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Sleeve gastrectomy as a revisional procedure
Abstract
Laparoscopic sleeve gastrectomy (LSG) has been an acceptable revisional option for previously failed bariatric surgeries, especially gastric banding (GB). While feasibility of performing LSG as a revisional procedure for failed GB, a purely restrictive procedure, has been controversial, it has been demonstrated to have nonrestrictive benefits reported, such as hormonal level changes and rapid gastric emptying time. Revisional LSG has potential to gain popularity according to the increasing number of failed GB due to its level of technical ease and relative safety.
In this chapter, we review general aspects of LSG as a revisional treatment modality, particularly after failed GB. We also describe the rationale, indications, technique, short-term results for feasibility, and recent debates surrounding revisional LSG.
... One of the valid options is conversion to sleeve gastrectomy (SG). However, the surgical community is presently debating whether to perform SG at the time of the band removal (1-stage/single-step) or at a later date (2-stage) [2]. Outcomes in the literature vary widely and, http://dx. ...
... A large body of literature has been summarized in the recent statement, endorsed by 45 medical societies, attesting to the benefit of bariatric surgery [1]. And yet the field of bariatric surgery is still in its infancy, popularized no more than 2 decades ago and consisting of an everchanging procedural armamentarium [2]. We have experienced the rise and fall of gastric banding, and the replacement of gastric bypass by sleeve gastrectomy as the most common primary bariatric procedure performed in the United States. ...
Background
No verdict has been reached on single-stage removal of gastric banding with sleeve gastrectomy.
Objectives
To report 5-year outcomes of 1-stage gastric band removal and sleeve gastrectomy (Conversion-LSG) compared with primary laparoscopic sleeve gastrectomy (Prim-LSG).
Setting
Large single-surgeon prospective database.
Methods
Two patient groups were included: Conversion-LSG as the study group and Prim-LSG for comparison. Preconversion characteristics, conversion indication, weight loss, and complications were compared. The surgical protocol was reviewed, focusing on key technical recommendations.
Results
A total of 209 Conversion-LSG and 3268 Prim-LSG patients, aged 32.9±9.8 and 31.8±10.7 years respectively (P = .2), were studied. No significant differences in age, body mass index (BMI), or gender distribution existed. Conversion-LSG Baseline BMI was 47±12 kg/m². Patients spent 6.2±2.6 years with the band before Conversion-LSG. BMI at 1, 2, 3, 4, and 5 years was 37±8, 31±9, 29±11, 30±9, and 30±11 kg/m², respectively. No significant difference in BMI change between the 2 groups existed. In the Conversion-LSG group, 1 patient had a successfully stented leak but developed a gastrobronchial fistula 1 year later. In the Prim-LSG group, 3 leak cases were reported and managed successfully through endoscopic stenting, 1 patient had pulmonary embolism that responded to standard treatment, and 3 patients had postoperative bleeding. No other major complications occurred, and there was no mortality in either group. Additionally, no Conversion-LSG patients required further bariatric intervention.
Conclusion
Employing the surgical technique described in this paper, conversion-LSG is as well tolerated and effective as primary sleeve gastrectomy.
The placement of a gastric band (GB) prior to a sleeve gastrectomy (LSG) would increase postoperative complications, whether it is withdrawn or not at the time of the LSG. The purpose of this retrospective study was to evaluate and compare postoperative morbidity and outcome weight for simultaneous GB removal (RGB) and LSG (the RGB + LSG group) and front-line LSG only (the LSG group) after unsuccessful GB. From May 2005 to May 2009, 305 patients underwent first- or second-line LSG at Amiens University Hospital. The primary endpoint was the postoperative complication rate (according to the Clavien classification) in the RGB + LSG and LSG groups. The secondary endpoints were intra-operative data, postoperative data, and weight loss over a period of 2 years (body mass index, percentage of excess weight loss, and percentage of excess body mass index (BMI) loss). Univariate and multivariate propensity score analyses were used to search for independent risk factors for postoperative complications. The RGB + LSG group (n = 46) had a mean age of 42 and a mean BMI of 44 kg/m(2). The indication for surgery was renewed weight gain or insufficient weight loss in 68 % of these cases. The LSG group (n = 259) had a mean age of 41 and a mean BMI of 49.2 kg/m(2). All procedures were performed laparoscopically. The complication rate was 8.6 % in the RGB + LSG group and 8 % in the SG group (p = 0.42). The fistula rates in the two groups were 4.3 and 3.4 %, respectively (p = 0.56), and the mean BMI at 2 years was 33.4 kg/m(2) (RGB + LSG group) and 34.4 kg/m(2), respectively (p = 0.83). The operating time for LSG (after subtracting the time associated with RGB for a combined procedure) averaged 107 min, whereas the operating time for front-line LSG was 89 min (p = 0.011). The propensity score analysis failed to find independent risk factors for postoperative complications. The performance of RGB + LSG is feasible and does not increase the postoperative morbidity rate. Weight loss after RGB + LSG validates the concept of "restrictive surgery after restrictive surgery". We did not find any independent risk factors that would have justified the avoidance of RGB + SG.
Background:
Laparoscopic sleeve gastrectomy (LSG) is an emerging surgical approach, but 1 that has seen a surge in popularity because of its perceived technical simplicity, feasibility, and good outcomes. An international expert panel was convened in Coral Gables, Florida on March 25 and 26, 2011, with the purpose of providing best practice guidelines through consensus regarding the performance of LSG. The panel comprised 24 centers and represented 11 countries, spanning all major regions of the world and all 6 populated continents, with a collective experience of >12,000 cases. It was thought prudent to hold an expert consensus meeting of some of the surgeons across the globe who have performed the largest volume of cases to discuss and provide consensus on the indications, contraindications, and procedural aspects of LSG. The panel undertook this consensus effort to help the surgical community improve the efficacy, lower the complication rates, and move toward adoption of standardized techniques and measures. The meeting took place at on-site meeting facilities, Biltmore Hotel, Coral Gables, Florida.
Methods:
Expert panelists were invited to participate according to their publications, knowledge and experience, and identification as surgeons who had performed >500 cases. The topics for consensus encompassed patient selection, contraindications, surgical technique, and the prevention and management of complications. The responses were calculated and defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement).
Results:
Full consensus was obtained for the essential aspects of the indications and contraindications, surgical technique, management, and prevention of complications. Consensus was achieved for 69 key questions.
Conclusion:
The present consensus report represents the best practice guidelines for the performance of LSG, with recommendations in the 3 aforementioned areas. This report and its findings support a first effort toward the standardization of techniques and adoption of working recommendations formulated according to expert experience.
Bariatric revision surgery is associated with several complications that can be attributed to decreased quality of tissue and complexity of the surgery. A laparoscopic sleeve gastrectomy is a simple technique with potential advantages. Therefore, the results of this procedure were evaluated as a revisional option. Fifty-one patients underwent laparoscopic sleeve gastrectomy (LSG). Indications for the LSG were insufficient weight loss (34 patients, group 1) or vomiting (17 patients, group 2) following a laparoscopic adjustable gastric banding (LAGB) or vertical banded gastroplasty (VBG). Patient and procedure characteristics as well as outcome were collected prospectively. From October 2006 to June 2010, 51 patients with a failed prior bariatic procedure (VBG or LAGB) were converted to (L)SG. The conversion rate was zero. The median procedure time was 99 min (range 54-221) and hospital stay was 3 days (range 2-38). There was no mortality after 30 days. Complications included bleeding (six) and leakage of the staple line (seven). Mean follow-up was 13.8 (2-46) months. LSG as revision surgery for insufficient weight loss resulted in extra weight loss of 52.7%, and the overall extra weight loss was 49.3%. When LSG was performed because of vomiting, 82% was able to eat solid food at follow-up. Of the 65 pre-existent co-morbidities, 21 were resolved and 18 improved. LSG as a revision procedure is feasible. An additional weight loss and further resolution of co-morbidity seem achievable, however, at the cost of a high number of complications. Therefore, revision bariatric surgery should be limited to expert tertiary bariatric centers.
Dumping syndrome is a well-known complication after upper gastrointestinal (GI) surgery. There are scarce data in the literature about the incidence of dumping after bariatric operations but, certainly no relation between this syndrome and laparoscopic sleeve gastrectomy (LSG) has been attempted.
We conducted a prospective clinical study in order to evaluate the potential presence, incidence and severity of Dumping syndrome after LSG. Thirty one non-diabetic morbidly obese patients (eight male, 23 female) eligible for LSG were evaluated. Median age was 38 (22-58 years) and mean body mass index (BMI) was 45.55 (± 5.37). The diagnosis of dumping syndrome was based on clinical provocation of signs and symptoms using an oral glucose challenge before and 6 weeks after the operation. The Sigstad's dumping score was estimated in order to separate dumpers from non-dumpers, and the Arts questionnaire was completed to distinguish between early and late dumping. Moreover, blood glucose levels during the oral glucose challenge were measured.
No patient had symptoms of dumping after provocation preoperatively, whereas after LSG 9 patients (29%) experienced definite dumping and other 5 patients (16%) symptoms suggestive of dumping syndrome. Arts' questionnaire demonstrated that dumping occurrence after LSG was associated with early symptoms. Late hypoglycaemia occurred in one patient.
A significant proportion of patients after LSG experienced dumping syndrome upon provocation. It seems that LSG should no longer be considered as a pure restrictive procedure, and it might be an option for heavy sweeters by changing their food tolerance patterns.
The aim of this study was to evaluate the possible role of sleeve gastrectomy (SG) per se in the reversibility of diabetes.
Insulin secretion and peripheral insulin sensitivity using the intravenous glucose tolerance test (IVGTT) were assessed in 18 obese type 2 diabetic patients and in 10 nondiabetic obese patients before and 3 days after SG, before any food intake and any weight change occurrence. At the same time, ghrelin, GLP-1, and PYY levels were determined.
In diabetic patients who had the disease less than 10.5 years, the first phase of insulin secretion promptly improved after SG. The early insulin area under the curve (AUC) significantly increased at the postoperative IVGTT, indicating an increased glucose-induced insulin secretion. The second phase of insulin secretion (late AUC) significantly decreased after SG in all groups, indicating an improved insulin peripheral sensitivity. In all groups, pre- and postoperatively, intravenous glucose stimulation determined a decrease in ghrelin values and an increase in GLP-1 and PYY values. However, in the group of patients with disease duration >10.5 years, the differences were not significant except for the late insulin AUC. Postoperative basal and intravenous glucose-stimulated ghrelin levels were lower than preoperative levels in all groups of patients. Basal and intravenous stimulated GLP-1 and PYY postoperative values were higher than preoperative levels in all groups.
Restoration of the first phase of insulin secretion and improved insulin sensitivity in diabetic obese patients immediately after SG, before any food passage through the gastrointestinal tract and before any weight loss, seem to be related to ghrelin, GLP-1, and PYY hormonal changes of possible gastric origin and was neither meal- nor weight-change-related. Duration of the disease up to 10.5 years seems to be a major cut off in the pathophysiological changes induced by SG. A "gastric" hypothesis may be put forward to explain the antidiabetes effect of SG.
Laparoscopic adjustable gastric banding (LAGB) is a purely restrictive procedure that has been proved to be an effective tool in achieving weight loss. The low operative morbidity and reversibility are often seen as advantages of this procedure compared with other bariatric approaches. We have attempted to define the reasons for revisional surgery after LAGB and the outcomes.
A retrospective review of a prospectively maintained database was performed from February 2001 to October 2008 at a center of excellence after institutional review board approval. The patients who had undergone revisional surgery after primary LAGB were evaluated.
Of 343 patients who had undergone primary LAGB, 60 subsequently underwent a revisional procedure. In addition, 28 revisional procedures were performed on patients who had undergone primary LAGB at an outside institution. These procedures included 39 (44.3%) band removals alone, 12 (13.6%) band removals with conversion to sleeve gastrectomy, 13 (14.8%) band removals with conversion to Roux-en-Y gastric bypass, 9 (10.2%) band repositioning, and 2 (2.3%) band replacements. In addition, 13 (14.8%) port-related procedures (3 relocations, 6 reconnections, and 4 replacements/removals) were performed.
Although reversible and efficacious, LAGB appears to have a high incidence of complications requiring revisional surgery and/or band removal. The results of our study have shown that laparoscopic revisional surgery after primary LAGB is safe and can be performed with minimal morbidity.
Sleeve gastrectomy (SG) is an alternative to gastric bypass and laparoscopic adjustable gastric banding (GB).
From January 2004 to January 2006, 111 patients with a follow-up longer than 24 months were prospectively followed. Three treatment groups were defined. Sleeve gastrectomy as first procedure (SGFP; n = 50), sleeve gastrectomy after failure of GB (SG after GB; n = 9) and GB (n = 52). We compared morbidity, mortality, length of stay, number of procedures under general anaesthesia, excess weight loss (EWL) and quality of life.
Mean initial body mass index (BMI) was 50.4 (SG), 50.8 (SG after GB) and 43.8 (GB; p = 0.000001). Mean operating time was 97.1 min (SGFP), 122.2 min (SG after GB) and 69.8 min (GB; p < 0.0001). The reoperation rate under general anaesthesia was 2% (SGFP), 11% (SG after GB) and 30.76% (GB; p = 0.00001).The fistula rate was 2% (SGFP), 0% (SG after GB) and 0% (GB). BMI at 24 months was 33.8 (SGFP), 35.3 (SG after GB) and 33.2 (GB; NS). EWL at 24 months was 67.4 (SGFP), 60.3 (SG after GB) and 58.6 (GB; NS). In the SGFP group and in the SG after GB group, the mean quality-of-life score was 1.1. In the GB group, the mean score was 0.95 (NS).
Initial BMI was significantly higher in the SG group but was no longer significantly different from the BMI of the GB group at 12 and 24 months. Excess BMI loss was higher after SG than after GB. This reduction of BMI was considered to be a success for GB. Thus, results of SG should be considered as a success. Quality of life was not significantly different between the three groups. These results validated SG as first procedure or after failure of GB.
Laparoscopic sleeve gastrectomy (LSG) has been used as a first step of a two-stage approach in bariatric surgery for high-risk patients. Recently, LSG is being utilized as a primary and final procedure for morbid obesity with acceptable short-term results. The aim of this study is to investigate the effectiveness of LSG as a revisional procedure for patients with unsatisfactory outcomes after laparoscopic adjustable gastric band (LAGB). A retrospective review of a prospectively maintained database was performed. Data were reviewed for all patients undergoing revision from LAGB to LSG during the period May 2005 and May 2009. Data collected included demographics, indication for revision, operative time, length of stay, postoperative complications, and degree of weight reduction. Fifteen patients (three males and 12 females) had revisional surgery converting a LAGB to a LSG. The indication in four patients (26.66%) was weight regains and in five patients (33.33%) was poor weight loss; four patients (26.66%) had a band slippage and symptoms of gastroesophageal reflux, and one patient (6.66%) had poor weight loss, band slippage, and reflux. In one patient (6.66%), the indication was slippage and duodenal fistula. One-step revision procedure was done in 13 patients (86.66%), while two-step procedure was done in two patients (13.33%). Mean preoperative weight and BMI were 233.02 (181.4-300) lb and 38.66 (29.7-49.3) kg/m2, respectively. Mean weight loss at 2, 6, 12, 18, and 24 months postoperatively was 20.7, 48.3, 57.2, 60.1, and 13.5 lb, respectively. Mean % excess BMI loss was 28.9%, 64.2%, 65.3%, 65.7%, and 22.25% at 2, 6, 12, 18, and 24 months, respectively. There was one major complication (staple line leak) and one postoperative acute gastric outlet obstruction. We had no mortality. Thirteen patients were followed up postoperatively. The number decreased as follow-up time progressed. LSG could provide short-term weight loss after previously failed LABG, but prone to more complications compared to an initial LSG without a prior bariatric procedure.
Sleeve gastrectomy (SG), which, thus far, is showing good resolution of comorbidities and good weight loss, shows increasing popularity among bariatric surgeons. The aim of this study was to evaluate clinical outcome and the gastric emptying of solid foods, 24 months after SG.
Fourteen morbidly obese patients, four males and ten females, median age 41 years (range 29-65), median body mass index (BMI) 49.46 kg/m(2) (range 41.14-55.63), who underwent SG for weight loss, were studied prospectively. Nine patients underwent gastric emptying studies, using radioisotopic technique before, 6 months and 24 months after the operation. The remaining five patients underwent gastric emptying studies, 6 months and 24 months after the operation.
A significant reduction in patients' weight and BMI was evident at 6, 12 and 24 months postoperatively. In the nine patients who underwent gastric emptying studies pre-, 6 and 24 months postoperatively, the T-lag phase duration significantly decreased, following the SG, from 17.30 (range 15.50-20.90) min, to 12.50 (range 9.20-18.00) min at 6 months and 12.16 (range 10.90-20.00) min at 24 months postoperatively (P < 0.05). The gastric emptying half time (T1/2) accelerated significantly postoperatively from 86.50 (range 77.50-104.60) min, to 62.50 (range 46.30-80.00) min at 6 months and 60.80 (range 54.80-100.00) min at 24 months after SG (P < 0.05). The percentage of gastric emptying (%GE) increased significantly postoperatively, from 52 (range 43-58) % to 72 (range 57-97) % at 6 months and 74 (range 45-82) % at 24 months, following SG (P < 0.05). No differences in gastric emptying were observed, when values at 24 months were compared to those at 6 months postoperatively. When the whole group of 14 patients was studied, there were also no significant changes in T-lag, T1/2 and %GE between 6 and 24 months postoperatively.
Our study indicates the constant effect of SG in the acceleration of gastric emptying of solids, which occurs faster, not only in short but also in long-term postoperatively. Such effects on gastric motility, in combination with the reported alterations in gut hormones, may explain how this 'food limiting' operation results in weight loss.
Different changes of plasma ghrelin levels have been reported following gastric banding, Roux-en-Y gastric bypass, and biliopancreatic diversion.
This prospective study compares plasma ghrelin levels and weight loss following laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) in 20 patients.
Patients who underwent LSG (n=10) showed a significant decrease of plasma ghrelin at day 1 compared to preoperative values (35.8 +/- 12.3 fmol/ml vs 109.6 +/- 32.6 fmol/ml, P=0.005). Plasma ghrelin remained low and stable at 1 and 6 months postoperatively. In contrast, no change of plasma ghrelin at day 1 (71.8 +/- 35.3 fmol/ml vs 73.7 +/- 24.8 fmol/ml, P=0.441) was found in patients after LAGB (n=10). Increased plasma ghrelin levels compared with the preoperative levels at 1 (101.9 +/- 30.3 fmol/ml vs 73.7 +/- 24.8 fmol/ml, P=0.028) and 6 months (104.9 +/- 51.1 fmol/ml vs 73.7 +/- 24.8 fmol/ml, P=0.012) after surgery were observed. Mean excess weight loss was higher in the LSG group at 1 (30 +/- 13% vs 17 +/- 7%, P=0.005) and 6 months (61 +/- 16% vs 29 +/- 11%, P=0.001) compared with the LAGB group.
As a consequence of resection of the gastric fundus, the predominant area of human ghrelin production, ghrelin is significantly reduced after LSG but not after LAGB. This reduction remains stable at follow-up 6 months postoperatively, which may contribute to the superior weight loss when compared with LAGB.
The use of the laparoscopic sleeve gastrectomy (LSG), a restrictive operation, in different settings, is presented.
31 patients underwent LSG in the following groups: 1) 7 patients with very high BMI as a first stage of the duodenal switch (DS); 2) 7 morbidly obese patients with severe medical conditions; 3) 16 obese patients with lower BMI (35-43); and 4) 1 patient converted from a prior gastric banding.
1 patient with BMI 74 died, a 3.2% mortality. The percentage of excess BMI loss (%EBMIL) in group 1 above was 63.1% from 4-27 months. The %EBMIL of the cirrhotics in group 2 was 76.0% (69-100%). The %EBMIL in group 3 patients was 68.5% (58.3-123%) at 3-27 months. The %EBMIL of the group 4 patient is 13% because she had previously lost almost all of her EBMI.
LSG may become the ideal operation for staging in patients with BMI >55, for treating morbidly obese patients with severe medical conditions, as an excellent alternative to adjustable bands in lower BMI patients, or for conversion of gastric banding patients.
Laparoscopic sleeve gastrectomy (LSG), initially described by Gagner's group as the first stage of the laparoscopic duodenal switch in super-obese patients, is now gaining wide diffusion among bariatric surgeons as a new restrictive operation.
From January 2005 to January 2006, 8 obese patients with BMI 37-74 kg/m(2) underwent LSG for conversion from a prior complicated or failed laparoscopic adjustable gastric banding (LAGB). Three patients had severe symptomatic esophageal dilation, while 5 patients had unsuccessful weight loss with poor "band compliance". After de-banding, LSG was calibrated upon a 34-Fr gastric bougie, and blue and green linear staplers were used. The staple-line was buttressed by placing a sero-serosal running suture in all but one patient, and methylene blue dye was used to test for leaks. All the patients underwent upper GI series with water-soluble contrast medium 2 days after the surgery.
The average operating-time for LSG was 90 minutes (range 60-120 min). The average hospital stay was 4 days (range 3-7). There were no perioperative complications, no conversion, and no mortality. No intraoperative or postoperative blood transfusions were required.
LSG proved to be feasible and safe after LAGB. Longer follow-up and larger series are needed to assess weight loss results.
Laparoscopic Roux-en-Y gastric bypass (LRYGBP) and laparoscopic adjustable gastric banding (LAGB) are the most commonly performed surgical procedures for weight reduction in the United States. Currently, laparoscopic sleeve gastrectomy (LSG) is being explored. The aim of this study was to assess the safety and short-term efficacy of LSG as a treatment option for weight reduction.
Data of all patients who underwent LSG for treatment of morbid obesity between November 2004 and March 2006 and completed the 3- and 6-month follow-up visits at the time of the study, were retrospectively reviewed. Data collected included demographics, operative time, length of stay, postoperative complications, and degree of weight reduction.
Of the 62 patients who underwent LSG performed by two surgeons, the data of 30 patients (7 males and 23 females) were further analyzed. Mean preoperative BMI was 41.4 (33-59) kg/m(2). Mean operative time was 80 min (range 65-130). Mean hospital stay was 3.2 days (range 2 to 25). Mean weight loss at 3 and 6 months following the procedure was 22.7 kg and 30.5 kg respectively, and mean % excess weight loss (EWL) was 40.7 and 52.8, respectively. Three patients were considered to have mild complications, and one patient had a major complication that necessitated surgical intervention. There was no mortality.
In the short-term, LSG is a safe and effective treatment option.
Background:
Laparoscopic adjustable gastric banding (LAGB) has emerged as one of the most commonly performed bariatric procedures worldwide. Unfortunately, revisional surgery is required in 20-30 % of cases. Several revisional strategies have been proposed, but there is no consensus regarding the best surgical option. This systematic review was designed to determine which revisional surgery (laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, or laparoscopic biliopancreatic diversion with duodenal switch) is best suited to enhance weight loss following failed LAGB due to complications or inadequate weight loss.
Methods:
EMBASE, MEDLINE, PsycINFO, and Cochrane Clinical Trials were searched using the most comprehensive timeline for each database. A total of 24 relevant articles were identified. Two investigators independently extracted data, and differences were resolved by consensus. The weighted means were calculated for weight loss measurements.
Results:
A total of 106, 514, and 71 patients underwent conversion from LAGB to laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), and laparoscopic biliopancreatic diversion and duodenal switch (BPDDS), respectively. Before revisional surgery, the weighted mean body mass index (BMI) was 38.8 (6.9), 43.3 (8.1), and 41.3 (7.2) kg/m(2) for the LSG, LRYGB, and BPDDS groups, respectively. The majority of data was reported at 12-24 months follow-up. The mean BMI within this interval was 28 (10.5), 32.2 (6.4), and 33 (5.7) kg/m(2) for the LSG, LRYGB, and BPDDS groups, respectively. In addition, the mean excess weight loss (EWL) was 22 % (2.8), 57.8 % (11.7), 47.1 % (14) for the LSG, LRYGB, and BPDDS groups, respectively. The EWL reached 78.4 % (35) in the BPPDS group after 2-year follow-up.
Conclusions:
Failed LAGB is best managed with conversion to another bariatric procedure. Stable weight loss occurs with salvage LRYGB. Although results for revisional BPPDS appear promising, additional research, with higher methodological quality, is needed.
Laparoscopic sleeve gastrectomy (LSG) is performed in certain circumstances after failure of gastric banding. The goal of this study was to evaluate the impact of first-line gastric banding on the morbidity associated with secondary LSG for obesity.
The case records of 102 consecutive patients undergoing LSG were studied retrospectively. The technique of LSG was standardized. Two groups were compared: one with patients having undergone LSG after first-line gastric banding (n = 31) and the second, with patients having undergone first-line LSG (n = 71). Endpoints were overall morbidity and intra/postoperative complications including gastric leaks consecutive to staple line disruption as well as other septic or hemorrhagic complications. Multivariable analysis was performed to detect independent risk factors for morbidity.
Overall morbidity was significantly higher in patients having undergone LSG after first-line gastric banding compared with those undergoing first-line LSG (32.2% vs. 7%, P = 0.002). Gastric leaks secondary to staple line disruption also occurred statistically significantly more often in patients with first-line gastric banding (16.1% vs. 2.8%, P = 0.043). Waiting 6 months between gastric band removal and performing LSG did not prevent the increased morbidity compared with first-line LSG. Multivariable analysis revealed that among the factors analyzed (age, gender, comorbidity, body mass index, surgeon, first-line gastric banding), the only independent risk factor for staple line disruption was first-line gastric banding with an odds ratio = 6.6 (95% confidence interval = [1.2-36.3]).
Undergoing first-line gastric banding increases the risk of complications after secondary LSG. We recommend that patients who undergo LSG after a first-line gastric banding should be warned of the increased risks of morbidity or, alternatively, that LSG be performed preferentially as the initial procedure.
Laparoscopic adjustable gastric banding (LAGB) is an effective bariatric procedure with low morbidity and mortality. Unfortunately, it is fraught with high failure rates in long-term follow-up. Laparoscopic sleeve gastrectomy (LSG) is an emerging procedure, quickly gaining momentum in the arsenal of bariatric practice as a first step toward gastric bypass/biliopancreatic diversion or as a stand-alone operation. Recently, it has been described as a revisional option for previous bariatric surgery failures. We report our early experience with LSG as a revisional procedure for failed LAGB.
From January 2007 to April 2010, 46 patients, who had undergone LAGB, underwent LSG. Patient demographics, reason for band removal, interval between removal and LSG, operative times, estimated blood loss, complications, length of hospital stay, and percent of excess weight loss were collected.
Of the 46 patients, 20 (43%) had their bands removed before LSG (median time interval, 2 years; range, 2 months to 9 years); the rest had concomitant band removal and LSG. Twelve patients were men (26%). Mean age and BMI were 40 (range, 20-60) years and 43.1 kg/m(2) (range, 33-57), respectively. In two cases, surgery was converted to an open procedure due to extensive adhesions related to previous surgeries. Median operative time, estimated blood loss, and length of hospital stay were 118 (range, 70-250) minutes, 41 (range, 5-600) ml, and 3 (range, 1-100) days, respectively. Major morbidity was encountered in three patients (6%; leak in 2 and bleeding in 1). There were no mortalities. Mean follow-up time for our cohort is 17 (range, 1-39) months. Percent of excess weight loss at 2, 6, 12, 24, and 36 months was 24, 37, 53, 51, and 48%, respectively.
Our results suggest that LSG is safe, feasible, and effective as a revisional procedure for failed LAGB and can be considered as an appealing option in these cases. Larger series and longer follow-up are needed to confirm this.
The aim of this study is to evaluate the safety and efficacy of converting failed restrictive procedures such as laparoscopic adjustable gastric banding (LAGB), non-adjustable gastric banding (NAGB), and vertical banded gastroplasty (VBG) to laparoscopic sleeve gastrectomy (LSG). A prospective database was maintained of 32 patients who failed restrictive procedures. Twenty-six patients failed LAGB, three patients failed NAGB, one of which was performed open, and three patients failed VBG. These patients were converted to LSG between January 2006 and May 2010. Post-conversion outcomes, BMI, and excess weight loss (EWL) were recorded. Four patients were excluded from the weight loss statistical data secondary to short follow-up (less than 6 months since conversion); however, these patients were included in the overall number of cases and in the discussion of complications. Causes of failed restrictive procedures in our series include inadequate weight loss, 15 (47%); weight gain, six (19%); slippage, five (16%); esophageal dilatation, one (3%); unhappy with device, one (3%); tear of silastic ring, one (3%); infection, one (3%), gastrogastric fistula with VBG and weight gain, one (3%); and intractable nausea and vomiting, one (3%). The average hospital stay was 1.5 days (range, 1-3). The average length of follow-up was 26 months. The mean pre-conversion BMI was 42.69, post-conversion to SG mean BMI was 33.3, mean EWL pre-conversion was 10%, and post-conversion mean EWL was 60%. There was no mortality, no conversion to open, and there was one complication, a contained leak resolved by antibiotic treatment. Conversion to LSG from a prior restrictive procedure may be a feasible and acceptable alternative for patients. Average EWL was 60% at an average of 26 months.
Laparoscopic sleeve gastrectomy (LSG) is considered an effective multipurpose operation for morbid obesity, although long-term results are still lacking. Also, the best procedure to be offered in the case of failed restrictive procedures is still debated. We here reported our results of LSG as a revisional procedure for inadequate weight loss and/or complications after adjustable gastric banding or gastroplasty.
Since April 2005, 57 patients (20 men and 37 women), with a mean age of 49.9 +/- 11.9 years, underwent revisional LSG, 52 after laparoscopic adjustable gastric banding/adjustable gastric banding and 5 after vertical banded gastroplasty at our institution. The mean interval from the primary procedure to LSG was 7.54 +/- 4.8 years. The LSG was created using a 34F bougie with an endostapler, after removing the laparoscopic adjustable gastric band or the anterior portion of the band in those who had undergone vertical banded gastroplasty. An upper gastrointestinal contrast study was performed within 3 days after surgery and, if the findings were negative, a soft diet was promptly started.
A total of 41 patients had undergone concurrent band removal and LSG and 16 had undergone band removal followed by an interval LSG. Three cases required conversion to open surgery because of a large incisional hernia. The mean operative time was 120 minutes (range 90-180). One patient died of multiple organ failure from septic shock. Three patients (5.7%) developed a perigastric hematoma, 3 (5.7%) had leaks, and 1 had mid-gastric short stenosis. The median hospital stay was 5 days. The mean body mass index at revisional LSG was 45.7 +/- 10.8 kg/m(2) and had decreased to 39 +/- 8.5 kg/m(2) after 2 years, with a mean percentage of the estimated excess body mass index lost of 41.6% +/- 24.4%. Two patients required a duodenal switch for insufficient weight loss.
LSG seems to be effective as revisional procedure for failed LAGB/vertical banded gastroplasty, although with greater complication rates than the primary procedures. Larger series and longer follow-up are needed to confirm these promising results.
The problem of revision of failed gastric banding (GB) and vertical banded gastroplasty (VBG) procedures has become a common situation in bariatric surgery. Laparoscopic sleeve gastrectomy (LSG) has been recently used to revise failed restrictive procedures. The objective of this study is to evaluate the results of LSG as revisional procedure for failed GB and VBG.
A prospective held database was questioned regarding patients' demographic, indication for revision, conversion to open surgery, morbidity, percentage of excess weight loss (%EWL), evolution of comorbidities, and need for a second procedure after LSG.
Forty-one patients, 34 women and seven men with a mean age of 42 years (range 19 to 63 years) and a mean body mass index at 49.9 kg/m(2) (range 35.9-63 kg/m(2)), underwent laparoscopic conversion of GB (36 patients) and VBG (five patients) into LSG. Indication for revisional surgery was insufficient weight loss in all the cases. All procedures were completed laparoscopically. There was no mortality and five patients (12.2%) developed complications (high leak, one patient; intra-abdominal abscess, three patients; and complicated incisional hernia, one patient). At a mean follow-up of 13.4 months, %EWL is on average 42.7% (range 4-76.1%). Six patients had a second procedure (four had laparoscopic duodenal switch, one had laparoscopic Roux-en-Y gastric bypass, and one had laparoscopic biliopancreatic diversion).
Conversion of GB and VBG into LSG is feasible and safe. LSG is effective in the short term with a mean %EWL of 42.7% at 13.4 months. Long-term results of LSG as revisional procedure are awaited to establish its efficacy in the long term.
We investigated early and midterm results of laparoscopic sleeve gastrectomy (LSG) as an isolated primary and secondary operation after failed gastric banding.
Between May 2004 and October 2007, a total of 70 patients (female 77%, mean age 43 (21-65) years, mean initial body mass index (BMI) 46 (35-61) kg/m(2)) were prospectively evaluated and operated by LSG. In 41 patients, LSG was performed as a primary operation (group 1) and in 29 patients as a secondary procedure after failed gastric banding (group 2). The overall average follow-up time after LSG was 24 (12-53) months; follow-up rate 1 year after operation was 100%, after 2 years 98%, and after 3 years 95%.
There were no intraoperative complications, no conversion with shorter operation time in group 1 (91 vs. 132 min, p = 0.001). Early morbidity of LSG was 5% (major) and 7% (minor); mortality was zero. Average excessive BMI loss after 1 year was 65% (9-127%), after 2 years 63% (13-123%), and after 3 years 60% (9-111%). Midterm morbidity was 13%. There was no significant difference between the two groups regarding early and midterm morbidity, reoperation rate for complications (11.4%), or insufficient weight loss (7%).
LSG is a safe bariatric procedure with good weight loss in the first 3 years postop. It can be used as an isolated initial treatment and as a secondary treatment after failed gastric banding. However, in the absence of long-term results, we suggest LSG to be performed only in controlled trials.
To evaluate the feasibility, safety, and short-term efficacy of the conversion of laparoscopic adjustable gastric banding (LAGB) to laparoscopic sleeve gastrectomy (LSG) because of inadequate weight loss.
The inclusion criteria were an inadequate percentage of excess weight loss (%EWL), defined as <30% at > or =1 year after LAGB. From August 2002 to October 2007, 27 patients (17 women and 10 men) had undergone removal of their LAGB and conversion to LSG. The average age at LSG was 43.6 +/- 11.4 years (range 25-66). Before LAGB, the mean weight and body mass index was 129.8 +/- 21.9 kg (range 95-178) and 45 +/- 8.1 kg/m(2) (range 35-64), respectively. The average interval between LAGB and LSG was 51.2 +/- 30.1 months (range 22-132). Before conversion, the mean weight, body mass index, and %EWL was 117.9 +/- 27.3 kg (range 63-170), 39 +/- 9.6 kg/m2 (range 24-61), and 18.1% +/- 18.3%, respectively. Of the 27 patients, 12 had 19 obesity-related co-morbidities, including arterial hypertension in 7, type 2 diabetes mellitus in 2, degenerative joint disease in 7, and sleep apnea in 3.
The mean operative time was 120.6 +/- 32.4 minutes (range 65-195). No conversion to open surgery was required, and no patient died. The postoperative complications included a subphrenic hematoma that required laparoscopic drainage; no postoperative leaks developed. The mean hospital stay was 3.2 +/- 1.4 days (range 2-8). After a mean follow-up of 18.6 +/- 14.8 months (range 1-59) for 23 patients (4 patients were lost to follow-up), the mean weight, body mass index, and weight loss was 100.7 +/- 23.5 kg (range 61-152), 34.6 +/- 8.7 kg/m2 (range 21-50.4), and 23 +/- 12.4 kg (range 2-55), respectively. The patients had had an additional 16.7% EWL after LSG for a total average %EWL of 34.8% +/- 21.8% (P <.05). Of the 12 patients with obesity-related co-morbidities, 5 had had resolution, including arterial hypertension in 1, type 2 diabetes mellitus in 1, degenerative joint disease in 2, and sleep apnea in 2.
The results of this study support the safety of LSG in the case of an inadequate %EWL after LAGB. However, the degree of weight loss and co-morbidity resolution is of concern.
Laparoscopic adjustable gastric banding (LAGB) is a commonly performed bariatric procedure. When LAGB fails, restrictive procedures such as gastric bypass have been performed. Laparoscopic sleeve gastrectomy (LSG) has been suggested as an alternative, but it has not yet been fully studied. Evaluated in this report are the experiences of patients who underwent LSG, a restrictive procedure, as a rescue procedure for failed LAGB.
From June 2002 to June 2007, charts of patients who underwent LAGB were reviewed to find those who had undergone LSG as a rescue procedure.
Of 294 patients who underwent LAGB, 10 later underwent LSG. Median excess weight loss (EWL) prior to LSG had been 34%; after LSG, median EWL was 55%. Before LSG was performed, patients had a median 11.5 comorbidities, all of which improved after LSG. No major complications or deaths resulted.
The results suggest LSG might be a reasonable choice for patients who fail LAGB. A formal study comparing LSG with other rescue procedures should be performed.
The revisional surgery for patients with inadequate weight loss after biliopancreatic diversion with duodenal switch (BPD/DS) is controversial. It has not yet been determined whether a common channel should be shortened or gastric pouch volume reduced. Since the revision of the distal anastomosis remains technically difficult and associated with possible complications, we turned our attention to the reduction of gastric sleeve volume. This operation is more feasible and potential complications are less probable. Patient and Method: We present the case of a 47-year-old women with a life-long history of morbid obesity. She was operated on in January 2000 with a laparoscopic BPD/DS with 100 ml gastric pouch, 150 cm of alimentary limb and 100 cm of common channel. Before this operation, her weight was 170 kg, with BMI 64 kg/m(2). She lost most of her excess weight within 17 months after surgery and was regaining weight at 77 kg and BMI 29 kg/m(2). Upper GI series showed a markedly dilated gastric pouch. Her second surgery consisted of a laparoscopic sleeve partial gastrectomy along the greater curvature using endo GIA staplers with bovine pericardium for reinforcement of the stapler line.
No postoperative complications occurred. The patient was discharged on the first postoperative day. Significant further weight reduction was noted, and at 10 months after surgery, her weight is 61 kg with BMI 22.
A repeat laparoscopic gastric sleeve resection was performed for inadequate weight loss after BPD/DS, and resulted in further weight reduction.
A review of conversions of gastric banding for obesity to Roux-en-Y gastric bypass, gastric sleeve, or duodenal switch attempts to determine which revisional procedure best enhances weight loss. Indications for these conversions are multiple and include hardware problems, motility problems, and miscellaneous like inadequate weight loss. Analysis of band conversions to band of 193 patients, and bands to gastric bypass in 214 patients reveals better weight loss with the latter strategy. Smaller cohorts of patients who underwent a biliopancreatic diversion or simply a sleeve gastrectomy are too small to conclude on their efficacy. Prospective randomized trials are needed to determine which revisional procedure is best in the setting of inadequate weight loss of excessive weight regain after gastric adjustable banding for severe obesity.
Good results obtained after laparoscopic sleeve gastrectomy (LSG), in terms of weight loss and morbidity, have been reported in few recent studies. Our team has designed a multicenter prospective study for the evaluation of the effectiveness and feasibility of this operation as a restrictive procedure.
From January 2003 to September 2006, 163 patients (68% women) with an average age of 41.57 years, were operated on with a LSG. Indications for this procedure were morbid obese [body mass index (BMI)>40 kg/m2] or severe obese patients (BMI>35 kg/m2) with severe comorbidities (diabetes, sleep apnea, hypertension...) with high-volume eating disorders and superobese patients (BMI>50 kg/m2).
The average BMI was 45.9 kg/m2. Forty-four patients (26.99%) were superobese, 84 (51.53%) presented with morbid obesity, and 35 (21.47%) were severe obese patients. Prospective evaluations of excess weight loss, mortality, and morbidity have been analyzed. Laparoscopy was performed in 162 cases (99.39%). No conversion to laparotomy had to be performed. There was no operative mortality. Perioperative complications occurred in 12 cases (7.36%). The reoperation rate was 4.90% and the postoperative morbidity was 6.74% due to six gastric fistulas (3.66%), in which four patients (2.44%) had a previous laparoscopic adjustable gastric banding. Long-term morbidity was caused by esophageal reflux symptoms (11.80%). The percentage of loss in excessive body weight was 48.97% at 6 months, 59.45% at 1 year (120 patients), 62.02% at 18 months, and 61.52% at 2 years (98 patients). No statistical difference was noticed in weight loss between obese and extreme obese patients.
The sleeve gastrectomy seems to be a safe and effective restrictive bariatric procedure to treat morbid obesity in selected patients. LSG may be proposed for volume-eater patients or to prepare superobese patients for laparoscopic gastric bypass or laparoscopic duodenal switch. However, weight regained, quality of life, and evolution ofmorbidities due to obesity need to be evaluated in a long-term follow up.
Alterations in gut hormones after laparoscopic sleeve gastrectomy: prospective clinical and laboratory investigational study
- E Dimitriadis
- M Daskalakis
- M Kampa
- A Peppe
- J A Papadakis
- J Melissas
Laparoscopic sleeve gastrectomy feasible for bariatric revision surgery
- C A Berende
- J P De Zoete
- J F Smulders
- S W Nienhuijs
- CA Berende
Updated position statement on sleeve gastrectomy as a bariatric procedure