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4th INTERNATIONAL CONSENSUS SUMMIT FOR SLEEVE GASTRECTOMY V: Conversions Figure 1: Indication for Revisional Surgery (LSG to RYGB) • Vomiting/intractable GERD • Esophageal dysmotility (unappreciated pre-operatively) • Failed (inadequate or unsustained weight loss) • Salvage procedure • Stricture • Leaks (DO NOT DO IN ACUTE SITUATIONS) conversion of sleeve gastrectomy to a biliopancreatic diversion with duodenal switch (BPD/DS), especially in the patient population with super obesity (body mass index [BMI] >60kg/m2) group. Studies have shown that conversion of LSG to BPD/DS results in the accrual of substantial weight loss.4,9 The downside to performing a conversion from LSG to BPD/DS is that a significant proportion of patients will experience nutritional deficiencies primarily related to fatsoluble vitamin malabsorption, metabolic bone disease, nutritional anemia, (oxalate) nephrolithiasis, and perhaps social problems related to more frequent malodorous flatus and bowel movements.10 Finally, particular caution should be given to offering this option (and conversion to RYGB for that matter) to patients who have previously been only marginally adherent to post-sleeve gastrectomy follow up. LSG is an excellent operation that provides sustained weight loss for most patients. The mechanism of action is certainly in part restrictive but also is likely related to decreases in ghrelin or peptide YY.11 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.11 As LSG is a relatively recent addition to the weight loss surgeon's armentarium, data on conversion and revision are still in the "show and tell phase." The decision to proceed expeditiously to convert a sleeve gastrectomy to another operation must be tempered by evaluating patients' adherence to post-operative follow up and expectations for weight loss. The most important consideration, however, is the individual's risk/benefit ratio for more surgery, as the improvement in general quality of life and comorbidity resolution is impressive even with modest weight loss and further benefits are not linear. 5. 6. 7. 8. 9. REFERENCES 1. 2. 3. 4. Himpens J, Dapri G, Cadiere GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: Results after 1 and 3 years. Obes Surg. 2006;16:1450–1456. Rosenthal RJ, International Sleeve Gastrectomy Expert Panel. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis. 2012;8 (1):8–19. Himpens J, Verbrugghe A, Cadière GB, et al, Long-term results of laparoscopic Roux-en-Y Gastric bypass: evaluation after 9 years. Obes Surg. 2012;22(10):1586–1593. Gumbs AA, Pomp A, Gagner M. Revisional bariatric surgery for inadequate weight loss. Obes 10. 11. Surg. 2007;17(9):1137–1145. Strain GW, Saif T, Gagner M, et al. Cross-sectional review of effects of laparoscopic sleeve gastrectomy at 1, 3, and 5 years. Surg Obes Relat Dis. 2011;7(6):714–719. Rosen DJ, Dakin GF, Pomp A. Sleeve gastrectomy. Minerva Chir. 2009;64(3):285–295. Regan JP, Inabnet WB, Gagner M, et al. Early experience with twostage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg. 2003;13:861–864. Langer FB, Bohdjalian A, ShakeriLeidenmühler S, et al.Conversion from sleeve gastrectomy to Rouxen-Y gastric bypass—indications and outcome. Obes Surg. 2010 (7):835–840. Kim WW, Gagner M, Kini S, et al. Laparoscopic vs. open biliopancreatic diversion with duodenal switch: a comparative study. J Gastrointest Surg. 2003;7:552–557. Almahmeed T, Pomp A, Gagner M. Laparoscopic reversal of biliopancreatic diversion with duodenal switch. Surg Obes Relat Dis. 2006;2(4):468–471. Karamanakos SN, Vagenas K, Kalfarentzos F, Alexandrides TK. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptideYY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Ann Surg. 2008;247(3):401–407. May 2013 • Supplement A • Bariatric Times A19