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Revisional surgery

Roux-en-Y “procedure of choice” to revise gastroplasty

Illustrations from the paper demonstrate pouch creation after a banded gastroplasty.
Procedure gives satisfactory long-term weight loss and revision of complications
Late complications observed in 7.7% of series

The “technically challenging but safe” use of Roux-en-Y gastric bypass should be considered the procedure of choice to revise a failed vertical banded gastroplasty, according to a new paper published in Obesity Surgery.

Describing the results of 153 revisional operations performed at AZ Sint Jan Brugge-Oostende AV, Bruges, Belgium, between February 2004 and February 2011, Peter Vasas, Bruno Dillemans, and colleagues showed that using Roux-en-Y to revise the now-outmoded gastroplasty operation resulted in an almost complete resolution of gastric outlet obstruction, and a statistically significant weight loss for the patients.

At two years after the revisional procedure, the average BMI among the patients had decreased from an average of 34.2 to 28.8. A vast majority of the patients also experienced a complete revision of their gastrointestinal symptoms, including dysphagia, intractable vomiting, and gastro-oesophageal reflux disease. Type 2 diabetes symptoms were resolved in 79% of patients, while hypertension improved in 70.6% of patients.

However, late complications developed in 11 patients - 7.7% of the series – and seven patients required surgery for correction.

Eight patients experienced unsuccessful weight loss or weight regain after the operation, and were given dietary modification and behavioural counselling. Two patients also received gastric bands to obtain food restriction, and one patient had pouch reconstruction five years after the revisional operation.

The authors say that while other papers have evaluated the procedure, few have included a substantial number of patients, or focused on long-term weight-loss data. They say that their study is the largest single-centre series recording the laparoscopic conversion of banded gastroplasty to Roux-en-Y.

Revision

While vertical banded gastroplasty was once a popular option for bariatric surgery, it has fallen out of favour after failure rates as high as 79% were reported – primarily due to insufficient long-term weight loss and late complications like band erosion and stenosis.

For this paper, failure was defined as less than 50% excess weight loss, or a residual BMI over 35.

The authors also recommended a series of “specific and individually patient-tailored surgical technical refinements” when performing a revisional gastric bypass in order to ensure a low complication rate. 

The authors always construct the new gastric pouch by horizontally transecting the stomach well above the location of the scar tissue surrounding the ring and mesh from the original operation.

Leaving a small pouch to create a gastrojejunostomy rather than an esophagojejunostomy, say the authors, avoids eliminating presumed neurological pathways between the stretch receptors in the gastric pouch and the cerebral appetite centres, which potentially hamper satiety.

The majority of patients also have a substantially thicker gastric wall than those observed in primary bypass patients, due to chronic distension of the gastric pouch, so the authors generally used a 4.8mm or higher staple when transecting the stomach tissue.

In creating the gastrojejunostomy, the authors prefer a circular stapled method, with a 25mm stapler brought in transabdominally through a left dilated incision.

The authors recommend that surgeons carefully identify the old staple lines on both the front and back of the stomach, to prevent mucocoele formation and possible ischemia between the new and original staple lines. 

They also recommend a methylene blue leak test via the orogastric tube at the end of the procedure, to help the surgeon detect anastomotic failures, and immediately correct them if necessary.

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