Bariatric Times

FEB 2018

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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11 Review Bariatric Times • February 2018 growth of revisional or reoperative bariatric surgery to correct weight l oss failure or regain after LRYGB, which now has become a common practice. Fortunately for revisional bariatric surgery, the complication rate is low with comparable o utcomes to primary procedures. 1 Furthermore, the evidence regarding reoperative surgery for failed weight loss and weight regain has demonstrated improved weight loss a nd comorbidity reduction after reintervention. 2 Less than 50 percent of excess weight loss at 18 months is the most frequent definition identified in the literature. 3 T he most common surgical and correctable reasons for failure and weight regain include enlarged gastric pouch, dilated gastro-jejunal anastomosis, gastro-gastric fistula, a nd shortened bilio-pancreatic and alimentary limbs. Most of the revisional surgery has focused on specific technical areas, such as resizing the gastric pouch and g astro-jejunal anastomosis or increasing the malabsorptive area by means of lengthening the alimentary limb during typically separate reoperative stages. 5–7 In addition, several endoscopic procedures have also been used to resize either the gastric pouch or gastro-jejunostomy with poor results. 8 ,9 Yet, for a large number of patients, revisions of malapsortive technical aspects are addressed one at a time, resulting in several surgeries for each patient. Many of those patients with obesity present for a second or even third revisional bariatric surgery. 10 During the ultimate revisional LRYGB, the creation of a small narrow gastric tube not only provides increased restriction to food intake but also increases early satiety via activation of the preserved stretch receptors within the newly created gastric tube. Both the gastric tube and the calibrated gastro-jejunal anastomosis are responsible for the increased restrictive component of this complete revision. The use of a silastic ring precludes both gastric tube and stoma dilation by diminishing the peristaltic waves originating from the esophagus. In addition, this silastic ring is easily dilated or removed by endoscopic means if needed. We require that patients receiving a silastic ring placement have easy access to an expert bariatric endoscopist. In a recent large cohort study, the use of the silastic ring (Banded GaBP Ring™, Bariatec Corporation, Palos Verdes Peninsula, California) during LRYGB was shown to provide improved long-term weight loss with significantly lower weight regain when compared to non-banded LRYGB. 11 A note of caution is that this small ring should be made of silastic material. The use of the commercially available laparoscopic a djustable gastric banding (LAP- BAND™, Apollo Endosurgery, San Diego, California) over the gastric tube and anastomosis is strongly discouraged because it might lead to t he disastrous complication of gastric tube or anastomotic necrosis and/or erosion. Furthermore, The LAP-BAND™ has no United States Food and Drug Administration ( FDA) approval for this indication. Removal of the remnant stomach and fundus not only abolishes residual sources of ghrelin production but also eliminates the p otential risk of developing a gastro- gastric fistula in the future. The only downside of this remnant gastrectomy is that it precludes its utilization as a conduit to the biliary t ree if needed. A cholecystectomy might also be performed if clinically indicated. The antral stump is left short in order to avoid the rare but potential complication of an antro- p yloric intussusception. We have previously described the importance of the bilio-pancreatic limb elongation during primary and revisional LRYGB for weight loss, weight regain, and diabetes recurrence. 12,13 The elongation of this limb maximizes the incretin effects of the duodenal and jejunal exclusions. It is known that the bilio- pancreatic limb is critical for the malabsorptive, incretin, and anti- incretin mechanisms of the LRYGB (i.e., entero-pancreatic axis theory). 14 Although the elongation of the alimentary limb traditionally has been the surgeon's focus during revisional bariatric surgery, this appears to provide only minimal and transient metabolic and weight loss benefits. If both limbs are elongated to 150cm, this will result in a common limb length of more than 300cm, which does not cause additional nutritional concerns or malabsorptive symptoms. This same length has been advocated as a revisional single anastomosis duodenal switch. To avoid multiple revisional reoperations, we have focused on the various technical aspects of the LRYGB, which can potentially lead to failure, weight regain, and diabetes recurrence. We believe that all of these should be addressed in a complete, single, and definitive stage revisional surgery. Although, this complete revision LRYGB might seem excessive, the costs of ongoing weight regain, recurring diabetes, multiple reoperations, and associated morbidity and mortality might be avoided. Furthermore, most of the revisional bariatric operations are currently not covered by many insurers. Hence, we favor the complete single-staged revisional LRYGB as our revisional procedure of choice. This revisional technique is suited for either failed primary LRYGB p rocedures or conversions from LAP-BAND™ and laparoscopic sleeve gastrectomy (LSG). The latter, which has increased in popularity in the United States, has n ow surpassed LRYGB as a primary bariatric procedure. 15 It is plausible that in the near future, a number of LSG will be converted to LRYGB or duodenal switch for weight loss f ailure, weight regain, intractable gastro-esophageal reflux, or diabetes recurrence. LRYGB continues to be the "gold standard" to which all other bariatric procedures are c ompared. In conclusion, we present a complete single-staged revisional LRYGB procedure that, in our view, corrects all potential technical f ailure sites and prevents future known complications of revisional surgery. We believe that this complete revision is feasible and should be part of the bariatric s urgeon's armamentarium. This complete revision does not appear to add significant additional morbidity to an already complex operation. We hypothesize that this approach might not only reduce the need for future reoperations and associated morbidity and mortality, but it also might be associated with significant healthcare system cost savings. Prospective studies evaluating the clinical and economic impact of the complete revisional LRYGB surgery are warranted. REFERENCES 1. Sudan R, Nguyen NT, Hutter MM, et al. Morbidity, mortality, and weight loss outcomes after reoperative bariatric surgery in the USA. J Gastrointest Surg. 2015;19(1):171–178; discussion 178–179. 2. Brethauer SA, Kothari S, Sudan R, et al. Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force. Surg Obes Relat Dis. 2014;10(5):952–972. 3. Mann JP, Jakes AD, Hayden JD, Barth JH. Systematic review of definitions of failure in revisional bariatric surgery. Obes Surg. 2015;25(3):571–574. 4. Nguyen D, Dip F, Huaco JA, et al. Outcomes of revisional treatment modalities in non-complicated Roux-en-Y gastric bypass patients with weight regain. Obes Surg. 2015. 5. Leon F, Maiz C, Daroch D, et al. Laparoscopic hand-sewn revisional gastrojejunal plication for weight loss failure after Roux-en-Y gastric bypass. Obes Surg. 2015. 6. Al-Bader I, Khoursheed M, Al Sharaf K, et al. Revisional laparoscopic gastric pouch resizing for inadequate weight loss after Roux-en-Y gastric bypass. Obes Surg. 2015. 7. Hamdi A, Julien C, Brown P, et al. Midterm outcomes of revisional surgery for gastric pouch and gastrojejunal anastomotic enlargement in patients with weight regain after gastric bypass for morbid obesity. Obes Surg. 2014;24(8):1386–1390. 8. Eid GM, McCloskey CA, Eagleton JK, et al. StomaphyX vs a sham procedure for revisional surgery to reduce regained weight in Roux- en-Y gastric bypass patients: a randomized clinical trial. JAMA Surg. 2014;149(4):372–379. 9. Goyal V, Holover S, Garber S. Gastric pouch reduction using StomaphyX in post Roux-en-Y gastric bypass patients does not result in sustained weight loss: a retrospective analysis. Surg Endosc. 2013;27(9):3417–3420. 10. Daigle CR, Aminian A, Romero- Talamas H, et al. Outcomes of a third bariatric procedure for inadequate weight loss. JSLS. 2014;18(3). 11. Lemmens L. Banded gastric bypass: better long-term results? A cohort study with minimum 5-year follow-up. Obes Surg. 2016. 12. Chaux F, Franco M, Varela JE. Metabolic surgery provides remission of pancreatogenic diabetes in a non-obese patient. Surg Obes Relat Dis. 2016;12(3):e25–26. 13. Chaux F, Bolanos E, Varela JE. Lengthening of the biliopancreatic limb is a key step during revisional Roux-en-Y gastric bypass for weight regain and diabetes recurrence. Surg Obes Relat Dis. 2015;11(6):1411. 14. Kamvissi V, Salerno A, Bornstein SR, et al. Incretins or anti- incretins? A new model for the "entero-pancreatic axis". Horm Metab Res. 2015;47(1):84–87. 15. Varela JE, Nguyen NT. Laparoscopic sleeve gastrectomy leads the U.S. utilization of bariatric surgery at academic medical centers. Surg Obes Relat Dis. 2015. FUNDING: No funding was provided. DISCLOSURES: The author report no conflicts of interest relevant to the content of this article. AUTHOR AFFILIATION: Felipe Chaux, MD, Mauricio Franco, MD, and J. Esteban Varela, MD, FACS, FASMBS, are with the Diabetes Surgery Institute and Centro de Cirugia para la Obesidad in Bogota D.C., Colombia. Dr. Varela is also Chairman of Surgery at HCA and Professor of Surgery at the University of Central Florida in Orlando, Florida. ADDRESS FOR CORRESPONDENCE: Esteban Varela, MD, FACS, FASMBS; Email: esteban.varela@ucf.edu BT

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