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 V: Conversions Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass by ALFONS POMP, MD, FACS, FRCSC Bariatric Times. 2013;10(5 Suppl A):A18–A19 AUTHOR AFFILIATIONS: Dr. Pomp is Leon C. Hirsch Professor and Chief, Section of Laparoscopic and Bariatric Surgery, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York. ADDRESS FOR CORRESPONDENCE: Alfons Pomp, MD, FACS, FRCSC, 525 East 68th Street, Box 294, New York, NY 10065 FUNDING AND DISCLOSURES: No funding was provided. The author reports no conflicts of interest relevant to the content of this article. KEY POINTS • Body of literature says it is okay to convert a LSG to RYGB, but it is important to note that it is still in the "show and tell" phase. • Conversion to RYGB does not result in very significant sustained weight loss. • Revision to RYGB is one option for failed weight loss after LSG, but the effectiveness of this operation is limited by the fact that the metabolic actions of the surgeries (LSG and RYGB) appear to be similar. L aparoscopic sleeve gastrectomy (LSG) is a popular weight loss surgery option with an almost exponential increase in frequency over the past five years.1,2 Advocates tout its relative technical simplicity (even in patients with extreme obesity), low complication rate, and the applicability of an effective operation to many different kinds of patient groups.2 Nonetheless, this procedure also has disadvantages. This surgery is irreversible (the only commonly performed weight loss surgery that is), and its complications, albeit rare, can have disastrous consequences. More concerning, however, is the lack of A18 data on long-term durability and, perhaps, that the percentage of excess weight loss (%EWL) may not be as substantial as with Rouxen-Y gastric bypass (RYGB). There are several indications for revisional surgery (e.g., converting a sleeve gastrectomy to RYGB [Figure 1]). For instance, patients may present with intractable gastroesophageal reflux disease (GERD) refractory to optimal medical management. Himpens et al1 postulated that the lack of gastric compliance and emptying and blunting of the angle of His may be responsible for this observation. More rarely, patients present with vomiting due to esophageal dysmotility that was not appreciated preoperatively. These patients are usually good candidates for symptom improvement/resolution after RYGB. In my experience, conversion from LSG to RYGB is the best salvage operation for persistent (chronic) complications, such as mid-sleeve stricture (at the angularis) and leaks that have not responded to more conservative management at the gastroesophageal junction. The previously mentioned indications are relatively rare, but, unfortunately, weight Bariatric Times • May 2013 • Supplement A regain after LSG is not uncommon. All weight loss surgeries show some weight regain after initial weight loss,3,4 and LSG is no exception.2,5 The most appropriate preliminary management for weight gain, in my opinion, is always nonsurgical and relates to patients making more suitable diet choices and avoiding excessive calorie intake between meals. Inadequate resection of the (posterior) fundus, a common technical error early in a surgeon's experience, may need to be addressed surgically.6 When the issues of nutritional management have been adequately addressed and technical problems of inadequate fundal resection have been ruled out, conversion to RYGB may be considered. Although our initial experience7 was encouraging, more recent data are less persuasive regarding sustained weight loss after conversion from sleeve gastrectomy to RYGB and mean weight reduction was only in the 15kg range.8 In addition, a recent international sleeve gastrectomy panel could not obtain consensus on whether RYGB was the best procedure for a failed sleeve gastrectomy.2 Dr. Michel Gagner has championed another option: