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Conversion from Gastric Bypass to Sleeve Gastrectomy for Complications of Gastric Bypass

Authors:

Abstract

Background: Complications after gastric bypass (RYGB) are well documented. Reversal of RYGB is indicated in select cases but can lead to weight gain. Conversion from RYGB to sleeve gastrectomy (SG) has been proposed for correction of complications of RYGB without associated weight gain. However, little is known about outcomes after this procedure. Objectives: To examine outcomes after conversion from RYGB to SG. Setting: University hospital. Methods: A retrospective study of patients who underwent RYGB to SG conversion was undertaken. Results: Twelve patients underwent RYGB to SG conversion for refractory marginal ulceration, stricture, dumping, gastrogastric fistula, hypoglycemia, and failed weight loss. No deaths occurred. Four patients experienced 7 major complications, including portal vein thrombosis, bleeding, pancreatic leak, pulmonary embolus, seroma, anastomotic leak, and stricture. Two required reoperation, and 6 were readmitted within 30 days. Four required nasoenteric feeding postoperatively because of prolonged nausea. The complication of RYGB resolved in 11 of 12 patients. At 14.7 months, change in body mass index for all patients was a decrease of 2.2 kg/m(2). In 5 patients with morbid obesity at conversion, the change in body mass index was a decrease of 6.4 kg/m(2) at 19 months. Conclusions: Laparoscopic conversion from RYGB to SG is successful in resolving certain complications of RYGB and does not result in short-term weight gain. However, conversion has a high rate of major complications as well as a high rate of readmission and need for supplemental nutrition. Although conversion to SG may be appropriate in carefully-selected patients, other options for patients with severe chronic complications after RYGB should be considered.
Surgery for Obesity and Related Diseases 12 (2016) 572576
Original article
Conversion from gastric bypass to sleeve gastrectomy for complications
of gastric bypass
Cullen O. Carter, M.D.
*
, Adolfo Z. Fernandez, M.D., Stephen S. McNatt, M.D.,
Myron S. Powell, M.D.
Department of Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina
Received June 2, 2015; accepted July 1, 2015
Abstract Background: Complications after gastric bypass (RYGB) are well documented. Reversal of RYGB
is indicated in select cases but can lead to weight gain. Conversion from RYGB to sleeve gas-
trectomy (SG) has been proposed for correction of complications of RYGB without associated
weight gain. However, little is known about outcomes after this procedure.
Objectives: To examine outcomes after conversion from RYGB to SG.
Setting: University hospital.
Methods: A retrospective study of patients who underwent RYGB to SG conversion was
undertaken.
Results: Twelve patients underwent RYGB to SG conversion for refractory marginal ulceration,
stricture, dumping, gastrogastric stula, hypoglycemia, and failed weight loss. No deaths occurred.
Four patients experienced 7 major complications, including portal vein thrombosis, bleeding, pan-
creatic leak, pulmonary embolus, seroma, anastomotic leak, and stricture. Two required reoperation,
and 6 were readmitted within 30 days. Four required nasoenteric feeding postoperatively because of
prolonged nausea. The complication of RYGB resolved in 11 of 12 patients. At 14.7 months, change
in body mass index for all patients was a decrease of 2.2 kg/m
2
. In 5 patients with morbid obesity at
conversion, the change in body mass index was a decrease of 6.4 kg/m
2
at 19 months.
Conclusions: Laparoscopic conversion from RYGB to SG is successful in resolving certain
complications of RYGB and does not result in short-term weight gain. However, conversion has a
high rate of major complications as well as a high rate of readmission and need for supplemental
nutrition. Although conversion to SG may be appropriate in carefully-selected patients, other options
for patients with severe chronic complications after RYGB should be considered. (Surg Obes Relat
Dis 2016;12:572576.) r2016 American Society for Metabolic and Bariatric Surgery. All rights
reserved.
Keywords: Gastric bypass; Sleeve gastrectomy; Intractable dumping syndrome; Revisional bariatric surgery; Conversion;
Bariatric surgery; Bariatric complications; Failed weight loss
Laparoscopic Roux-en-Y gastric bypass (RYGB) was the
most common bariatric procedure performed in the United
States from 2004 to 2012, after which sleeve gastrectomy
(SG) became the most common procedure [1]. Despite
excellent weight loss and resolution of co-morbid condi-
tions experienced by most patients, RYGB is known to
cause long-term complications.
Overall, indications for reversal of RYGB are extremely
rare and include intractable nausea, severe dumping syn-
drome, cachexia, psychological issues, chronic pain, recur-
rent anastomotic ulceration, and refractory neuroglycopenia
[2]. Although long-term results of reversal of RYGB are not
http://dx.doi.org/10.1016/j.soard.2015.07.001
1550-7289/r2016 American Society for Metabolic and Bariatric Surgery. All rights reserved.
*
Correspondence: Cullen O. Carter, M.D., Department of Surgery, 1
Medical Center Boulevard, Winston-Salem, NC 27157, USA.
E-mail: cullencarter@gmail.com
published in the literature, it is known that most patients who
undergo reversal of other weight loss procedures such as
jejunoileal bypass regain all of the lost weight [3] and that re-
establishment of normal anatomy in the form of gastrogastric
stula can lead to signicant weight gain [4]. Thus, many
patients who experience severe complications of RYGB are
hesitant to undergo reversal to normal anatomy.
Conversion from RYGB to SG has been proposed as a
method for correcting certain complications of RYGB without
associated weight gain. Such a procedure has been described
for correction of retrograde intussusception [5], weight regain
[6,7], intractable dumping syndrome [8], cachexia [7], severe
neuroglycopenia [7,9], and hypocalcemia after inadvertent
parathyroidectomy [9]. Currently, there are 5 series in the
literature describing a total of 27 patients who have undergone
conversion from RYGB to SG. Thus, little is known about the
long-term outcome of the procedure. We hereby report our
experience with conversion from RYGB to SG.
Methods
A total of 12 patients who underwent conversion from
RYGB to SG between 2012 and 2014 were identied. After
Institutional Review Board approval, a retrospective review
was performed to collect patient data. Information regarding
patient demographic characteristics, initial surgeries, reason
for conversion to sleeve, postoperative complications, post-
operative readmissions, need for supplemental enteral
nutrition, and weight were collected.
Surgical technique
Patients were placed in the supine position, and laparo-
scopic surgery was attempted in all cases. Four standard
ports suitable for gastric bypass and a port for liver
retraction were placed. Adhesions to the peritoneum and
the left lobe of the liver were lysed as needed. The Roux
limb was identied and traced to the gastric pouch. Endos-
copy was used to conrm the location of the gastrojejunal
anastomosis. The gastric pouch was divided proximal to the
gastrojejunal anastomosis with an extra-thick (black) staple
load (Ethicon, Somerville, NJ). The Roux limb was
mobilized, stapled proximal to the jejunojejunal anastomo-
sis, and resected. The remnant stomach was then mobilized.
A gastrotomy was made along the greater curvature,
through which a 25-mm EEA circular stapler was intro-
duced. The spike was deployed in the appropriate position
on the proximal lesser curvature of the remnant stomach. It
was mated to a 25-mm anvil, which was placed transorally
using the Orvil device (Covidien, Manseld, MA). The
circular stapler was then red, creating a gastrogastrostomy.
A 36F bougie (ViSiGi, Phoenixville, PA) was then passed
transorally, directed through the gastrogastric anastomosis,
and aligned along the lesser curvature of the stomach. The
gastric sleeve was then created by transecting the stomach
along the bougie in the standard fashion with sequential
rings of a linear stapler, and the specimen was removed.
Endoscopic leak test was performed in all cases. Drains and
jejunal feeding tubes were placed at the discretion of the
operating surgeon.
If open surgery was required because of severe adhesive
disease, the same steps were followed in an open fashion.
Results
From January 2012 to November 2014, 12 patients
underwent conversion from RYGB to SG. All patients
were female, and 10 of 12 had undergone the original
RYGB at another institution. Three had undergone prior
revision. As shown in Table 1, mean age was 44.4 years
(range 3154), and the mean body mass index (BMI) before
conversion was 32.2 kg/m
2
(range 20.147.9).
Six patients underwent conversion to SG for refractory
marginal ulceration (MU) with or without associated
stenosis. Patient 1 had undergone 3 years of maximal
medical therapy (proton pump inhibitor and sucralfate)
along with smoking cessation with persistence of MU on
4 diagnostic endoscopies. She eventually developed a
stricture refractory to 2 endoscopic dilation procedures.
Patient 2 experienced epigastric pain, nausea, and vomiting
because of MU as well as stricture refractory to 4 months of
maximal medical therapy, attempts at smoking cessation,
and 3 endoscopic dilations. Patient 5 developed early
circumferential MU that persisted after 2 months of
maximal medical therapy, prompting surgical resection
and revision of the anastomosis. MU recurred soon after
surgical revision and symptoms continued, requiring several
admissions, until conversion to SG was performed 6 months
later. Patient 6 was a smoker who had undergone 3
endoscopic interventions for MU-related upper gastrointes-
tinal bleeding over 4 years at another institution; this patient
was referred for nausea, vomiting, and cachexia because of
continued MU. Her MU did not heal despite 6 months of
maximal medical therapy, supplemental feeding, and
attempts at smoking cessation. Patient 7 developed MU,
which failed to heal despite 2 years of maximal medical
therapy and unsuccessful attempts at smoking cessation.
She ultimately developed a stricture refractory to several
treatments with endoscopic dilation. Patient 12 developed
MU after a revision of RYGB for failed weight loss. This
was treated at another facility with 6 months of medical
therapy, then 3 endoscopic dilations for associated stricture,
followed by surgical revision of gastrojejunal anastomosis.
She developed recurrent MU and underwent conversion to
SG after 5 months of unsuccessful medical treatment.
Two patients underwent conversion to SG after gastro-
gastric stula (GGF) development. Patient 3 had undergone
remote anastomotic revision for smoking-related MU and
was referred with 8 months of epigastric pain, reux, and
weight gain because of GGF. Patient 8 was referred after
Conversion from Gastric Bypass to Sleeve Gastrectomy / Surgery for Obesity and Related Diseases 12 (2016) 572576 573
9 months of worsening nausea secondary to GGF with
associated anastomotic stenosis treated with endoscopic
dilation twice. Neither patient with GGF underwent any
attempt at endoscopic closure.
Two patients underwent conversion for hyperinsulinemic
hypoglycemia. Patient 4 presented with 3 years of post-
prandial hypoglycemia that initially improved with dietary
modication and alpha-glucosidase inhibitor therapy but
then continued despite these treatment measures. Patient 9
experienced 8 years of gradually more severe postprandial
hypoglycemia associated with poor dietary choices. Dietary
counseling was attempted for 1 year, at which point
conversion was performed for continued frequent hypogly-
cemia. Both patients were admitted for 72-hour fast testing
to rule out endogenous hyperinsulinemia.
Patient 11 underwent conversion to SG for refractory
dumping syndrome, which had been present for several
years but worsened signicantly over 1 year despite nutri-
tional counseling and medical treatment with octreotide.
Patient 10 presented with weight gain that occurred 10
years after RYGB. Before conversion, she underwent 6
months of a physician-supervised weight-loss program that
did not include prescription medication.
Ten of the 12 procedures were completed laparoscopi-
cally, whereas 2 were converted to open surgery because of
severe adhesive disease. Average surgical time was 262
minutes (range 128396), and estimated blood loss was 146
mL (range 50300). All surgeries were technically success-
ful, and the average length of stay was 6.2 days (range
218, median 4.5).
A total of 4 patients (25%) experienced 7 signicant
postoperative complications. These included portal vein
thrombosis (Clavien-Dindo Grade II), bleeding requiring
transfusion (Clavien-Dindo Grade II), pancreatic leak
(Clavien-Dindo Grade IIIb), pulmonary embolus (Clavien-
Dindo Grade IVa), wound seroma (Clavien-Dindo Grade
IIIa), and anastomotic leak resulting in gastrocolic stula
and anastomotic stenosis treated with endoscopic stenting
(Clavien-Dindo Grade IIIb). Two patients required reoper-
ative intervention within 30 days, the rst for a pancreatic
leak and the second for a dislodged jejunostomy tube.
Six of the 12 patients (50%) required readmission within
30 days of surgery. The most common indication for
readmission was prolonged nausea and inability to tolerate
an oral diet. Four patients underwent jejunostomy feeding
tube placement at the time of surgery, and of the 8 who did
not, 4 required readmission and prolonged nasoenteric
feeding because of an inability to tolerate an oral diet.
One patient required total parenteral nutrition. All patients
were ultimately able to tolerate an oral diet without need for
supplementation. Of note, evaluation with upper gastro-
intestinal series and endoscopy revealed a structural explan-
ation for nausea in only 1 of the 6 patients readmitted. This
patient was found to have stenosis at the gasto-gastric
anastomosis.
Average follow-up was 14.7 months (range 538), and
the average change in BMI for all 12 patients was a
decrease of 2.2 kg/m
2
(range 13.9 to þ12.0 kg/m
2
).
Five of 12 patients were class 2 or 3 obese at the time of
conversion (BMI range 36.047.9 kg/m
2
). Only 1 of these
patients gained weight during the follow-up period, and at
an average follow-up of 19 months, these 5 patients saw a
decrease in BMI of 6.4 kg/m
2
. Percent excess weight loss
was 30.1%, percent total weight loss was 13.0%, and
percent excess BMI lost was 28.7%.
For the 7 patients who were not morbidly obese at the
time of conversion (BMI range 20.130.5 kg/m
2
), the
average change in BMI was þ0.8 kg/m
2
, and all patients
Table 1
Patient characteristics
Patient
No.
Age
(y)
Prior
revision
Indication BMI (kg/m
2
)
Preop
Current Change F/U
(mo)
Lap/
open
Complication LOS
(d)
Readmit
(d)
Supplemental
feeding
1 40 N MU, GJ strict 26.7 29.7 þ3.0 18 Lap None 3 N YJ
2 39 N MU, GJ strict,
smoker
22.3 21.5 .8 20 Lap None 4 Y (30) YNJ
3 46 Y GGF, smoker 30.0 25.4 4.8 4 Lap None 2 N N
4 38 N Hypoglycemia 36.0 48.0 þ12.0 15 Lap PVT, seroma 6 Y (21) YNJ
5 54 Y MU 25.0 26.7 þ1.7 8 Lap Bleeding 4 N N
6 37 N MU, smoker 20.2 20.4 þ.2 10 Lap None 10 Y (24) YJ
7 51 N MU, smoker 39.4 19.6 19.2 38 Open Panc leak,
PE
18 Y (22) YJ
8 47 N GGF 20.1 28 þ7.9 16 Lap None 2 N YJ
9 44 N Hypoglycemia 46.7 42.6 4.1 24 Lap None 5 N N
10 61 N Weight gain 47.9 34.0 13.9 12 Open None 4 N N
11 31 N Dumping 41.6 35.0 6.6 6 Lap None 6 Y (16) YNJ
12 45 Y MU 30.5 29.0 1.5 5 Lap Leak, GC
stula
10 Y (20) YNJ, TPN
Average 44.4 32.2 30.0 2.2 14.7 6.2
No. ¼number; BMI ¼body mass index; F/U ¼follow-up; LOS ¼length of stay; Readmit ¼readmission; MU ¼marginal ulcer; Lap ¼laparoscopic;
Panc ¼pancreatic; PVT ¼portal vein thrombus; GGF ¼gastrogastric stula; NJ ¼nasojejunal; Y ¼yes; N ¼no; GC ¼gastrocolic.
C. O. Carter et al. / Surgery for Obesity and Related Diseases 12 (2016) 572576574
maintained a healthy BMI of less than 30 kg/m
2
over an
average follow-up of 11.5 months. No patients were lost to
follow-up.
Discussion
In this cohort, conversion from RYGB to SG is described
in 12 patients with successful resolution of the complication
prompting revisional surgery and without signicant weight
gain. High rates of major complication and readmission
were, however, experienced.
As bariatric surgery has become more common, the need
for revisional surgery for both complications of the primary
procedure and for unsuccessful weight loss has grown.
Revisional surgery can be performed without a prohibitive
complication rate [10]. Some complications of RYGB, such
as refractory or recurrent marginal ulceration, intractable
dumping syndrome, and refractory hyperinsulinemic hypo-
glycemia, require reversal of RYGB to normal anatomy.
Although little is documented in the literature regarding
weight gain after reversal of RYGB, it is known that many
patients regain much of the weight they had lost after reversal
of other bariatric procedures, such as jejunoileal bypass and
laparoscopic adjustable gastric banding [3,11].Thus,reversal
to normal anatomy should be undertaken cautiously.
Conversion of RYGB to SG has been proposed as an
alternative to reversal of RYGB to correct the above
complications without resulting in weight gain. Such a
technique has been described by 5 case series in the
literature. In 2010, Simper et al. reported 8 patients who
underwent successful conversion for retrograde intussus-
ception or roux stasis, with complete relief of symptoms in
6[5]. In 2011, Dapri, Cadiere, and Himpens described
4 patients with unsuccessful weight loss after RYGB who
underwent conversion to SG as a rst step in conversion to
duodenal switch and reported 59.3% excess weight loss
after conversion to SG alone [6]. In 2013, Zurita, Tabari,
and Hong reported 2 patients with resolution of intractable
dumping syndrome after conversion to SG [8]. Also in
2013, Vilallonga, van de Vrande, and Himpens described
10 patients who underwent conversion to SG and 10 who
underwent reversal to normal anatomy for a variety of
indications [7]. Finally, Campos et al. described 3 patients
converted to SG and 2 reversed to normal anatomy, all with
resolution of hyperinsulinemic hypoglycemia or severe
hypocalcemia after inadvertent parathyroidectomy after
RYGB [9].
Although conversion from RYGB to SG is reported to be
successful in resolving certain complications of RYGB, the
conversion procedure can also result in signicant perioper-
ative complications. Simper et al. saw signicant compli-
cations in 5 of 8 patients, including gastric stula, superior
mesenteric vein thrombosis, bowel obstruction, anastomotic
stricture, and splenic bleeding [5]. Vilallonga et al. reported
3 anastomotic leaks and 1 gastric ulcer in 10 patients [7].
We similarly report major complications in 4 of 12 patients.
Revisional bariatric surgery is known to have a higher
complication rate than primary bariatric surgery, with up to
21.823% morbidity and 1.3% mortality in large series
[12,13]. Anastomotic leak can be seen in 4.211% of
patients undergoing revision [1416]. Thus, the complica-
tion rate of 25% seen in the present series is not unexpected.
The alternative to conversion to SG for most of the patients
described is reversal to normal anatomy, an operation for
which the rate of complication is unknown because it is so
infrequently reported in the literature.
Regarding the technical aspect of conversion from RYGB
to SG, the creation of the gastrogastric anastomosis varies in
published reports. Parikh, Pomp, and Gagner used a circular
stapled gastrogastric anastomosis in conversion from RYGB
to duodenal switch and reported a 25% anastomotic stricture
rate [17]. Dapri et al. and Vilallonga et al. used a hand-sewn
technique for gastrogastrostomy creation, without stricture in
any patient, while Simper et al. reported a 50% stricture rate
using a similar hand-sewn technique [57]. Using a circular
stapled anastomosis, we had only 1 patient develop a stricture
requiring dilation. Regarding sleeve creation, Vilallonga et al.
reported 3 leaks in the rst 5 patients converted to SG using a
standard stapled technique. Thereafter, no leaks occurred by
rst removing the fundus with a stapled technique and
performing plication of the stomach distal to the gastro-
gastrostomy to avoid ischemic areas lateral to the anastomo-
sis [7]. We experienced 1 leak after a more standard stapling
technique, including stapling the portion of the stomach
distal to the gastrogastrostomy.
The frequent incidence of postoperative nausea and
inability to tolerate an oral diet in the present series was
not reported by other authors. The cause of nausea is
unclear. In 5 of 6 patients readmitted for severe nausea, no
anatomic cause was found on imaging or endoscopy. It is
possible that poor function of the sleeve stomach due to
vagal denervation contributed to these symptoms. Gastro-
esophageal acid and nonacid reux after conversion may
have contributed to these symptoms, and an important
limitation of this study is that patients did not undergo
objective assessment with pH probe and impedance mon-
itoring. These 6 patients required supplemental enteral
nutrition and were only able to tolerate an oral diet after a
period of several weeks. We recommend considering
feeding jejunostomy placement in patients undergoing
conversion from RYGB to SG.
The goal in performing most of the surgeries in this series
was not to induce weight loss but to resolve a specic
complication related to RYGB without causing weight gain.
However, others have performed conversion from RYGB to
SG for failure of weight loss [67], with Vilallonga et al.
reporting a 59% excess weight loss in 4 patients [6].Inthe
present series, 5 patients had class II or III obesity at the time
of conversion, and the average change in BMI after 19
months was a decrease of 6.4 kg/m
2
, or 30.1% excess weight
Conversion from Gastric Bypass to Sleeve Gastrectomy / Surgery for Obesity and Related Diseases 12 (2016) 572576 575
loss. It is important to note that the indication for conversion
to SG in most of these patients was not failed weight loss and
that long-term follow-up is not available. Given the high risk
of complication, we would not recommend conversion from
RYGB to SG for failure of weight loss.
The current report has several limitations. It describes a
small number of patients and is retrospective in nature. The
follow-up was also relatively short at 14.7 months. How-
ever, this series contributes to bring the total number of
reported patients in the literature to 39.
Conclusions
Laparoscopic conversion from RYGB to SG is successful
in resolving certain complications of RYGB and does not
result in short-term weight gain. However, conversion has a
high rate of major complication as well as a high rate of
readmission and need for supplemental nutrition. Although
conversion to SG may be appropriate in carefully-selected
patients, other options for patients with severe chronic
complications after RYGB should be considered.
Disclosure
None of the authors have anything to disclose.
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C. O. Carter et al. / Surgery for Obesity and Related Diseases 12 (2016) 572576576
... Secondline therapies include acarbose, diazoxide, and somatostatin analogs. Other treatments include gastrostomy tube placement and surgical reversal procedures [13][14][15][16][17][18]. However, studies comparing the efficacy of these therapies are lacking. ...
... The treatment of PGBH is challenging due to its complex clinical presentation and poorly understood pathophysiology [13][14][15][16][17][18]. Most patients adapt well to dietary changes, including a meal plan based on avoiding simple sugars and eating frequent small meals [11,21]. ...
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Purpose Following bariatric surgery, patients can develop non-specific symptoms self-described as hypoglycemia. However, confirming hypoglycemia can be technically challenging, and therefore, these individuals are frequently treated empirically. This study aimed to describe what diagnostic evaluation and therapeutic interventions patients referred for post-bariatric surgery hypoglycemia undergo. Methods Retrospective observational cohort study of patients with a history of bariatric surgery was evaluated for post-bariatric surgery hypoglycemia in a tertiary referral center from 2008 to 2017. We collected demographic and bariatric surgery information, clinical presentation of symptoms referred to as hypoglycemia, laboratory and imaging studies performed to evaluate these symptoms, and symptom management and outcomes. Results A total of 60/2450 (2.4%) patients who underwent bariatric surgery were evaluated in the Department of Endocrinology for hypoglycemia-related symptoms. The majority were middle-aged women without type 2 diabetes who had undergone Roux-en-Y gastric bypass. Thirty-nine patients (65%) completed a biochemical assessment for hypoglycemia episodes. Six (10%) had confirmed hypoglycemia by Whipple’s triad, and four (6.7%) met the criteria for post-bariatric surgery hypoglycemia based on clinical and biochemical criteria. All patients were recommended dietary modification as the initial line of treatment, and this intervention resulted in most patients reporting at least some improvement in their symptoms. Eight patients (13%) were prescribed pharmacotherapy, and two patients required additional interventions for symptom control. Conclusions In our experience, evaluation for hypoglycemia-related symptoms after bariatric surgery was rare. Hypoglycemia was confirmed in the minority of patients. Even without establishing a diagnosis of hypoglycemia, dietary changes were a helpful strategy for symptom management for most patients. Graphical abstract
... Las indicaciones más frecuentes para realizar una R-BPG reportadas en la literatura son úlceras marginales recurrentes 9,11,15-17 , hipoalbuminemia severa 9,10,15,17-19 e hipoglicemias 10,16,18,[20][21][22][23] (Tabla 3). Otras causas son el dolor abdominal crónico 10,15 , dumping persistente 22 , fístulas gastro-gástricas 16 e incluso intususcepciones recurrentes 24 . ...
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Introducción: Debido a su eficacia en el tratamiento de la obesidad mórbida, el bypass gástrico (BPG) sigue siendo una intervención realizada frecuentemente. Sin embargo, un grupo reducido de pacientes puede desarrollar complicaciones nutricionales y metabólicas que no logran controlarse con un tratamiento médico óptimo. En estos casos, puede ser necesario reestablecer la continuidad del tracto gastrointestinal por medio de la reversión del BPG (R-BPG). Objetivo: Presentar las indicaciones y resultados obtenidos en una serie de pacientes sometidos a una R-BPG. Materiales y Método: Identificación y evaluación retrospectiva de todos los pacientes sometidos a una R-BPG en nuestra institución de manera consecutiva. Se registraron las características demográficas y antropométricas de la cirugía original y al momento de la reversión. Las complicaciones se registraron de acuerdo con la clasificación de Clavien-Dindo. Resultados: Se identificaron 7 pacientes en los cuales se realizó una R-BPG. En 2 casos la reversión fue por síndrome de intestino corto, en 3 casos por hipoglicemias severas refractarias a manejo médico y en 2 casos por diarrea crónica. La mediana de edad al momento de la reversión fue de 55 años. La mediana de tiempo desde la cirugía original hasta el momento de la reversión fue de 77 meses. La mediana de estadía hospitalaria fue de 6 días. No hubo complicaciones Clavien-Dindo ≥ III. La R-BPG logró revertir en todos los casos las complicaciones nutricionales y metabólicas. Conclusión: La restauración de la continuidad del tracto gastrointestinal permite el control de las complicaciones nutricionales y metabólicas.
... Studies with a small sample size often include specific patients, which can result in a higher incidence of PVST. For example, Roriz-Silva et al (2019) 25 51 included patients who underwent a conversion from RYGB to laparoscopic sleeve gastrectomy (LSG), while Bassiouny et al (2020) included patients complaining of some symptoms after bariatric surgery. 22 Thus, the 3 studies reported a higher incidence of PVST. ...
... Initially, RYGB changes the normal anatomy of gastrointestinal tract. 51 But when RYGB is converted to LSG, adhesions should be dissolved and the normal anatomy of gastrointestinal tract would be re-established, which is technically complex and needs a longer operation time (RYGB followed by LSG versus LSG alone: 262 minutes 51 vs 51 minutes 29 ) with a higher rate of major complications. Regardless, our current findings did not still support a definite association of secondary bariatric surgery with PVST. ...
Article
Background Portal venous system thrombosis can develop after bariatric surgery. A systematic review and meta-analysis was conducted to evaluate the incidence of portal venous system thrombosis after bariatric surgery and clarify the role of anticoagulation for the prevention of portal venous system thrombosis after bariatric surgery. Methods PubMed, EMBASE, and Cochrane Library databases were searched. The incidence of portal venous system thrombosis after bariatric surgery was pooled by a random-effect model. Subgroup analyses were performed to explore the incidence of portal venous system thrombosis according to the average duration of prophylactic anticoagulation (extended versus short-term). Meta-regression and sensitivity analyses were performed to explore the source of heterogeneity. Results Among 2,714 papers initially screened, 68 studies were included. Among 100,964 patients undergoing bariatric surgery, 300 developed portal venous system thrombosis. The pooled overall incidence of portal venous system thrombosis after bariatric surgery was 0.419% (95% confidence interval: 0.341%–0.505%). The pooled incidence of portal venous system thrombosis after bariatric surgery was numerically lower in patients who received extended prophylactic anticoagulation protocol after bariatric surgery than those who received short-term prophylactic anticoagulation protocol (0.184% vs 0.459%). Meta-regression analyses demonstrated that sample size (P = .006), type of surgery (P < .001), and average duration of prophylactic anticoagulation (P = .024) might be sources of heterogeneity, but not region, publication year, history of bariatric surgery, follow-up duration, or use of prophylactic anticoagulation. Sensitivity analyses could not identify any source of heterogeneity. The estimated mortality of portal venous system thrombosis after bariatric surgery was 1.33%. Conclusion Portal venous system thrombosis after bariatric surgery is rare, but potentially lethal. Extended prophylactic anticoagulation protocol may be considered in patients at a high risk of developing portal venous system thrombosis after bariatric surgery.
... 4,5,8,9,13,14 In the previously published data, authors have added a gastric sleeve or the plication of the gastric antrum to prevent any weight regain. 5,8,[13][14][15] In 2006, Himpens et al published the first case of laparoscopic conversion of GBP to normal anatomy to treat hypoglycemia using a gastro-gastrostomy and antral plication. Meanwhile, other authors have used the same surgical technique or a an antrum resection in addition, instead of a plication. ...
... Two patients required a reoperation, and 6 were readmitted within 30 days. 15 The same complications were identified in other series after the reversal procedure. 16 Reportedly, weight regain in these patients, as well as metabolic consequences, is likely to occur after an RNA. ...
Article
Background. Laparoscopic Roux-en-Y gastric bypass (GBP) is an essential bariatric surgical procedure which is globally performed because of the associated effective weight loss and resolution of metabolic comorbidities, such as diabetes and dyslipidemia. Although some complications may occur, hypoglycemia is a rare complication, which can lead to lethal consequences. We aimed to describe the technical aspects and surgical results after reversal to normal anatomy (RNA). Methods. We conducted a retrospective data analysis including 16 patients who underwent laparoscopic RNA from 2011 to 2018. All data were archived in a prospective database. Previous bariatric surgery and postoperative outcomes were analyzed. Results. Sixteen patients underwent RNA, most of them after GBP, and 15 patients required sleeve gastrectomy. Among them, 80% were women; 5 patients presented with postoperative complications, such as colitis with intra-abdominal collection (n = 1), gastric leak (n = 2) treated with an endoprosthesis, mesenteric venous thrombosis (n = 1), and intra-abdominal bleeding (n = 1). Mean length of hospital stay was 5.93 (3-30). All patients recovered from their initial condition although 3 patients presented with mild hypoglycemia during follow-up. Seven patients regained weight (43.75%), and another 4 developed gastroesophageal reflux disease (25%). Conclusions. These laparoscopic RNA results are acceptable, indicating a clinical improvement in the hypoglycemic syndrome in all patients.
... In these cases, after reversal to normal anatomy and creation of a gastrogastrostomy between the gastric pouch and gastric remnant, the gastric sleeve is fashioned. Two studies looking at these cases have found high complication rates, although Vilallonga et al. [85] and Carter et al. [86] improved their leak rate by plicating the middle part of the greater curvature instead of resecting it. ...
Article
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With the rising prevalence of obesity, there has been a steady rise in the number of bariatric surgeries performed worldwide. As expected, there has also been an increase in the number of revisional surgeries performed to manage acute and chronic postoperative complications. This review will discuss the major complications that can arise from the most common bariatric surgeries, their diagnosis, medical management, and potential revisional surgical options.
Chapter
Das Dumping Syndrom ist eine Langzeitkomplikation nach Magenoperationen. Eine beschleunigte Entleerung („dumpen“) von Mageninhalt in den Dünndarm scheint ursächlich für die resultierende Symptomatik. Hieraus können sich zwei Symptomenkomplexe entwickeln, das sogenannte Frühdumping und das Spätdumping. Die Benennung erfolgte entsprechend des zeitlichen Abstandes der Beschwerden zur zuvor eingenommenen Mahlzeit. So tritt das Frühdumping direkt und bis zu 30 min nach dem Essen auf, während das Spätdumping nach ca. 120–180 min mit einer Hypoglykämie symptomatisch wird, generiert durch eine inadäquat hohe Insulinausschüttung. Beim Frühdumping löst die schnelle Anflutung hyperosmolaren Nahrungsvolumens eine quantitative Flüssigkeitsverschiebung vom Interstitium in das Darmlumen aus, die zu den entsprechenden Symptomen führt.
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Resumen La hipoglucemia hiperinsulinémica posprandial es una complicación frecuente de la cirugía bariátrica. Aunque en general tiene una evolución leve y autolimitada, puede cursar con neuroglucopenia y comprometer la seguridad y la calidad de vida del paciente. El objetivo de este documento es ofrecer unas recomendaciones para facilitar la atención clínica a estos pacientes complejos, revisando la etiopatogenia, su diagnóstico y tratamiento que, de manera secuencial, incluirá medidas dietéticas, farmacológicas y cirugía en casos refractarios. Ante la ausencia de estudios de alta calidad, el abordaje diagnóstico y terapéutico propuesto se basa en el consenso de expertos del Grupo de Obesidad de la Sociedad Española de Endocrinología y Nutrición, GOSEEN. Las personas sometidas a cirugía bariátrica deben ser informadas de la posibilidad de desarrollar esta complicación.
Article
Aims Hypoglycemia is a serious complication of bariatric surgery. The aim of the present meta-analysis was to evaluate the rate and the timing of post-bariatric hypoglycemia (PBH) with different bariatric procedures using reliable data from continuous glucose monitoring (CGM). Data synthesis Studies were systematically searched in the Web of Science, Scopus and PubMed databases according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The prevalence of PBH was expressed as weighted mean prevalence (WMP) with pertinent 95% confidence intervals (95%CI). A total of 8 studies (16 datasets) enrolling 280 bariatric subjects were identified. The total WMP of PBH was 54.3% (95%CI: 44.5%–63.8%) while the WMP of nocturnal PBH was 16.4% (95%CI: 7.0%–34%). We found a comparable rate of PBH after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) (OR 1.62, 95%CI: 0.71–3.7; P = 0.248); likewise, the percent time spent in hypoglycemia was similar with the two procedures (mean difference 5.3%, 95%CI: −1.4%–12.0%; P = 0.122); however, RYGB was characterized by a higher glycaemic variability than SG. Regression models showed that the time elapsed from surgical intervention was positively associated with a higher rate of both total PBH (Z-value: 3.32, P < 0.001) and nocturnal PBH (Z-value: 2.15, P = 0.013). Conclusions PBH, both post-prandial and nocturnal, is more prevalent than currently believed. The rate of PBH increases at increasing time from surgery and is comparable after RYGB and SG with a higher glucose variability after RYGB.
Article
Background One of the short and long-term complications following Roux-en-Y Gastric Bypass (RYGB) for morbid obesity is the development of marginal ulcers (MUs). Although chronic and recurrent marginal ulcers (rMUs) are common, there is no consensus in their optimal management. Objectives To perform a systematic review of the elective operative management of rMUs. Methods A systematic search of the literature was conducted. Relevant databases were searched up to May 16, 2020. Articles were included if they met the following inclusion criteria: 1) bariatric patients were included as the study population, 2) laparoscopic RYGB was performed as the index operation, 3) study patients developed rMUs, and 4) MUs required elective operative (surgical, endoscopic) interventions. Quality of articles were assessed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system. Results The search identified 3470 citations; of these, 16 observational studies were included. Elective management of rMUs consisted of endoscopic (oversewing +/- stents) and surgical interventions (gastro-jejunostomy revision, vagotomy, conversion to sleeve gastrectomy, subtotal/total gastrectomy, reversal to normal anatomy). Quality of the studies as assessed by the GRADE system was low to very low. Conclusions Recalcitrant/recurrent marginal ulcers are challenging complications both for the bariatric patients and their treating surgeon. There are no established algorithms for the management of rMUs, and the currently available evidence in the literature is limited both in quantity as well as quality. Future multicenter, multi-surgeon, randomized control trials are needed to address this issue.
Chapter
Metabolic surgery is the most effective and proven therapeutic option for obesity and obesity-related complications. Recent years have seen an increment in the number of bariatric surgeries performed, ranging from purely restrictive to a combination of restrictive and malabsorptive procedures. These metabolic procedures carry substantial risks, pertaining to procedural related complications, micro-nutritional, hormonal, endocrinal, and metabolic disturbances. The above complications are likely due to the surgically induced changes in the anatomy, incurred by the patient's gastrointestinal tract. In addition to the monitoring of weight and related comorbidities outcomes, timely screening, counseling, monitoring, nutrient, and mineral supplementation are essential for the treatment and prevention of complications following bariatric surgery. Through this chapter, we aim to bring forth certain rare, yet documented case scenarios concerning the micro-nutritional, endocrine, and metabolic complications after bariatric surgery. The surgeon, treating physician, intern, and the patient must be aware of these rare complications of the surgery, for its timely diagnosis and intervention.
Article
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The anatomic and physiologic changes with Roux-en-Y gastric bypass (RYGB) may lead to uncommon but occasionally difficult to treat complications such as hyperinsulinemic hypoglycemia with neuroglycopenia and recalcitrant hypocalcemia associated to hypoparathyroidism. Medical management of these complications is challenging. Laparoscopic reversal of RYGB anatomy with restoration of pyloric function and duodenal continuity is a potential treatment. The objective of this study was to present the indications, surgical technique, and clinical outcomes of laparoscopic reversal of RYGB. Prospective study of consecutive patients offered laparoscopic reversal of RYGB. Five patients with remote laparoscopic RYGB underwent laparoscopic reversal of RYGB to normal anatomy (n = 2) or modified sleeve gastrectomy (n = 3). Indications were medically refractory hyperinsulinemic hypoglycemia with neuroglycopenia (n = 3), recalcitrant hypocalcemia with hypoparathyroidism (n = 1), and both conditions simultaneously (n = 1). Before reversal, all patients had a gastrostomy tube placed in the excluded stomach to document improvement of symptoms. Laparoscopic reversal was accomplished successfully in all patients. Three postoperative complications occurred: bleeding that required transfusion, gallstone pancreatitis, and a superficial trocar site infection. Average length of stay was 3 days. At a mean follow-up of 12 months (range 3 to 22), no additional episodes of neuroglycopenia occurred, average number of hypoglycemic episodes per week decreased from 18.5±12.4 to 1.5±1.9 (P = .05), and hypocalcemia became responsive to oral replacement therapy in both patients. Laparoscopic reversal of RYGB to normal anatomy or modified sleeve gastrectomy is feasible and may be a therapeutic option for selected patients with medically refractory hyperinsulinemic hypoglycemia and/or recalcitrant hypocalcemia associated with hypoparathyroidism.
Article
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This study was designed to describe and analyze the outcomes after laparoscopic reversal to normal anatomy (NA) with or without concomitant "sleeve gastrectomy" (SG), after Roux-en-Y gastric bypass (RYGB). Reversal has been proposed as corrective strategy after RYGB. We propose a retrospective analysis of a prospectively kept database. From January 2005 to October 2012, 20 female patients underwent laparoscopic reversal after RYGB for one or more of the following conditions: hypoglycaemic syndrome (nine patients), weight regain (six patients), severe dumping (six patients), and cachexia (two patients). Preoperative BMI was 28.0 (19.2-40.3) kg/m². Reversal was performed to NA in ten patients and included a SG procedure in another ten. Postoperative complications included one bleeding and three leaks (15 %; all in SG patients). Mean hospital stay was 7 days. Mortality was 0. With a mean follow-up of 11.5 months, all but one patient recovered from their initial condition. However, three developed severe gastroesophageal reflux disease (GERD) symptoms and three had chronic diarrhoea. Outcomes of laparoscopic reversal of RYGB are good, but complications may occur when SG is added. The surgical alterations caused by the reversal may explain the GERD or diarrhoea experienced by some patients.
Article
Reoperative bariatric surgery has become a common practice in many bariatric surgery programs. There is currently little evidence-based guidance regarding specific indications and outcomes for reoperative bariatric surgery. A task force was convened to review the current evidence regarding reoperative bariatric surgery. The aim of the review was to identify procedure-specific indications and outcomes for reoperative procedures. Literature search was conducted to identify studies reporting indications for and outcomes after reoperative bariatric surgery. Specifically, operations to treat complications, failed weight loss, and weight regain were evaluated. Abstract and manuscript reviews were completed by the task force members to identify, grade, and categorize relevant studies. A total of 819 articles were identified in the initial search. After review for inclusion criteria and data quality, 175 articles were included in the systematic review and analysis. The majority of published studies are single center retrospective reviews. The evidence supporting reoperative surgery for acute and chronic complications is described. The evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. Procedure-specific outcomes are described. Complication rates are generally reported to be higher after reoperative surgery compared to primary surgery. The indications and outcomes for reoperative bariatric surgery are procedure-specific but the current evidence does support additional treatment for persistent obesity, co-morbid disease, and complications.
Article
There are growing numbers of patients who require revisional bariatric surgery due to the undesirable results of their primary procedures. The aim of this study was to review our experience with bariatric patients undergoing revisional surgery. We conducted a retrospective analysis to review the indications for revisional bariatric procedures and assess their postoperative outcomes. From 04/04 to 01/11, 2,918 patients underwent bariatric surgery at our institution. A total of 154 patients (5.3 %) of these cases were coded as revisional procedures. The mean age at revision was 49.1 ± 11.3 and the mean BMI was 44.0 ± 13.7 kg/m(2). Revisional surgery was performed laparoscopically in 121 patients (78.6 %). Laparoscopic revisions had less blood loss, shorter length of hospital stay, and fewer complications compared to open revisions. Two groups (A and B) were defined by the indication for revision: patients with unsuccessful weight loss (group A, n = 106) and patients with complications of their primary procedures (group B, n = 48). In group A, 74.5 % of the patients were revised to a bypass procedure and 25.5 % to a restrictive procedure. Mean excess weight loss was 53.7 ± 29.3 % after revision of primary restrictive procedures and 37.6 ± 35.1 % after revision of bypass procedures at >1-year follow-up (p < 0.05). In group B, the complications prompting revision were effectively treated by revisional surgery. Revisional bariatric surgery effectively treated the undesirable results from primary bariatric surgery. Laparoscopic revisional surgery can be performed after both failed open and laparoscopic bariatric procedures without a prohibitive complication rate. Carefully selected patients undergoing revision for weight regain have satisfactory additional weight loss.
Article
Background: Laparoscopic sleeve gastrectomy is gaining popularity in the US; however, there has been no study examining the use of sleeve gastrectomy at a national level and its impact on the use of other bariatric operations. The aim of this study was to examine contemporary changes in use and outcomes of bariatric surgery performed at academic medical centers. Methods: Using ICD-9 diagnosis and procedure codes, clinical data obtained from the University HealthSystem Consortium database for all bariatric procedures performed for the treatment of morbid obesity between October 1, 2008 and September 30, 2012 were reviewed. Quartile trends in use for the 3 most commonly performed bariatric operations were examined, and a comparison of perioperative outcomes between procedures was performed within a subset of patients with minor severity of illness. Results: A total of 60,738 bariatric procedures were examined. In 2008, the makeup of bariatric surgery consisted primarily of gastric bypass (66.8% laparoscopic, 8.6% open), followed by laparoscopic gastric banding (23.8%). In 2012, there was a precipitous increase in use of laparoscopic sleeve gastrectomy (36.3 %), with a concurrent reduction in the use of laparoscopic (56.4%) and open (3.2%) gastric bypass, and a major reduction in laparoscopic gastric banding (4.1%). The length of hospital stay, in-hospital morbidity and mortality, and costs for laparoscopic sleeve gastrectomy were found to be between those of laparoscopic gastric banding and laparoscopic gastric bypass. Conclusions: Within the context of academic medical centers, there has been a recent change in the makeup of bariatric surgery. There has been an increase in the use of laparoscopic sleeve gastrectomy, which has had an impact primarily on reducing the use of laparoscopic adjustable gastric banding.
Article
Background: During the past decade, nonoperative treatment of leaks after bariatric surgery has been deemed acceptable in selected patients. The setting of our study was 2 university affiliated hospitals. Methods: We reviewed gastric leaks in 1069 consecutive bariatric operations that were performed by 1 surgeon during the past 8 years, including 836 primary laparoscopic Roux-en-Y gastric bypass (RYGB), 114 primary open RYGBs, and 119 revisional procedures. Drains were used routinely in the laparoscopic and revision groups and selectively in the open group. Perforations and jejunojejunostomy leaks were excluded. Results: There were no leaks after open RYGB, 8 leaks (.95%) after laparoscopic RYGB, and 5 leaks (4.2%) after the revisional procedures. Of the 13 leaks, 7 occurred at the gastrojejunostomy, 6 at the staple line of the upper pouch, and none in the excluded stomach. Of the 8 postlaparoscopic RYGB leaks, 3 required reoperation versus 2 of 5 postrevision leaks. There were no perioperative deaths. All but 2 patients in the nonoperative group were treated with endoscopic injection of fibrin sealant (EIFS). Of the 4 leaks in the laparoscopic RYGB group, 2 treated by EIFS closed after 1 treatment; however, all leaks in the revision group required >1 EIFS treatment. The mean length of stay was 36 ± 34 days in the operative group and 33 ± 7 days in the EIFS patients. Operation for failure of EIFS was not required in any patient. Conclusion: EIFS provides safe and successful treatment of patients who develop gastric leaks after bariatric operations. We recommend EIFS for all patients with endoscopically accessible leaks who can safely be treated nonoperatively.
Article
Revisional bariatric operations performed for weight loss failure are frequently associated with inconsistent weight reduction and serious perioperative complications. Outcomes of 151 consecutive revisional operations performed by one surgeon for unsatisfactory weight loss were compared to determine whether postoperative weight loss is influenced by the type of primary procedure. Minimum follow-up was 12 months. Primary operations included 14 jejunoileal bypass (JIB): one revised to gastroplasty, 13 to RY gastric bypass; 71 gastroplasty/banding (GP/B): all revised to Roux-en-Y gastric bypass (RYGB); and 66 gastric bypass: 49 revised to distal/malabsorptive RYGB, 12 restapled without malabsorption, and 5 loop bypasses revised to standard RYGB. Perioperative morbidity/mortality rates were 21.8% and 1.3%, respectively. Follow-up at 12 months was 93%. Mean weight/body mass index unit loss after revision of JIB was 90 pounds/17 units versus 113 pounds/16 units after revision of GP/B and 71 pounds/11 units after revision of gastric bypass (P < or = 0.05) with corresponding mean percent of excess weight loss of 51% for JIB, 56% for GP/B, and 48% for gastric bypass. Five of the JIB revisions (38%) lost > or = 50% excess weight loss versus 39 of the GP/B revisions (61%) and 28 of the gastric bypass revisions (48%). Comorbidities improved/resolved in 100% of those who lost > or = 50% of excess weight versus 89% who did not. Weight loss after revision of pure restrictive operations is significantly better than after revision of operations with malabsorptive components. Improvement of comorbidities in the great majority of patients justifies revision of all types of bariatric operations for unsatisfactory weight loss.
Article
We reported on our experience of 23 patients with retrograde intussusception (RINT) in 2007. That series has increased to 54 patients. Surgical resection of the jejunojejunostomy appears to be the most effective treatment. We treated 8 patients with documented or suspected recurrent RINT despite resection, by reversing their gastric bypass with sleeve gastrectomy to avoid weight regain. The medical records of 8 patients who had undergone treatment of suspected recurrent RINT with reversal of their gastric bypass followed by sleeve gastrectomy were reviewed to evaluate the outcomes, complications, weight loss, and relief of symptoms. All 8 patients were women, aged 29-56 years. The mean body mass index at reversal was 22.3-36.5 kg/m(2) (mean 30). The follow-up period was 1-28 months (mean 20.8). The body mass index at the last visit was 21.3-33 kg/m(2) (mean 26). Complications occurred in 5 patients. Patient 1 developed delayed splenic bleeding that required splenectomy on the second postoperative day. Patient 2 developed a gastric fistula 6 weeks after surgery after dilation. Patient 4 developed a superior mesenteric vein thrombosis at 2 weeks postoperatively. Patient 7 developed a proximal small bowel obstruction. Also, 4 patients required dilation of the gastrogastrostomy. At the last follow-up visit, the patients did not have symptoms of recurrent RINT and had not regained their weight. Laparoscopic reversal of gastric bypass with sleeve gastrectomy for recurrent RINT or RINT-like symptoms (Roux stasis symptoms) resulted in a significant risk of complications in this small group of patients but appears to be effective for relieving the symptoms of RINT with minimal risk of weight regain, at least in the medium term.
Article
Background: Failure of primary bariatric surgery is frequently due to weight recidivism, intractable gastric reflux, gastrojejunal strictures, fistulas, and malnutrition. Of these patients, 10-60% will undergo reoperative bariatric surgery, depending on the primary procedure performed. Open reoperative approaches for revision to Roux-en-Y gastric bypass (RYGB) have traditionally been advocated secondary to the perceived difficulty and safety with laparoscopic techniques. Few studies have addressed revisions after RYGB. The aim of the present study was to provide our experience regarding the safety, efficacy, and weight loss results of laparoscopic revisional surgery after previous RYGB and sleeve gastrectomy procedures. Methods: A retrospective analysis of patients who underwent laparoscopic revisional bariatric surgery for complications after previous RYGB and sleeve gastrectomy from November 2005 to May 2007 was performed. Technical revisions included isolation and transection of gastrogastric fistulas with partial gastrectomy, sleeve gastrectomy conversion to RYGB, and revision of RYGB. The data collected included the pre- and postoperative body mass index, operative time, blood loss, length of hospital stay, and intraoperative and postoperative complications. Results: A total of 26 patients underwent laparoscopic revisional surgery. The primary operations had consisted of RYGB and sleeve gastrectomy. The complications from primary operations included gastrogastric fistulas, refractory gastroesophageal reflux disease, weight recidivism, and gastric outlet obstruction. The mean prerevision body mass index was 42 ± 10 kg/m(2). The average follow-up was 240 days (range 11-476). The average body mass index during follow-up was 37 ± 8 kg/m(2). Laparoscopic revision was successful in all but 1 patient, who required conversion to laparotomy for staple line leak. The average operating room time and estimated blood loss was 131 ± 66 minutes and 70 mL, respectively. The average hospital stay was 6 days. Three patients required surgical exploration for hemorrhage, staple line leak, and an incarcerated hernia. The overall complication rate was 23%, with a major complication rate of 11.5%. No patients died. Conclusion: Laparoscopic revisional bariatric surgery after previous RYGB and sleeve gastrectomy is technically challenging but compared well in safety and efficacy with the results from open revisional procedures. Intraoperative endoscopy is a key component in performing these procedures.