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Revisional Bariatric Surgery

Revisional Bariatric Surgery in the Gulf

Since 2014, LSG has become the most commonly performed bariatric procedure worldwide as well as the number one performed procedure in the Asia/Pacific region
With the rising number of patients undergoing revisional/secondary bariatric surgeries, the interest in researching their utilization and effectiveness is conversely on a rise

Obesity has become a global clinical concern, and especially alarming in the Arabian Gulf. With an area close to that of Europe, investigating this topic has caused a rise in interest among physicians and the population alike. The latest report from the World Health Organization (WHO) was able to show them as being the countries with the highest incidence of obesity in the 30% plus group [1]. Furthermore, the estimated percentage of individuals aged 18 and above with a body mass index (BMI) of 30 and above in each of the Gulf countries as of 2014 proved to be 42.3% in Qatar, 39.7% in Kuwait, 37.2% in United Arab Emirates (UAE), 35.1% in Bahrain, 34.7 in Saudi Arabia, and 30.9% in Oman [1].

This article was authored by - Salman Al-Sabah MD MBA FRCSC FACS, President of the Kuwait Association of Surgeons, American College of Surgeons, Governor, Kuwait, Consultant Surgeon, Al-Amiri Hospital, Kuwait,Assistant Professor of Surgery, Kuwait University

Additionally, the prevalence of obesity has significantly increased in all countries of the Gulf as compared with 2010. Obesity has been proven to be linked with multiple co-morbidities, including type 2 diabetes, hypertension, chronic kidney disease, hyperlipidemia, cancer, asthma, cardiac failure, gout and sleep apnea, to name a few. Therefore, it is plausible to explore and identify effective solutions for managing and treating obesity especially in the region that has become the global leaders of obesity.

While conventional methods for weight loss such as dietary restriction, increased exercise, and weight loss medications can be effective for a certain population of people, some patients fall into extreme conditions for which bariatric surgery comes into play. Presently, bariatric surgery is the only available treatment for morbid obesity that consistently achieves and maintains substantial weight loss, decreases the incidence and severity of obesity-related comorbidities, and improves overall quality of life and survival [2]. The most commonly recognized bariatric procedures nowadays include gastric balloons, gastric bypass surgeries (LRYGB), sleeve gastrectomy, adjustable gastric banding (LAGB), biliopancreatic diversion with/without duodenal switch (LBPD-DS) and laparoscopic sleeve gastrectomy (LSG) surgery which has widely gained popularity over recent years [3].

Since 2014, LSG has become the most commonly performed bariatric procedure worldwide as well as the number one performed procedure in the Asia/Pacific region [3]. According to the International Federation of Surgical Obesity (IFSO) 2017 global registry, LSG is performed in the majority of the number of procedures in Kuwait and Saudi Arabia as compared to Sweden where RYGM is the most performed of the procedures. In Kuwait alone, the total number of LSG’s performed annually between the years 2012 and 2015 was 4500-6000, and therefore, it is imperative to examine the outcomes after this procedure in particular in that part of the world. The popularity of LSG’s can most likely be attributed to the relative surgical simplicity of the procedure, as well as a low complication rate, significant improvement in comorbidities and evident weight loss seen after it [4].

“Our study showed that revising an LSG with an LRSG or LRYGB for poor weight loss is feasible with good outcomes and comparable results after a 1-year follow-up period” the researchers concluded. “In addition, by comparing both LRSG and LRYGB groups, we found that patients who failed to lose weight after the primary LSG achieved better outcomes than those who regained weight after the primary LSG.”

While bariatric surgery is a highly effective and durable form of therapy, as with many other chronic diseases requiring medical or surgical therapy, there will be patients who respond well to an initial therapy and others with only a partial response. There will also be a subset of patients who are non-responders or have recurrent or persistent disease or complications of therapy; these patients may require escalation of therapy, a new treatment modality, or correction of complications. Weight regain and the recurrence of obesity is one of the major concerns for patients and surgeons alike in the bariatric domain.

With the rising number of patients undergoing revisional/secondary bariatric surgeries, the interest in researching their utilization and effectiveness is conversely on a rise, making them a main research interest in recent years, and given that LSG’s are of the most preformed bariatric surgeries in the Arabian Gulf, the interest of revisional surgeries from LSG’s is of even more interest from that region.

One of the complications after LSG is gastroesophageal reflux disorder (GERD). There is increase in the evidence that suggests that GERD is a growing concern after LSG. There is a need for research to look at the management of GERD for patients that have undergone LSG. Some of the underlying areas to explore include causes, management and the effects in long term outcomes. One of the recent techniques used to manage GERD is by performing a cardiopexy utilizing the ligamentum teres [6].

A study conducted at our institute was able to shed some light on this topic [7]. Looking at long-term failure rates from the list mentioned earlier, with failure defined as < 50% excess weight loss at 1 year post-operatively, LAGB was leading with >50% failure rate, followed by LSG with 30% failure rate, then LRYGB (15%) and LBPD-DS (<5%) [7]. Furthermore, according to Felsenreich DM et al.’s study [8] analyzing the 10-year outcomes after LSG, 36% of patients that had undergone primary sleeve gastrectomy required a revisional surgery; with that said, in comparison to malabsorptive procedures, weight regain is known to be more common in restrictive procedures.

Key Messages:

Prevention of weight regain, through development of multidisciplinary bariatric programs
10%-20% of LSG, which is the most common procedure in the region, may require revisional procedures on the mid-long term follow up
Revisional procedures should be performed by specialized centers with experienced teams
More research is needed on obesity and metabolic surgery from the region
The Gulf Obesity Surgery Society was established to collaboratively impact the burden of obesity with a primary focus on research and sharing of experiences within the Gulf region.
However, both the LRSG and the LRYGB groups managed to achieve a %EWL of 57.6 and 61.3% at 1 year after undergoing their respective revisional surgery. It is interesting to note that the selection criteria included patients that had insufficient weight loss and dilation of the gastric sleeve.

As seen from these numbers, and keeping in mind the fact that LSG’s are the most performed bariatric procedures in the Arabian gulf, investigating the reasons and outcomes for revisional surgeries post initial LSG is of critical importance from that region. From our study 2.6% of our 1300 LSG patients underwent a revisional procedure post LSG, of which 67% of them underwent laparoscopic re-sleeve gastrectomy (LRSG), while the rest opted for LRYGB. Prior to undergoing initial LSG, the weight and BMI of the patients was 134.6Kg and 50Kg/m2. After one year from surgery, these numbers managed to decrease to only 104Kg and 42Kg/m2 in the group of patients that had to undergo a revisional procedure, corresponding to a % excess weight loss of 47.4%.

When looking into previously conducted studies, Ranvier et al. [9] undertook a review that combined the current recommendations for revisional bariatric surgery. According to their findings, patients that suffer from severe reflux post initial LSG benefit more from a RYGB, while those who present with a dilated sleeve can sometimes benefit from receiving a re-sleeve gastrectomy. With all of that said, certain    questions are brought to mind; what caused the patient to fail their initial surgery to begin with, was it certain patient pre-operative factors, or the surgery chosen to begin with was not compatible for that individual patient? What factors come into play when looking into revisional options, and how do you choose the correct revisional bariatric surgery? All of these factors are of particularly equal and relative importance and that is why exploring them was a main objective of our research.

Therefore, we can see that taking in individual pre-operative patient characteristics is imperative when it comes to choosing the appropriate revisional surgery. “Our study showed that revising an LSG with an LRSG or LRYGB for poor weight loss is feasible with good outcomes and comparable results after a 1-year follow-up period” the researchers concluded. “In addition, by comparing both LRSG and LRYGB groups, we found that patients who failed to lose weight after the primary LSG achieved better outcomes than those who regained weight after the primary LSG. [6]”

There is a need of standard definition for weight loss, successful weight loss and weight regain. Larger prospective studies are required to further understand the underlying mechanisms of weight regain following Bariatric surgery.

References

  1. Global status report on noncommunicable diseases 2014. World Health Organization (ISBN: 978-92-4-156485-4)
  2. Sjöström L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, Dahlgren S, Larsson B, Narbro K, Sjöström CD, Sullivan M, Wedel H, Swedish Obese Subjects Study Scientific Group Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. New Engl J Med. 2004;351:2683–2693. doi: 10.1056/NEJMoa035622. John Dibaise 14 Sep 2012
  3. Angrisani, L., Santonicola, A., Iovino, P., Vitiello, A., Zundel, N., Buchwald, H., & Scopinaro, N. (2017). Bariatric surgery and endoluminal procedures: IFSO worldwide survey 2014. Obesity surgery, 1-11.
  4. Deitel, M., Gagner, M., Erickson, A., & Crosby, R. (2011). Third International Summit: current status of sleeve gastrectomy. Surgery For Obesity And Related Diseases7(6), 749-759.
  5. Alsabah, S., Alsharqawi, N., Almulla, A., Akrof, S., Alenezi, K., Buhaimed, W., . . . Haddad, M. A. (2016). Approach to Poor Weight Loss After Laparoscopic Sleeve Gastrectomy: Re-sleeve Vs. Gastric Bypass. Obesity Surgery, 26(10), 2302-2307.
  6. Al-Sabah, S., Akrouf, S., Alhaddad, M., & Vaz, J. D. (2017). Management of gastroesophageal reflux disease and hiatal hernia post–sleeve gastrectomy: cardiopexy with ligamentum teres. Surgery for Obesity and Related Diseases.
  7. Madura, J., & Dibaise, J. (2012). Quick fix or long-term cure? Pros and cons of bariatric surgery. F100 Medicien Reports, 4. doi:10.3410/m4-19
  8. Felsenreich, D. M., Langer, F. B., Kefurt, R., Panhofer, P., Schermann, M., Beckerhinn, P., . . . Prager, G. (2016). Weight loss, weight regain, and conversions to Roux-en-Y gastric bypass: 10-year results of laparoscopic sleeve gastrectomy. Surgery for Obesity and Related Diseases, 12(9), 1655-1662
  9. Ranvier, G., & Ghanem, M. (2016). Revisional bariatric surgery: A review of the current recommendations. Saudi Journal of Laparoscopy, 1(1), 5. 

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