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SAGES 2013

Revisional surgery is safe and effective

revisional surgery should be undertaken by an experienced surgeon and in selected patients
Bypass and sleeve comparable after band failure

Several studies present at SAGES 2013 showed that revisional bariatric surgery is safe and effective, and can result in excellent perioperative outcomes. However, researchers noted that revisional surgery should be undertaken by an experienced surgeon and in selected patients, and a prospective randomised trial should be designed to determine which the most suitable revisional procedure. 

Researchers from CMC-Mercy, Carolinas Healthcare System, Charlotte, carried out a review from 1,519 patients undergoing bariatric surgery and examined the indications and perioperative risk profile of revisional bariatric surgery, compared with primary bariatric procedures. 

Between June 2005 and June 2012, all patients records who underwent bariatric surgery (performed by three fellowship trained bariatric surgeons) were reviewed and divided into four categories: band to bypass, band to sleeve gastrectomy, bypass revision and fundoplication to bypass.

Patient demographics (age, baseline BMI, etc) and procedural data (type of initial and revisional operation, number of prior gastric surgeries at time of operation, indications for revision, postoperative morbidity and mortality, length of stay, 30-day readmissions, reoperations, and leaks) were recorded and compared between revisional and primary procedures.

From the 1,519 patients undergoing bariatric surgery 4.9 % (74) had revisional procedures, the indications for revisions included: inadequate weight loss (47 patients), failed fundoplications with recurrent GERD (25 patients), recalcitrant anastomotic ulcers and excess weight loss (in one patient each).

The outcomes revealed that revisional procedures were associated with higher rates of readmissions and overall morbidity, but no differences were found in leak rates and mortality compared with primary procedures.

With regard to the procedure type, band revisions had similar length of stay and did not require reoperations, compared with the respective primary procedures but the length of stay after bypass revision or fundoplication to bypass revision was longer with a higher leak rate and 20% required repeat surgery.  

“In experienced hands, revisional bariatric procedures can be accomplished with excellent perioperative outcomes that are similar to primary procedures,” the authors concluded. “As the complexity of the revisional procedure and number of prior surgeries increases, however, so does the perioperative morbidity; fundoplication revisions to gastric bypass represent the highest risk group. Further analysis to determine which is the best procedure should be addressed with a prospective randomised trial.” 

Revisional surgery for banding

A further two studies have reported the results of conversion from band to either sleeve gastrectomy and Roux-en-Y gastric bypass.

Investigators from Las Americas Private Hospital, Guatemala City, Guatemala, reported that the results of conversion from band to either sleeve gastrectomy and Roux-en-Y gastric bypass are comparable. However, conversion to bypass was associated with increased operative times, length of hospital stay and length to return to normal activities, primarily due to the more demanding technical aspects of converting a gastric band to bypass.

The investigators conducted their study to assess whether sleeve gastrectomy or Roux-en-Y gastric bypass is the most appropriate operation following failed gastric banding.

They reviewed the records of 916 patients who underwent gastric banding since 2000. Of the 42 patients who had u revisional bariatric surgery for failed gastric banding, 22 (underwent conversion to sleeve and 20 had a conversion to bypass.

There were no significant different in the procedural weight (236+/-26 and 257+/-45lb), age (35 +/-11 vs. 43+/-14 years), gender ratio (73% vs 60% male patients), estimated blood loss (163 [50-600] vs 180 [50-800] ml), rate of conversion to open surgery (9% vs. 5%), intraoperative complications (9% vs. 10%), postoperative complications (14% vs. 20%) patients who had conversion to sleeve and bypass, respectively.

They did report a significant difference in operative time (155+/-26 vs. 208+/-45 min), length of hospital stay (2+/0.5 vs. 4+/2 days), and return to normal activities (7+/2 vs. 11+/4 days) between patients the two groups. There was no difference in the postoperative weight loss (66+/-24 and 80+/-33lb), between the groups.

“Revisional bariatric surgery through laparoscopic approach in patients with inadequate weight loss following gastric banding is safe and effective,” the researchers concluded. “Both procedures result in significant weight loss at long-term follow-up with low complication rates. Further analysis to determine which is the best procedure, should be addressed with a prospective randomized trial.”

In the second study, researchers from Penn State Milton S Hershey Medical Center, reported the incidence and outcomes of revisional weight loss surgery after laparoscopic gastric banding.  

From June 2006 to August 2012, 253 patients received a gastric band of whom 101 patients (40%) required reoperation, either bypass (48) or sleeve (7). The majority of the indication for conversion were dysphagia (62%), inadequate weight loss (29%), symptomatic reflux (4%), gastric prolapse (4%) and needle phobia (2%). Two of the 55 patients required conversion to an open bypass because of extensive adhesions.

Revisional surgery was undertaken approximately 33±13 months after the initial banding procedure. A staged removal of gastric band and revisional weight loss procedure was performed in 15 patients with a median interval of 2.5 [1.2-7] months between procedures, median operative time was 160 [142-183] minutes and median hospital length of stay was two (1-3) days.

Early complications occurred in nine patients (16%) including two anastomotic leaks and 12 patients (22%) presented with late complications requiring intervention, and there was one mortality.

At a median follow up of seven months, excess body weight loss was 42± 24% and 49% of patients achieved a BMI of less than 33.  

“Reoperative weight loss surgery can be performed in selected patients with a higher rate of complications than primary surgery with food short term weight loss outcomes can be achieved,” they concluded.

Patient selection

Female patients who are under 50 and who have had a gastric band for less than five years have better %EWL after revisional surgery, according to researchers from Chang Gung University, Taiwan and the University Hospital of Strabourg, France.

They examined the results of revisional surgery with respect to age, gender, revisional procedure and timing to try and ascertain which patients would most benefit from additional surgery following band failure.

From January 1996 to November 2011, 243 patient received a gastric band of which 130 (53.5%) were removed.  Ninety 37.7%) of the 243 patients (had revisional surgery: 40 patients had a bypass after they presented with gastroesophageal reflux disease, post-banding oesophageal motility disturbance, hiatal hernia or diabetes. 48 patients receiving a sleeve as it was not contraindicated.

The one-stage revisional surgery consisted in removing the band and performing the bariatric procedure simultaneously. Two-stage surgery consisted in removing band and performing revisional surgery three to six months later.  

Eighty-eight patients (74 females; mean age 42.79±10.03 years; mean body weight 123.22±23.09kg; mean BMI 44.73±6.19) successfully underwent revisional sleeve or bypass, in two cases, revisional surgery by laparoscopy was aborted due to the impossibility to approach safely the upper stomach for severe adhesions.  

One-stage surgery was performed in 29 cases and two-stage surgery in 59 cases. The follow up rate was 78.2% (n=61) and 40.9% (n=36) at 12 and 24 months, respectively.  

One major complication (staple-line leakage) after sleeve was managed surgically and there were no deaths. During follow-up, there were ten additional complications including: six portsite hernias, two unexplained cases of abdominal pain and vomiting with negative imaging and laparoscopic exploration, one internal herniation (managed by laparoscopic repair) and one gastro-jejunostomy stricture (managed through endoscopic dilatations).

The results showed that %EWL was 31.24%, 40.92%, 52.41%, and 51.68% at three, six, 12, and 24 months of follow-up, respectively. EWL at one-year was independent of:

  • the revisional procedure (49.84% after sleeve vs. 56.49% after bypass p=0.18);
  • the reasons for band removal (52.82% after failure to lose weight vs. 51.03% if removed for complications; p=0.52);
  • the timing of revision (51.04% one-stage vs.54.11% two-stage p=0.43); and
  • initial BMI (42.64% in patients with BMI≥50 vs.55.27% in patients with BMI<50 p=0.05).

However, they reported a statistically significantly higher %EWL in patients <50 years old (55.90% vs. 41.50% in patients >50 years-old; p= 0.01), females (55.22% vs. 40.73% in male; p=0.04), and in patients in which the band was in place for less than five years (57.09% vs. 47.43% if >5 years, p=0.02).  

The researchers report no differences with regard to timing or type of surgery.  

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