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 Table of Contents  
REVIEW ARTICLE
Year : 2016  |  Volume : 1  |  Issue : 1  |  Page : 5-8

Revisional bariatric surgery: A review of the current recommendations


1 Department of Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY 10029, USA
2 Department of Surgery, Division of Metabolic, Endocrine and Minimally Invasive Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY 10029, USA

Date of Web Publication25-Oct-2016

Correspondence Address:
Gustavo Fernandez Ranvier
Department of Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 5 East 98th Street, Box 1259, New York, NY 10029
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2542-4629.193038

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  Abstract 

Revisional bariatric surgery is increasingly becoming popular as the number of primary procedures for the treatment of obesity gains popularity. It is estimated that about 10% of patients who underwent a bariatric procedure will need revisional surgery. The most common indications for revisional bariatric surgery are inadequate weight loss (<25% of excess body weight loss) and weight regain (gain of more than 10 kg based on the nadir weight); however, procedure-specific complications are also indication of the need for revisional surgery. In this article, we review the current most common bariatric procedures with its complications, indications for revision, alternative procedures, and outcomes.

Keywords: Adjustable gastric banding; bariatric surgery; duodenal switch; revisional; Roux-en-Y gastric bypass; sleeve gastrectomy; vertical-banded gastroplasty.


How to cite this article:
Ghanem M, Ranvier GF. Revisional bariatric surgery: A review of the current recommendations. Saudi J Laparosc 2016;1:5-8

How to cite this URL:
Ghanem M, Ranvier GF. Revisional bariatric surgery: A review of the current recommendations. Saudi J Laparosc [serial online] 2016 [cited 2017 Oct 21];1:5-8. Available from: http://www.saudijl.org/text.asp?2016/1/1/5/193038


  Introduction Top


Morbid obesity is the ailment of the 21 st century. The number of bariatric surgery is significantly increasing in the last decade, with a number of revisions. The incidence of surgical revisions depends on the bariatric procedure, but in general, it can reach up to 50%, [1] with the average being 10%-25%. [2] The lowest rates are associated with biliopancreatic diversion with duodenal switch (BPD/DS) [3] and the highest with adjustable gastric band (AGB). [4] As purely restrictive procedures such as the vertical-banded gastroplasty (VBG) and AGB have fallen out of favor due to their high failure rate, bariatric surgeons nowadays commonly encounter patients in need of revisional procedures to malabsorptive or combined procedures. The indications for revisional bariatric surgery vary according to the primary procedure done, and so do the technical challenges. The most common indication for revision is weight regain. [1] Even though still scarce, new studies show that revisional surgery is both safe and effective if performed by experienced hands. [5]

This review discusses the variable procedures, challenges, and controversies associated with revisional bariatric surgery.



Vertical-banded Gastroplasty

VBG is a restrictive procedure of the past, and is very rarely performed nowadays. However, bariatric surgeons often have to manage patients with failed VBG, commonly performed in the open technique. The most common reason for revision from VBG is weight regain either due to breakdown of the staple line or the patients learn to eat food that disintegrates easily, bypassing the restrictive element of the procedure. [1] A preoperative endoscopy is key in such cases and can show dehiscence of the staple line or signs of reflux.

In such cases, the revision should first of all include the removal of the VBG band. Patients who are suffering from restrictive symptoms and are not interested in further bariatric intervention can benefit from gastrogastrostomy. The patients are very likely, however, to gain weight after the procedure. Those who wish to have a bariatric procedure performed can be revised to either a Roux-en-Y gastric bypass (RYGB) or BPD. From the author's experience, BPD is the wiser option, as it avoids having tissue in the pouch incarcerated between the previous VBG staple line.

Revision from VBG to RYGB has shown relatively satisfying results in terms of weight loss and seems to be safe in the experienced hands, [9] despite having higher morbidity and mortality than primary procedures, as in most revisional procedures [Table 1].
Table 1: Surgical treatment per etiology after VBG


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  Adjustable Gastric Band Top


Once the most popular bariatric procedure, it has eventually fallen out of favor around the late 1990s, mostly due to high failure rates. [7] The indications for failure vary from technical failures in the band instrumentations, as leaks from the pipe connecting the band to the port to slippage require removal of the band or simply weight regain.

Patients who suffer from purely technical problems with the band can benefit from replacement of the band or even the port alone, depending on the problem. [10] Removal of the band alone, while relieving restrictive symptoms, is highly associated with weight regain.

Replacement of the band is often associated with a high complication rate of up to 20%. [11] It is recommended to replace the band only in patients who had a highly successful first procedure and need a revisional procedure due to hardware malfunction.

After removal of the band, revision to sleeve gastrectomy can be performed. Even though some might argue that a RYGB is the safer procedure, multiple studies have shown that a laparoscopic sleeve gastrectomy (LSG) is a safe and effective procedure in experienced hands. [12]

It can be done either as a one-staged operation with performing the sleeve gastrectomy at the same time of the band removal or as a two-staged procedure with the LSG performed at a later time. Some surgeons argue that band removal and an interval sleeve are safer, with the sleeve performed months after the band is removed. Advocates for the two-staged technique believe that after a few months, the tissue underneath the previous band becomes less fibrotic, and the chronic inflammation created by the band partially subsides, hence making the procedure safer with less leak rates. One study that collected the American College of Surgeons National Surgical Quality Improvement Program data between the years 2010 and 2012 identified 11,546 patients who underwent LSG, of which 3% had band removal as well. [13] The primary outcome studied was sepsis in the early postoperative period (<30 days). The patients who underwent concomitant LSG and removal of band were significantly more likely to develop sepsis as opposed to those who underwent LSG alone (P = 0.022). There was no difference in mortality. The authors of the study reached a conclusion that it is safe to perform a one-staged band removal and LSG nonetheless, as a higher complication rate is to be expected in any revisional procedure as opposed to a primary one.

To the contrary, one retrospective multicenter cohort study compared a two-staged band removal and LSG to a control group. Seventy-six two-staged revisional procedures were compared to 279 primary LSG, with the revisional sleeves done at least 2 months after the band removal. [14] The primary end point was early (<30 day) postoperative mortality and morbidity. The study showed comparable results in terms of complications and estimated weight loss (EWL) at 2-year follow up.

Laparoscopic conversion to Roux En Y Gastric Bypass (LRYGB) is a more logical approach, as it is believed by many that once one restrictive procedure failed (laparoscopic adjustable gastric banding [LAGB]), the other restrictive procedures such as LSG are deemed for failure as well in these patients. [12] There are studies with medium-term follow-up showing results as good as primary LRYGB in terms of EWL, with an acceptable complication rate. [15] Some would add an adjustable or nonadjustable band to the pouch, creating a banded gastric bypass. The band is usually placed just above the gastrojejunostomy in these cases, and it is believed to prevent widening of the anastomosis and help maintain restriction over time.

Conversion to BPD/DS does seem to be effective for EWL, even though data are limited. [16] The complication rate seems to be higher than primary procedures.


  Revision from Sleeve Gastrectomy Top


Laparoscopic sleeve gastrectomy (LSG) was a procedure historically made as the first of a two-staged procedure, which enabled the patients to lose weight and reduce the comorbidities before the ultimate procedure was done, either a BPD/DS or LRYGB. Eventually, the LSG started getting used as a stand-alone procedure after proving its efficacy in weight loss and comorbidity improvement, and it is nowadays the most commonly performed bariatric procedure in the United States. [17] However, the revision rate can reach up to 11% in some studies, whether due to inadequate weight loss or severe gastroesophageal reflux disease (GERD). [8] The revision options are multiple, and the most appropriate procedure depends on the cause of the revision. Patients who suffer from severe reflux can benefit from RYGB, and those who have a dilated sleeve can sometimes benefit from re-sleeve gastrectomy. Other options would be conversion to BPD or a mini gastric bypass [Table 2].
Table 2: Etiology for revision of LAGB


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One study comparing the conversion of 43 LSG patients to bypass or BPD/DS showed better weight loss with the BPD/DS group, with however increased risk of vitamin deficiencies as opposed to bypass with no difference between the two groups in short-term complications. [8] The indications to conversion were inadequate weight loss and weight regain.

Another complication after LSG that may require surgery is chronic leak. These leaks usually persist as chronic fistulas or abscesses. Abscesses are usually drained either surgically or laparoscopically, and fistulas are managed endoscopically with stents or clips. Those that persist despite the above treatment may require definitive surgery. The options are resection of the fistula and conversion to a bypass, total resection of the sleeve with esophagojejunostomy, or fistulojejunostomy as an "omega loop." The choice of procedure depends on the location of the leak. [15]


  Discussion Top


The rate of revisional surgery after bariatric procedures varies depending on the primary procedure, but can however be as high as 60% in some studies. [18] With such high rates of revisional surgery, more data are emerging on the efficacy and safety of the conversion of each procedure to another. Short- and medium-term results are showing acceptable outcomes with favorable results in terms of weight loss and resolution of comorbidities, along with an expected higher yet acceptable rate of short-term complications such as leak when compared to primary procedures.

A proper preoperative workup before such revisional procedures is key and the etiology for failure of the primary procedure which needs to be thoroughly studied and analyzed, as the type of revisional procedure to be performed depends on the etiology. The most common cause for revision is weight regain. Not all causes of weight regain are procedure related, some can be addressed with dietary and behavioral modifications. [1] One must remember that not all obesity can be cured. Other common causes of revision include GERD, especially after LSG or obstructive symptoms after VBG and LAGB.

The most commonly encountered revisional procedure is post-AGB. Data vary on the type of procedure and timing, but most bariatric surgeons nowadays tend to remove the gastric band and either convert to LSG or RYGB, whether one or two staged.

With LSG being the most commonly performed bariatric procedure nowadays, we are facing an increasing number of patients suffering from weight regain after LSG. These patients can be converted to either a RYGB or a BPD/DS. Those suffering from a chronic leak after LSG may eventually need surgical intervention with a variety of surgical options to consider depending on the type and location of the leak. Another cause of revision after LSG is GERD, and these patients can improve significantly after conversion to RYGB.

Even though long-term studies are still scarce, the results of revisional procedures seem promising. All bariatric procedures are at a risk for failure mainly from either poor weight loss or procedure-specific complications. One must remember that failure of one bariatric procedure is not the end of the road, and referring these patients to experienced bariatric surgeons can be of extreme benefit for these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Vijgen GH, Schouten R, Pelzers L, Greve JW, van Helden SH, Bouvy ND. Revision of laparoscopic adjustable gastric banding: Success or failure? Obes Surg 2012;22:287-92.  Back to cited text no. 11
    
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Dapri G, Cadière GB, Himpens J. Feasibility and technique of laparoscopic conversion of adjustable gastric banding to sleeve gastrectomy. Surg Obes Relat Dis 2009;5:72-6.  Back to cited text no. 12
    
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Ramly EP, Alami RS, Tamim H, Kantar R, Elias E, Safadi BY. Concomitant removal of gastric band and sleeve gastrectomy: Analysis of outcomes and complications from the ACS-NSQIP database. Surg Obes Relat Dis 2016;12:984-8.  Back to cited text no. 13
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Silecchia G, Rizzello M, De Angelis F, Raparelli L, Greco F, Perrotta N, et al. Laparoscopic sleeve gastrectomy as a revisional procedure for failed laparoscopic gastric banding with a "2-step approach": A multicenter study. Surg Obes Relat Dis 2014;10:626-31.  Back to cited text no. 14
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Brethauer SA, Kothari S, Sudan R, Williams B, English WJ, Brengman M, et al. Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force. Surg Obes Relat Dis 2014;10:952-72.  Back to cited text no. 15
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Topart P, Becouarn G, Ritz P. Biliopancreatic diversion with duodenal switch or gastric bypass for failed gastric banding: Retrospective study from two institutions with preliminary results. Surg Obes Relat Dis 2007;3:521-5.  Back to cited text no. 16
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[PUBMED]    



 
 
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