Revisional laparoscopic sleeve gastrectomy provides long-term weight loss, although peri-operative complications are significantly elevated compared to primary LSG, according to researchers from Monash University, Melbourne, Australia, who compared the long-term outcomes of sleeve gastrectomy as a revisional procedure after laparoscopic adjustable gastric banding (LAGB) across a range of measures and determined predictors of outcomes. The investigators noted that four variables predicted worse outcomes: eroded band, multiple prior bands, severe oesophageal dysmotility and elevated baseline weight. The findings were featured in the paper, ‘Long-term Outcomes of Laparoscopic Sleeve Gastrectomy as a Revisional Procedure Following Adjustable Gastric Banding: Variations in Outcomes Based on Indication’, published in Obesity Surgery.
For this study, the investigators retrospectively analysed data from 2006 to 2021 on the outcomes of LSG patients after LAGB (revisional LSG (RLSG)) and compared the outcomes from primary LSG (PLSG) patients (controls). A total of 1,800 patients were included in the study with 600 in the RLSG group and 1200 in the PLSG group. A 1:2 analysis of RLSG and controls were performed based on age, gender, pre-operative weight and BMI. In addition, patients were categorised into indications for RLSG based on the CORE classification for LAGB complications. Conversion of LAGB to LSG was performed for patients who had weight regain, adverse symptoms or complications of LAGB.
They reported that band removal was primarily due to weight loss failure (36.3%) and the median time between LAGB placement and revisional LSG was 91 months, with 80% (n=472) conducted as two-stage conversion procedures; 8/600 (1.3%) conversions were open procedures.
The median length of stay was significantly longer in RLSG vs the controls (3 days vs 2 days, p<0.001) and RLSG patients with post-operative complications had a longer length of stay (4 days vs 3 day, p<0.001) vs the controls. Furthermore, the RLSG group also had overall higher complications (4.8% vs 2.0%, p<0.0001) and re-admissions (4.3% vs 2.4%, p<0.012). The RLSG group had more frequent staple line leaks, compared to the control group (0.9% vs 2.5%, p<0.011). Interestingly, the leak site was at the proximal compartment of the sleeve in all patients.
A total of 22 RLSG patients (3.7%) had prior eroded bands, overall complication rates (65%) and readmission rates (55%) were markedly high in the eroded band patient group. LAGB patients who were converted due to pan oesophageal dilatations had higher complication (15%) and readmission rates (12%) when compared with the other CORE physiological groupings.
Using multivariate regression analysis, the researchers reported that eroded bands, number of band revisions and baseline weight were independent predictors of complications after RLSG:
The adjusted odds of having a complication among eroded band patients are 6.9-fold higher;
The odds of complications among those who have had two revision band procedures are 2.9-fold higher;
With every unit (kg) increment in baseline weight, the odds of having a complication increase by 8.8%.
In total, 7.3% of patients in the RLSG group had subsequent revisional surgery compared to the controls (3.2%) (p<0.0001). Reflux and weight regain were the most common indication for revision in both groups. Roux-en-Y gastric bypass (RYGB) was the most popular revision procedure in both groups. However, the rate of conversion to RYGB was higher in the RLSG group vs to the controls (3.3% vs 1.2%, <0.0001).
Those in the RLSG group reported that their quality of life was significantly less than the controls and community normal scores. Comparisons between the two sleeve groups demonstrated significant differences in physical function, energy/fatigue, pain and general health scores.
“Eroded LAGB, multiple prior band operations, oesophageal dilatation and elevated baseline weight significantly increased the risk of peri-operative complications, poor weight loss and long-term re-operation in the RLSG group,” the authors concluded. “These factors should be considered when discussing conversion of LAGB to LSG…Four situations following LAGB predict substantially worse outcomes: eroded gastric bands, multiple prior bands, oesophageal dysfunction and increased body weight. Eroded bands demonstrate a substantially increased risk of leaks that should preclude LSG. These data provide a framework for understanding the expected long-term outcomes and specific criteria for delineating situations that are at much higher risk of worse overall outcomes.
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