Surgery for Obesity and Related Diseases 11 (2015) 1413
Commentary
Comment on: Worthy or not? Six Year Experience of Revisional Bariatric Surgery from an Asian Centre of Excellence1 As primary bariatric surgery is increasing in magnitude across the world, the need for revisions is also increasing. At present, inadequate weight loss or weight regain after primary bariatric surgery is a vexing problem. It is dependent on the type of initial procedure, the patient’s initial weight and other unexplained patient factors [1]. In cases of primary restrictive bariatric surgery, the option of conversion to a combination restrictive and malabsorptive Roux-en-Y gastric bypass (RYGB) has shown very promising results. However, in cases of primary RYGB, any revision is associated with only moderate weight loss. Haung et al. [2] present their experience of revisional bariatric surgery from a high-volume Asian bariatric center between July 2006 and June 2012. The authors do not include their initial 50 procedures, citing a learning curve. Also, patients with a minimum of 6 months follow-up after the revisional bariatric surgery are included. This resulted in 52 revisional bariatric procedures out of a total of 1578 bariatric operations. The indications were primarily weight loss failure in 21 patients and complications related to the primary operation in 31 patients. Weight loss failure was defined as excess weight loss (EWL) of less than 50% at 2 years, or weight regain 415% from baseline following primary bariatric surgery. The authors had good response in patients who had a primary restrictive bariatric operation with a mean body mass index (BMI) change of 8.9 kg/m2. But, patients who had a revision of RYGB for inadequate weight loss had only a mean BMI change of 3.2 kg/m2. Authors from Cleveland clinic [3] also noted a similar success with mean EWL of 53.7% after revision of a primary restrictive procedure, but only 37.6% after revision of RYGB at 41-year follow-up. However, when you consider the total weight loss from initial primary bariatric surgery, these patients still achieved greater than 50% mean EWL. Similarly, in the present study as noted in Fig. 2, the final BMI was similar in both primary restrictive and primary RYGB patients after revision. Hence, this small change in BMI after revision should not be totally discouraging.
Complications requiring revision of bariatric surgery are varied, and the treatment is individualized usually with good success. Recalcitrant stricture and marginal ulceration of the RYGB are successfully treated with revision of the gastrojejunostomy with an intracorporeal hand-sewn anastomosis using absorbable suture material. However, treatment of the dumping syndrome with revision of the gastrojejunal anastomosis is not successful as there was only a 25% success rate in this small group of patients. This emphasizes the fact that the dumping syndrome is better managed with medical treatment and a surgical option, such as conversion to a sleeve gastrectomy, should be considered in only a very select group of patients. The authors report a morbidity of only 5.8% in these complex revisional cases, which is on the lower side, compared to as high as 39.3% quoted in the literature [3]. This is likely a result of their increased expertise over time, as the authors mentioned that they had a large number of technical complications in their initial 50 patients. In conclusion, these authors demonstrated that revisional bariatric surgery can be performed safely laparoscopically in a large volume center in experienced hands. Excess weight loss after revision of RYGB is moderate and should be communicated to the patient. Pradeep Kumar Pallati, M.D., F.A.C.S. References [1] Benoit SC, Hunter TD, Francis DM, De La Cruz-Munoz N. Use of Bariatric Outcomes Longitudinal Database (BOLD) to Study Variability in Patient Success After Bariatric Surgery. Obes Surg 2014;24:936–43. [2] Huang CK, Vij A, Malapan K, Tsai CC, Hung KC, Chang PC. Worthy or not? Six Year Experience of Revisional Bariatric Surgery from an Asian Centre of Excellence. Surg Obes Relat Dis 2015;11:612–20. [3] Shimizu H, Annaberdyev S, Motamarry I, Kroh M, Schauer PR, Brethauer SA. Revisional bariatric surgery for unsuccessful weight loss and complications. Obes Surg 2013;23:1766–73.
1
This commentary is a response to an article published in a previous issue of Surgery for Obesity and Related Diseases: Vij A, Malapan K, Tsai C-C, Hung K-C, Chang P-C, Huang C-K. Worthy or not? Six-year experience of revisional bariatric surgery from an Asian center of excellence. Surg Obes Relat Dis 2015;11:612-620. http://dx.doi.org/10.1016/j.soard.2014.05.015 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Commentary
Comment on: Worthy or not? Six Year Experience of Revisional Bariatric Surgery from an Asian Centre of Excellence1 As primary bariatric surgery is increasing in magnitude across the world, the need for revisions is also increasing. At present, inadequate weight loss or weight regain after primary bariatric surgery is a vexing problem. It is dependent on the type of initial procedure, the patient’s initial weight and other unexplained patient factors [1]. In cases of primary restrictive bariatric surgery, the option of conversion to a combination restrictive and malabsorptive Roux-en-Y gastric bypass (RYGB) has shown very promising results. However, in cases of primary RYGB, any revision is associated with only moderate weight loss. Haung et al. [2] present their experience of revisional bariatric surgery from a high-volume Asian bariatric center between July 2006 and June 2012. The authors do not include their initial 50 procedures, citing a learning curve. Also, patients with a minimum of 6 months follow-up after the revisional bariatric surgery are included. This resulted in 52 revisional bariatric procedures out of a total of 1578 bariatric operations. The indications were primarily weight loss failure in 21 patients and complications related to the primary operation in 31 patients. Weight loss failure was defined as excess weight loss (EWL) of less than 50% at 2 years, or weight regain 415% from baseline following primary bariatric surgery. The authors had good response in patients who had a primary restrictive bariatric operation with a mean body mass index (BMI) change of 8.9 kg/m2. But, patients who had a revision of RYGB for inadequate weight loss had only a mean BMI change of 3.2 kg/m2. Authors from Cleveland clinic [3] also noted a similar success with mean EWL of 53.7% after revision of a primary restrictive procedure, but only 37.6% after revision of RYGB at 41-year follow-up. However, when you consider the total weight loss from initial primary bariatric surgery, these patients still achieved greater than 50% mean EWL. Similarly, in the present study as noted in Fig. 2, the final BMI was similar in both primary restrictive and primary RYGB patients after revision. Hence, this small change in BMI after revision should not be totally discouraging.
Complications requiring revision of bariatric surgery are varied, and the treatment is individualized usually with good success. Recalcitrant stricture and marginal ulceration of the RYGB are successfully treated with revision of the gastrojejunostomy with an intracorporeal hand-sewn anastomosis using absorbable suture material. However, treatment of the dumping syndrome with revision of the gastrojejunal anastomosis is not successful as there was only a 25% success rate in this small group of patients. This emphasizes the fact that the dumping syndrome is better managed with medical treatment and a surgical option, such as conversion to a sleeve gastrectomy, should be considered in only a very select group of patients. The authors report a morbidity of only 5.8% in these complex revisional cases, which is on the lower side, compared to as high as 39.3% quoted in the literature [3]. This is likely a result of their increased expertise over time, as the authors mentioned that they had a large number of technical complications in their initial 50 patients. In conclusion, these authors demonstrated that revisional bariatric surgery can be performed safely laparoscopically in a large volume center in experienced hands. Excess weight loss after revision of RYGB is moderate and should be communicated to the patient. Pradeep Kumar Pallati, M.D., F.A.C.S. References [1] Benoit SC, Hunter TD, Francis DM, De La Cruz-Munoz N. Use of Bariatric Outcomes Longitudinal Database (BOLD) to Study Variability in Patient Success After Bariatric Surgery. Obes Surg 2014;24:936–43. [2] Huang CK, Vij A, Malapan K, Tsai CC, Hung KC, Chang PC. Worthy or not? Six Year Experience of Revisional Bariatric Surgery from an Asian Centre of Excellence. Surg Obes Relat Dis 2015;11:612–20. [3] Shimizu H, Annaberdyev S, Motamarry I, Kroh M, Schauer PR, Brethauer SA. Revisional bariatric surgery for unsuccessful weight loss and complications. Obes Surg 2013;23:1766–73.
1
This commentary is a response to an article published in a previous issue of Surgery for Obesity and Related Diseases: Vij A, Malapan K, Tsai C-C, Hung K-C, Chang P-C, Huang C-K. Worthy or not? Six-year experience of revisional bariatric surgery from an Asian center of excellence. Surg Obes Relat Dis 2015;11:612-620. http://dx.doi.org/10.1016/j.soard.2014.05.015 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
