating fasting plasma ghrelin concentrations compared with the other two bariatric techniques which conserve direct contact of the fundus with ingested food (P=0.003 vs AGB and P=0.020 vs BPD). Conclusion: Fasting circulating ghrelin concentrations in patients undergoing diverse bariatric operations depend on the degree of dysfunctionality of the fundus.     

Laparoscopic Conversion of Vertical Banded Gastroplasty (Mason MacLean) into Roux-en-Y Gastric Bypass

Background Revision of bariatric procedures is required in 10 to 25% of patients either for insufficient weight loss or for complications. Patients undergoing vertical banded gastroplasty (VBG; Mason MacLean) may require revision in up to half of the cases in the long term. Roux-en-Y gastric bypass (RYGBP) is considered the procedure of choice for revision of VBG gastroplasty. Patients and Methods Eighteen patients, 16 women and 2 men with a mean age of 41.7 years (range 27–72) and a mean BMI at 37.6 kg/m² (range 22.5–47), underwent laparoscopic conversion of VBG into RYGBP. Indications for revisional surgery were insufficient weight loss (11 patients), stoma stenosis (4 patients), and acid reflux (3 patients). Results Operative time was on average 203 min (range 60–300 min), and conversion was required in one patient (5.5%). There was no early postoperative mortality, and four patients (22.2%) developed immediate postoperative complications (gastrojejunostomy leak 1; stenosis of the gastrojejunal anastomosis 2; liver abscess 1). One patient died 6 months after conversion because of a bleeding anastomotic ulcer (late mortality 5.5%). Two patients (11.5%) developed late complications (incisional hernia 1; internal hernia 1). At a mean follow-up of 23, 4 months BMI is on average 29.8 kg/m² (range 22.7–37). Conclusion Although revision of failed VBG into RYGBP gives good functional results, the risk of postoperative serious complications must be carefully evaluated before revision.     

Roux-en-Y Gastric Bypass versus a Variant of Biliopancreatic Diversion in a Non-Superobese Population: Prospective Comparison of the Efficacy and the Incidence of Metabolic Deficiencies

Background: In the non-superobese population, an agreement has not been made as to the optimal bariatric operation. The present study reports the results of a prospective comparison of Roux-en-Y gastric bypass (RYGBP) and a variant of biliopancreatic diversion (BPD) in a non-superobese population. Methods: From a cohort of 130 patients with BMI 35 to 50 kg/m², 65 patients were randomly selected to undergo RYGBP and 65 to undergo BPD. All patients underwent complete follow-up evaluation at 1, 3, 6, and 12 months postoperatively and every year thereafter. Results: Patients in both groups have completed their second postoperative year. Mean % excess weight loss (%EWL) was significantly better after BPD at all time periods (12 months, P=0.0001 and 24 months, P=0.0003), and the %EWL was >50% in all BPD patients compared to 88.7% in the RYGBP patients at 2-year follow-up. No statistically significant differences were observed between the 2 groups in early and late non-metabolic complications. Hypoalbuminemia occurred in only 1 patient (1.5%) after RYGBP and in 6 patients after BPD (9.2%). Only 1 patient from each group was hospitalized and received total parenteral nutrition. Glucose intolerance, hypercholesterolemia, hypertriglyceridemia and sleep apnea completely resolved in all patients in both groups, although mean total cholesterol level was significantly lower in BPD patients at the second year follow-up (t-test, P<0.0001). Diabetes completely resolved in all BPD patients and in 7 of the 10 diabetic RYGBP patients. Conclusion: Both RYGBP and BPD were safe and effective procedures when offered to non-superobese patients. Weight loss after BPD was consistently better than that after RYGBP, as was the resolution of diabetes and hypercholesterolemia. Because the nutritional deficiencies that occurred following this type of BPD were not severe and were not significantly different between the 2 operations, both may be offered to non-superobese patients, keeping in mind the severity and type of preoperative co-morbidities as well as the desired weight loss.     

Effect of Revisional Bariatric Surgery on Weight Loss and Frequency of Complications

Background: The relative risks and effectiveness of primary and revision operations done to produce weight loss are of interest both from a patient care and an economic perspective. The possibility that patients requiring revision surgery comprise a treatment resistant subgroup who are more likely to have post-operative complications is a valid concern. Methods: The records of all patients having bariatric procedures since January of 1970 were evaluated for weight loss and complications. Results: Most revisions were from jejunoileal bypass or a gastric restrictive procedure. Early complications were significantly more common following revision surgery (19%) than after primary procedures (6%), although late and combined early and late complication rates were similar. Operative mortality was lower following primary procedures (2/382) than revisions (1/75). Cholecystectomy was a common sequela following primary procedures but did not occur after revision procedures. Regardless of surgical category, weight loss after revision was equivalent to weight loss after primary procedures. Conclusions: Weight loss following revisional bariatric surgery is equivalent to weight loss following a primary operation of the same type. Although mortality and early complications are more common after revisional bariatric surgery, the frequency of late complications is not different. In all groups wound infections and hernias were relatively common complications and cholecystectomies are rare after revisional bariatric operations.     

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.     

Comparison of Nutritional Consequences of Conventional Therapy of Obesity, Adjustable Gastric Banding, and Gastric Bypass

Background: Roux-en-Y gastric bypass (RYGBP) is more efficient than adjustable gastric banding (AGB) in weight loss and relieving co-morbidities, but nutritional complications of each surgical procedure have been poorly evaluated. Methods: A cross-sectional study was performed to compare nutritional parameters in 201 consecutive obese patients, who had been treated either by conventional behavioral and dietary therapy (CT, n=110) or by bariatric surgery, including 51 AGB and 40 RYGBP. Results: BMI was similar after AGB (36.6 ± 5.3 kg/m²) and RYGBP (35.4 ± 6.3 kg/m²), but patients in the RYGBP group had lost more weight and had less metabolic disturbances than those in the AGB group. On the other hand, the prevalence of nutritional deficits was significantly higher in the RYGBP group than in the 2 other groups (P <0.01), whereas the AGB group did not differ from CT. Particularly, the RYGBP group presented an unexpected high frequency of deficiencies in fat-soluble vitamins. Moreover, vitamin B₁₂, hemoglobin, plasma prealbumin and creatinine concentrations were low in the RYGBP group. Conclusion: RYGBP is more efficient than AGB in correcting obesity, but this operation is associated with a higher frequency of nutritional deficits that should be carefully monitored.     

A Prospective Comparison of Vertical Banded Gastroplasty and Roux-en-Y Gastric Bypass in a Non-Superobese Population

Background: In the non-superobese population, consensus is currently unavailable in bariatric surgery. We report the results of a prospective comparison of vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGBP) in a non-superobese population. Methods: From 1994 to 2000, 179 patients with clinically severe obesity underwent various surgical procedures in our department. During this time a prospective study was undertaken in order to compare VBG with RYGBP in morbidly obese patients with a BMI <50 kg/m². Based on specific criteria including eating behavior, 68 patients were selected to undergo RYGBP and 35 VBG. All patients have undergone complete follow-up evaluation at 1, 3, 6, and 12 months postoperatively and every year thereafter. Results: All patients have now completed their 5th postoperative year. Mean follow-up period to date is 96.5±12.2 months for VBG and 67.6±11.3 months for RYGBP. 3 patients (8.6%) in the VBG group and 9 patients (13.2%) in the RYGBP group are lost to follow-up. Mean excess weight loss (EWL) was always better in the RYGBP group (P=0.0013). The percentage of failure, defined as EWL <25%, was not significantly different between the two procedures. No statistically significant differences were observed between the 2 groups in the total number of non-metabolic complications, and the only statistically significant difference observed in metabolic complications was vitamin B₁₂ deficiency after RYGBP. Frequency of vomiting was significantly less and quality of eating significantly better in RYGBP than in VBG patients. Conclusion: This prospective long-term study, with nearly complete follow-up, suggests that in the non-superobese population, preoperative eating habits may play a role in choosing the most appropriate bariatric operation for each patient. Although RYGBP is associated with better mean weight loss outcomes, the percentage of patients who achieved and maintained ≥50% EWL after VBG in this pre-selected patient population was not significantly different. Each type of operation has advantages and disadvantages, and, if properly chosen, a purely restrictive procedure can be successful for some patients. Therefore, it can be said that the decision regarding which bariatric procedure to perform in non-superobese patients must be based on in-depth preoperative evaluation as well as the patients' own preferences and outcome expectations.     

Early Results after Laparoscopic Gastric Bypass: EEA vs GIA Stapled Gastrojejunal Anastomosis

Background: Various surgical techniques have been successfully applied to isolated Roux-en-Y gastric bypass (RYGBP). Many surgeons rely on stapling devices for the gastrojejunal (GJ) anastomosis. Early follow-up results were compared for two laparoscopic techniques for GJ anastomosis: circular end-to-end (EEA) and linear cutting (GIA) staplers. Methods: Medical charts were retrospectively reviewed of all patients who had undergone stapled GJ anastomosis for isolated RYGBP over a 2-year period. The jejunal limb used for GJ anastomosis was fashioned at 1 cm / unit body mass index (BMI). Patients were grouped by GJ anastomotic technique, EEA or GIA, and the results compared. Results: 61 patients underwent RYGBP (EEA=32; GIA=29), with no differences in preoperative BMI or co-morbidities. Mean (±SD) operative time was shorter for the GIA group (EEA=180±56.1 minutes; GIA=145.3±27.9 minutes, P=0.003). There were 2 early re-operations in the GIA group for anastomotic leaks. Postoperative complications were not statistically different; however, there was an increased incidence of wound infections in the EEA group vs the GIA group (21.9% vs 6.9%, P=0.08). Follow-up at 6-8 months revealed an average percent excess weight loss of 46.7%±12.2% for EEA and 51.4%±10.7% for GIA (P=0.25). Length of stay, total hospital costs and operating-room costs were similar (P=0.34, 0.53 and 0.96 respectively). Conclusion: Operative time was significantly shorter in the GIA group. Complications, length of stay, weight loss and costs were similar between the groups. Selection of anastomotic technique may be based on surgeon preference, operative time, and potential for serious complications.     

Hand-Assisted Laparoscopic Revision of Previous Restrictive Operations to Vertical Banded Gastroplasty

Background: Revision of failed gastric restrictive procedures to proximal Roux-en-Y gastric bypass (RYGBP) is the standard for many bariatric surgeons. Where the patient is not a suitable candidate or simply refuses gastric bypass, an alternative is herewith proposed. Methods: 3 patients had undergone a gastric banding as the original operation and 1 patient had had a vertical banded gastroplasty (VBG). 1 patient presented with insufficient weight loss, 1 with regain of weight and 2 with complaints of food intolerance and vomiting. The gastric bands were removed by hand-assisted laparoscopy (HALS), with conversion to a VBG. In the patient with stomal stenosis after a VBG, HALS interposition of PTFE was performed to enlarge the collar. Results: In 2 patients, further weight reduction was achieved. In the other 2 patients, relief of symptoms was achieved.There were no complications during or after the revisional surgery. Conclusion: HALS conversion of a gastric banding to a VBG, or PTFE interposition in the case of stomal stenosis after a VBG, can be a valuable alternative for patients unsuitable for or refusing proximal RYGBP.     

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.     

Comparison of Recovery Time after Open and Laparoscopic Gastric Bypass and Laparoscopic Adjustable Banding

Background: Laparoscopy is believed to reduce recovery time and patient discomfort following bariatric surgical operations. This study tests that hypothesis. Methods: 60 randomly selected bariatric surgery patients, consisting of 20 open Roux-en-Y gastric bypass (RYGBP), 19 lap RYGBP, and 21 laparoscopic adjustable banding, were studied. Outcome measures including hospital length of stay (LOS), days to return to normal activity, days to surgical recovery, and pain medication usage were defined by the patients' subjective responses to a retrospective questionnaire. Overall differences among the three surgeries were first determined using the Kruskal-Wallis test, and then individual comparisons were made between each of the three pairs of operations using a Wilcoxon rank-sum test when a significant difference existed. Results: Patients reported an average LOS of 3.45 days following open RYGBP, 2.47 days following lap RYGBP, and 1.33 days following Lap-Band? surgery. There was little difference in return to normal activity, with open RYGBP patients reporting a 17.55 day delay in return to normal activity, and lap RYGBP reporting an 18.16 day delay. In contrast, Lap-Band? patients responded that the delay was only 7.24 days. Days to recovery were reported to be 29.05 for open RYGBP patients, 21.68 for lap RYGBP patients and 15.81 for Lap-Band? patients. Hospital days (P=0.0002), days to normal activity (P=0.0115), and days to recovery (P<0.0001) differed significantly among the surgery types. Lap and open RYGBP did not differ significantly regarding days to resumption of normal activities. Open RYGBP and banding differed significantly regarding days to recovery (P <0.001). Conclusions: Lap-Band? patients returned to normal activity levels earlier than gastric bypass patient's irrespective of approach. Lap-Band? patients also reported recovering from surgery significantly sooner than open RYGBP patients. Perceived differences in recovery time between open and laparoscopic RYGBP patients did not affect their time to resumption of normal activity.     

Revisional vs. Primary Roux-en-Y Gastric Bypass—a Case-matched Analysis

With the increase in bariatric procedures performed, revisional surgery is now required more frequently. Roux-en-Y gastric bypass (RYGB) is considered to be the gold standard revision procedure. However, data comparing revisional vs. primary RYGB is scarce, and no study has compared non-resectional primary and revisional RYGB in a matched control setting. Analysis of 61 revisional RYGB that were matched one to one with 61 primary RYGB was done. Matching criteria were preoperative body mass index, age, gender, comorbidities and choice of technique (laparoscopic vs. open). After matching, the groups did not differ significantly. Previous bariatric procedures were 13 gastric bands, 36 vertical banded gastroplasties, 10 RYGB and two sleeve gastrectomies. The indication for revisional surgery was insufficient weight loss in 55 and reflux in 6. Intraoperative and surgical morbidity was not different, but medical morbidity was significantly higher in revisional procedures (9.8% vs. 0%, p = 0.031). Patients undergoing revisional RYGB lost less weight in the first two postoperative years compared with patients with primary RYGB (1 month, 14.9% vs. 29.7%, p = 0.004; 3 months, 27.4% vs. 51.9%, p = 0.002; 6 months, 39.4 vs. 70.4%, p < 0.001; 12 months, 58.5% vs. 85.9%, p < 0.001; 24 months, 60.7% vs. 90.0%, p = 0.003). Although revisional RYGB is safe and effective, excess weight loss after revisional RYGB is significantly less than following primary RYGB surgery. Weight loss plateaus after 12 months follow-up.     

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 Gastric Bypass for Failed Restrictive Procedures: Comparison of Single-Anastomosis (Mini-) and Roux-en-Y Gastric Bypass

Background

Ten to 50% of patients who received restrictive bariatric operations may require reoperation for unsatisfactory weight loss or weight regain. Failed restrictive procedures are usually managed with conversion to another bariatric procedure with a favor of conversion to laparoscopic gastric bypass. Our aim is to evaluate two different bypass techniques, laparoscopic RY gastric bypass (RYGB) versus single-anastomosis (mini-) gastric bypass (SAGB) as a revision option (R-RYGB and R-SAGB) for failed restrictive bariatric operations.

Material and Methods

From May 2001 to December 2015, a total of 116 patients with failed restrictive bariatric operations underwent laparoscopic revisional bypass surgery (81 R-SAGB and 35 R-RYGB). Among them, 81 were failed after vertical banded gastroplasty (VBG) and 35 were after adjustable gastric band (AGB). The demographic data, surgical parameters, and outcomes were studied.

Results

The average age at revision surgery was 35.7 years (range 22–56), and the average body mass index (BMI) before reoperation was 37.2 kg/m² (29.0–51.8). Revision surgery was performed after 58.8 months from the primary surgery on average (14–180 months). The main reasons for the revisions were weight regain (50.9%), inadequate weight loss (31%), and intolerance (18.1%). All of the procedures were completed laparoscopically as one-stage procedure. R-RYGB had significantly longer operative times than R-SAGB. Major complication occurred in 12 (10%) patients without significant difference between R-SAGB group and R-RYGB group. At 1 year follow-up, weight loss was better in R-SAGB than R-RYGB (76.8 vs. 32.9% EWL; p = 0.001). At 5 year follow-up, a significantly lower hemoglobin level was found in R-SAGB group (p = 0.03).

Conclusion

Both SAGB and RYGB are acceptable options for revising a restrictive type of bariatric procedures with equal safety profile. R-SAGB was shown to be a simpler procedure with better weight reduction than R-RYGB but anemia is a considerable complication at long-term follow-up.

     

Revisional Bariatric Surgery by Conversion to Gastric Bypass or Sleeve—Good Short-Term Outcomes at Higher Risks

This is a retrospective study of prospectively collected data from 34 patients who had revisional bariatric surgery at a single centre. The aim was to report the indications for revisional surgery, operative time, conversion to open surgery, mortality, hospital stay, early and late complications, reoperations and short-term efficacy. From 2006 to 2011, 31 patients who formerly had been operated for morbid obesity with restrictive operations and 3 patients who had been operated in the upper abdomen for other morbidities (fundoplications 2, Heller's myotomy 1) underwent a revisional Roux-en-Y gastric bypass operation (n = 30) or sleeve gastrectomy (n = 4). Demographic data, perioperative characteristics and follow-up data were entered prospectively in the hospital's database for bariatric patients. Twenty-five operations were done by laparoscopic and nine by open technique. The mean operative time was 113.17 (33.98, 54–184) min. The mean postoperative hospital stay was 3.25 (5.71, 1–32) days. Intra-operative complications occurred in six patients (17.65%), postoperative complications in nine (26.47%), and major complications in three patients (8.82%), including leakage in the gastrojejunal anastomosis in two (5.88%) patients. The conversion rate to open surgery was 2.94% (one emergency patient). There was no mortality. Excess weight loss (%, ±SD) at 3 months follow-up averaged 42.31%, ±21.54. Revisional bariatric surgery can be performed with an increased but acceptable risk, with at least short-term weight loss comparable to primary operations.     

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.     

Reoperative Laparoscopic Roux-en-Y Gastric Bypass: An Experience with 49 Cases

Background: Long-term complications leading to reoperation after primary bariatric surgery are not uncommon. Reoperations are particularly challenging because of tissue scarring and adhesions related to the first operation. Reoperations must address the complication(s) related to the scarring and, at the same time, prevent weight regain that would inevitably occur after simple reversal. Conversion to Roux-en-Y gastric bypass (RYGBP) has repeatedly been demonstrated to be the procedure of choice in most situations. It has traditionally been performed through an open approach. Our aim is to describe our experience with the laparoscopic approach in reoperations to RYGBP over the past 5 years. Methods: All patients undergoing laparoscopic RYGBP as a reoperation were included in this study. Patients with multiple previous operations or patients with band erosion after gastric banding were submitted to laparotomy. Data were collected prospectively. Results: Between June 1999 and August 2004, 49 patients (44 women, 5 men) underwent laparoscopic reoperative RYGBP. The first operation was gastric banding in 32 and vertical banded gastroplasty in 15. The mean duration of the reoperation was 195 minutes. No conversion to open was necessary. Overall morbidity was 20%, with major complications in 2 patients (4%). Weight loss, or weight maintenance, was satisfactory, with a BMI <35 kg/m² up to 4 years in close to 75% of the patients. Conclusions: Laparoscopic RYGBP can be safely performed as a reoperation in selected patients provided that the surgical expertise is available. These procedures are clearly more difficult than primary operations, as reflected by the long operative time. Overall morbidity and mortality, however, are not different. Long-term results regarding weight loss or weight maintenance are highly satisfactory, and comparable to those obtained after laparoscopic RYGBP as a primary operation.