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 Revision of Sleeve Gastrectomy to Duodenal Switch by VIVEK N. PRACHAND, MD, FACS Bariatric Times. 2013;10(5 Suppl A):A22–A24 AUTHOR AFFILIATIONS: Dr. Prachand is Associate Professor of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois. ADDRESS FOR CORRESPONDENCE: Vivek N. Prachand, MD, FACS, 5841 S. Maryland Ave., MC 5030, Chicago, IL 60637; Phone: (773) 702-0190; Fax: (773) 834-3204; E-mail: vprachan.bsd.uchicago.edu FUNDING AND DISCLOSURES: Dr. Prachand has served as an educational preceptor for Covidien, W.L. Gore, and Ethicon Endo-Surgery. KEY POINTS • • Revision of LSG to DS offers several important advantages over conversion to RYGB or re-sleeve gastrectomy in patients with inadequate weight loss. In comparison to primary DS, conversion to DS after LSG may reduce the incidence of short-term and long-term nutritional deficiencies. R evisional bariatric surgery is generally technically more challenging, and subsequently higher risk, than primary procedures, and weight loss and other outcomes are frequently not as favorable as with primary operations.1 As laparoscopic sleeve gastrectomy (LSG) has rapidly gained acceptance as a primary bariatric procedure by patients, surgeons, and even payors, the need for subsequent revisional surgery for inadequate weight loss or anatomic complications will undoubtedly increase. Most bariatric surgery referral centers, for example, have developed experience revising LSG to Roux-en-Y gastric bypass (RYGB) for intractable gastroesophageal reflux or refractory staple line leaks. It is important to note, however, that LSG was initially described by Gagner et al as the first step of a staged laparoscopic biliopancreatic diversion A22 with duodenal switch (LDS) in highrisk patients.2 With regard to inadequate weight loss after LSG, revision to LDS may in fact be the most appropriate surgical option, particularly in the case of a patient with superobesity at the time of the initial LSG. Given that the relative advantage in mean weight loss outcomes between primary LSG and primary RYGB is relatively small (5–10%),3,4 revision of LSG to RYGB for inadequate weight loss may not be particularly effective in achieving meaningful subsequent weight loss. "Re-sleeve" gastrectomy has been described as an option for inadequate weight loss associated with an excessively dilated LSG,5 but given the variable and often marked gastric tissue thickness in proximity to the original staple line, the potential for mechanical staple line failure may be substantially increased. In contrast, revision of LSG to DS offers several important advantages and ameliorates both the risks of revisional bariatric surgery and primary DS. As compared to either revision to RYGB or re-sleeve, the need for extensive sleeve mobilization and adhesiolysis is minimized, as the orad extent of dissection is generally limited to the proximal duodenum and pylorus. As a result, the subsequent proximal anastomosis (duodenoileostomy) of the Bariatric Times • May 2013 • Supplement A DS is created using tissues that are not scarred or had microcirculatory disruption, facilitating safe duodenal transection and reducing risk of leak. Furthermore, given that the most frequent site of leak following DS is in fact the gastric sleeve,6 as opposed to either anastomosis, one can argue that the most dangerous part of the DS, which historically had been associated with higher perioperative morbidity and mortality, has already been obviated in the setting of LSG to DS revision. In addition to the historically greater perioperative risk following primary DS as compared to other bariatric procedures,7 the concern for development of long-term nutritional complications that may result from the excess combination of restriction and malabsorption, particularly in cases where patients are nonadherent to diet, supplementation, and follow up, has limited the broader adoption of DS among bariatric surgeons. Revision to DS in the setting of inadequate weight loss after LSG offers a hedge against these concerns. It is highly unlikely, for example, that excessive restriction would remain a significant factor in such a setting, and as such, the ability of the patient to reach and maintain appropriate protein and micronutrient supplement intake may in fact be substantially better than that