A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
Issue link: https://bariatrictimes.epubxp.com/i/130204
4th INTERNATIONAL CONSENSUS SUMMIT FOR SLEEVE GASTRECTOMY IV: Sleeve as a Revisional Surgery to note that no matter the procedure, the approach can be a one-step or twostep operation. Although the decision to conduct a one-step or two-step procedure is largely dependent on the individual surgeon's experience and preferences, the patient needs to be aware that more than one operation may be required according to intraoperative findings. If the stomach is very inflamed, with a degree of ischemia, or if a complication arises, it may be wise to remove the band and consider a second bariatric reoperation in the future. LSG after failed LAGB is typically chosen in the following two situations: 1) the band was successful in reducing and maintaining weight, but a complication arose forcing the band to be removed, and 2) the band worked for a while, but the patient is regaining weight in spite of band adjustments. The rationale is that the restrictive procedure was successful; and therefore another restrictive operation should produce similarly effective results. If one considers the hormonal component of the LSG, results should be durable and may be more dramatic than with the previous intervention. It is important to note that if performing LSG on an inflamed and fibrotic stomach, larger staplers may be required. RYGB after failed LAGB if typically chosen in the following situations: 1) The patient's LAGB procedure never "worked" (i.e., there was no weight loss or the band was not tolerated by the patient); 2) the band worked, but weight loss was insufficient; and 3) the band produced complications, such as gastric motility dysfunction or severe reflux. In these cases, the same situation is likely to resurface if a restrictive procedure is performed. Other conditions, such as diabetes, super obesity, a large hiatal hernia, established gastroesophageal reflux disease (GERD) or Barrett's esophagus, and patients who failed due to nonadherence to their postoperative diet, may be arguments to choose RYGB. In a series performed by Cleveland Clinic Florida, Weston, Florida,2 researchers compared results of LAGB conversion to either RYGB or LSG. They found that after converting from LAGB to RYGB, patients had a significantly greater reduction in body mass index (BMI) as compared to patients who underwent LSG. The researchers stated that the decision of the technique was based only on patient and surgeon preference. It is important to note, however, that in 2009 that same group recommended performing LSG only in cases where gastric bypass was not a feasible option. My colleagues and I presented a series that included 3,876 primary LAGBs performed in a 12-year period.9 Of those cases, 21.6 percent of patients underwent revisional surgery. Band removal was conducted as early as two months after the primary operation and as late as 130 months. Reasons for conducting a revisional surgery in these patients included the following: failure to loose weight (57%), band prolapse (21.2%), band erosion (8.8%), patients request for removal of band (6.1%), GERD or ulceration (5.1%), and intractable nausea and vomiting (1.8%). LAGB was converted to a different bariatric operation in 18.3 percent of patients; 57 percent underwent LSG and 43 percent RYGB. Patients in both groups successfully lost weight and fared well. The revisional operation performed was decided according to the individual patient's characteristics and their results with the band in place. Mean reduction of BMI in the RYGB and LSG groups 19.3 and 16.2 percent, respectively. We found no significant difference between the groups. After this study, we concluded that LSG has an important place as a revisional operation, but selection of the right procedure for each patient is paramount to reduce complications and to achieve better results in terms of weight loss and quality of life. It is important to remember that reoperation is challenging in any case. Attempting a revision to a primary bariatric operation is difficult and the risk of intraoperative and postoperative complications is higher. For this reason, surgeons, experienced not only in bariatric surgery, but also in reoperations, must carry out this kind of intervention. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. Acholonou E, McBean E, Court I, et al. Safety and short-term outcomes of laparoscopic sleeve gastrectomy as a revisional approach for failed laparoscopic adjustable gastric banding in the treatment of morbid obesity. Obes Surg. 2009;19:1612–1616. Tucker O, Sucandy I, Szomstein S, Rosenthal RJ. Revisional surgery after failed laparoscopic adjustable gastric banding. Surg Obes Relat Dis. 2008;4:740–747. Chapman AE, Kiroff G, Game P, et al. Laparoscopic adjustable gastric banding in the treatment of obesity: a systematic literature review. Surgery. 2004;135(3):326–351. Gagner M, Gentileschi P, de Csepel J, et al. Laparoscopic reoperative bariatric surgery: experience from 27 consecutive patients. Obes Surg. 2002;12:254–260. Martikainen T, Pirinene E, Alhava E, et al. Long-term results, late complications and quality of life in a series of adjustable gastric banding. Obes Surg. 2004;14:648–654. Silecchia G, Perrotta N, Boru C, et al. Role of a minimally invasive approach in the management of laparoscopic adjustable gastric banding postoperative complications. Arch Surg. 2004;139:1225–1230. Belachew M, Belva PH, Desaive C. Longterm results of laparoscopic adjustable gastric banding for the treatment of morbid obesity. Obes Surg. 2002;12:564–568. Chevalier J, Zinzindohoúe F, Douard R, et al. Complications after laparoscopic adjustable gastric banding for morbid obesity: experience with 1,000 patients over 7 years. Obes Surg. 2004;14:407–414. Zundel N. Data presented at IV Congress of the Latin American Chapter of the International Federation for the Surgery of the Obesity (IFSO) Cartagena de Indias, Colombia. March 2011. May 2013 • Supplement A • Bariatric Times A15