OBES SURG DOI 10.1007/s11695-015-1749-9
VIDEO SUBMISSION
Laparoscopic Conversion of a Sleeve Gastrectomy to the Roux-en-Y Gastric Bypass Imed Ben Amor 1 & Tarek Debs 1 & Francesco Martini 1 & Bachir Elias 2 & Radwan Kassir 3 & Jean Gugenheim 1
# Springer Science+Business Media New York 2015
Abstract After the failure of sleeve gastrectomy (SG), three options are available as a second intervention: the conversion into a biliopancreatic diversion with duodenal switch, the Roux-en-Y gastric bypass (RYGBP), and more recently, a re-SG consisting in the refashioning of a dilated gastric tube. We describe two different approaches for the conversion. The conversion to RYGBP remains a technically challenging operation but feasible and effective, and it should be reserved to specialized centers. Keywords Surgical technique . Roux-en-Y gastric bypass . Sleeve gastrectomy . Failure of weight loss
are available as a second intervention: the conversion into a biliopancreatic diversion with duodenal switch, the Roux-en-Y gastric bypass (RYGBP), and more recently, a re-SG consisting in the refashioning of a dilated gastric tube [2–4]. After SG, weight loss failure and gastroesophageal reflux disease (GERD) are the most common indications for redo surgery. A preoperative assessment with a volumetric computed tomography scan is essential before the conversion. A good evaluation of the gastric tube is needed; the presence of a dilatation of the gastric tube especially the existence of a pouch at the fundus should be determined [5].
Surgical Technique Introduction The implementation of laparoscopic techniques has led to a spectacular increase in the number of bariatric procedures made [1]. With all these developments in bariatric surgery, there has been a tendency by bariatric specialists to operate on these patients more than once using different types of bariatric surgeries. After the failure of the sleeve gastrectomy (SG), three options Electronic supplementary material The online version of this article (doi:10.1007/s11695-015-1749-9) contains supplementary material, which is available to authorized users. * Radwan Kassir [email protected] 1
Department of Bariatric Surgery, Hospital Archet 2, Nice, France
2
Department of Digestive Surgery, Centre Hospitalier Régional Metz-Thionville, Thionville, France
3
Department of General Surgery, CHU Hospital, Jean Monnet University, Avenue Albert Raimond, 42270 Saint Etienne, France
We describe two different approaches for the conversion. The first case represents a narrow gastric tube without a neofundus. In this case, a horizontal transection of the stomach should be performed, without dissection at the angle of His and a 30-cc gastric pouch should be created. These cases usually occur in patients undergoing the conversion for a functional pathology, such as GERD. The second approach is used in the presence of a primary or a secondary dilatation of the gastric tube or in the presence of an unresected fundus. In this case, the angle of His should be approached first, and a more meticulous dissection is needed to create the gastric pouch. The fundic pouch remnant should be resected. The morbidity rate after revisional surgery is slightly higher than a primary RYGBP, however, the mortality risk is not increased. The possible postoperative complications with an increased rate are wound infection, leak, pulmonary embolus, anemia/hemorrhage, and pneumonia/prolonged ventilation [6, 7]. Another possible limitation is the weight regain after the conversion. Weight regainers are patients resistant to both
OBES SURG
restricted and malabsorptive procedures. In the case of functional complications of laparoscopic SG (LSG) such as GERD, the laparoscopic RYGBP (LRYGBP) remains the procedure of choice [2]. The search for the ideal weight loss operation is still ongoing. Surgical pioneers developed innovative procedures that initially created malabsorption, then restricted volume intake, and eventually combined both techniques. Nowadays, with a long-term follow-up of the patients, we are observing more failures, and a second procedure is becoming more and more common [6]. The conversion to RYGBP remains a technically challenging operation but feasible and effective, and it should be reserved to specialized centers.
References 1.
2.
3.
4.
5. Conflict of Interest The authors declare that they have no competing interests. 6. Statement of Informed Consent Informed consent was obtained from all individual participants included in the study. 7. Statement of Human and Animal Rights Informed consent was obtained from all individual participants included in the study.
Kassir R, Blanc P, Lointier P, et al. An analysis of surgical anatomy of the gastric fundus in bariatric surgery: why the gastric pouch expands? A point of technique. Int J Surg. 2014;12(11): 1151–6. Langer FB, Bohdjalian A, Shakeri-Leidenmühler S, et al. Conversion from sleeve gastrectomy to Roux-en-Y gastric bypass—indications and outcome. Obes Surg. 2010;20(7):835– 40. Noel P, Nedelcu M, Nocca D, et al. Revised sleeve gastrectomy: another option for weight loss failure after sleeve gastrectomy. Surg Endosc. 2014;28(4):1096–102. Kassir R, Lointier P, Tiffet O, et al. Laparoscopic Roux-en-Y gastric bypass: creation of the neogastric pouch. Obes Surg. 2015;25(1): 131–2. Deguines JB, Verhaeghe P, Yzet T, et al. Is the residual gastric volume after laparoscopic sleeve gastrectomy an objective criterion for adapting the treatment strategy after failure? Surg Obes Relat Dis. 2013;9(5):660–6. Nesset EM, Kendrick ML, Houghton SG, et al. A two-decade spectrum of revisional bariatric surgery at a tertiary referral center. Surg Obes Relat Dis. 2007;3(1):25–30. Spyropoulos C, Kehagias I, Panagiotopoulos S, et al. Revisional bariatric surgery: 13-year experience from a tertiary institution. Arch Surg. 2010;145(2):173–7.
VIDEO SUBMISSION
Laparoscopic Conversion of a Sleeve Gastrectomy to the Roux-en-Y Gastric Bypass Imed Ben Amor 1 & Tarek Debs 1 & Francesco Martini 1 & Bachir Elias 2 & Radwan Kassir 3 & Jean Gugenheim 1
# Springer Science+Business Media New York 2015
Abstract After the failure of sleeve gastrectomy (SG), three options are available as a second intervention: the conversion into a biliopancreatic diversion with duodenal switch, the Roux-en-Y gastric bypass (RYGBP), and more recently, a re-SG consisting in the refashioning of a dilated gastric tube. We describe two different approaches for the conversion. The conversion to RYGBP remains a technically challenging operation but feasible and effective, and it should be reserved to specialized centers. Keywords Surgical technique . Roux-en-Y gastric bypass . Sleeve gastrectomy . Failure of weight loss
are available as a second intervention: the conversion into a biliopancreatic diversion with duodenal switch, the Roux-en-Y gastric bypass (RYGBP), and more recently, a re-SG consisting in the refashioning of a dilated gastric tube [2–4]. After SG, weight loss failure and gastroesophageal reflux disease (GERD) are the most common indications for redo surgery. A preoperative assessment with a volumetric computed tomography scan is essential before the conversion. A good evaluation of the gastric tube is needed; the presence of a dilatation of the gastric tube especially the existence of a pouch at the fundus should be determined [5].
Surgical Technique Introduction The implementation of laparoscopic techniques has led to a spectacular increase in the number of bariatric procedures made [1]. With all these developments in bariatric surgery, there has been a tendency by bariatric specialists to operate on these patients more than once using different types of bariatric surgeries. After the failure of the sleeve gastrectomy (SG), three options Electronic supplementary material The online version of this article (doi:10.1007/s11695-015-1749-9) contains supplementary material, which is available to authorized users. * Radwan Kassir [email protected] 1
Department of Bariatric Surgery, Hospital Archet 2, Nice, France
2
Department of Digestive Surgery, Centre Hospitalier Régional Metz-Thionville, Thionville, France
3
Department of General Surgery, CHU Hospital, Jean Monnet University, Avenue Albert Raimond, 42270 Saint Etienne, France
We describe two different approaches for the conversion. The first case represents a narrow gastric tube without a neofundus. In this case, a horizontal transection of the stomach should be performed, without dissection at the angle of His and a 30-cc gastric pouch should be created. These cases usually occur in patients undergoing the conversion for a functional pathology, such as GERD. The second approach is used in the presence of a primary or a secondary dilatation of the gastric tube or in the presence of an unresected fundus. In this case, the angle of His should be approached first, and a more meticulous dissection is needed to create the gastric pouch. The fundic pouch remnant should be resected. The morbidity rate after revisional surgery is slightly higher than a primary RYGBP, however, the mortality risk is not increased. The possible postoperative complications with an increased rate are wound infection, leak, pulmonary embolus, anemia/hemorrhage, and pneumonia/prolonged ventilation [6, 7]. Another possible limitation is the weight regain after the conversion. Weight regainers are patients resistant to both
OBES SURG
restricted and malabsorptive procedures. In the case of functional complications of laparoscopic SG (LSG) such as GERD, the laparoscopic RYGBP (LRYGBP) remains the procedure of choice [2]. The search for the ideal weight loss operation is still ongoing. Surgical pioneers developed innovative procedures that initially created malabsorption, then restricted volume intake, and eventually combined both techniques. Nowadays, with a long-term follow-up of the patients, we are observing more failures, and a second procedure is becoming more and more common [6]. The conversion to RYGBP remains a technically challenging operation but feasible and effective, and it should be reserved to specialized centers.
References 1.
2.
3.
4.
5. Conflict of Interest The authors declare that they have no competing interests. 6. Statement of Informed Consent Informed consent was obtained from all individual participants included in the study. 7. Statement of Human and Animal Rights Informed consent was obtained from all individual participants included in the study.
Kassir R, Blanc P, Lointier P, et al. An analysis of surgical anatomy of the gastric fundus in bariatric surgery: why the gastric pouch expands? A point of technique. Int J Surg. 2014;12(11): 1151–6. Langer FB, Bohdjalian A, Shakeri-Leidenmühler S, et al. Conversion from sleeve gastrectomy to Roux-en-Y gastric bypass—indications and outcome. Obes Surg. 2010;20(7):835– 40. Noel P, Nedelcu M, Nocca D, et al. Revised sleeve gastrectomy: another option for weight loss failure after sleeve gastrectomy. Surg Endosc. 2014;28(4):1096–102. Kassir R, Lointier P, Tiffet O, et al. Laparoscopic Roux-en-Y gastric bypass: creation of the neogastric pouch. Obes Surg. 2015;25(1): 131–2. Deguines JB, Verhaeghe P, Yzet T, et al. Is the residual gastric volume after laparoscopic sleeve gastrectomy an objective criterion for adapting the treatment strategy after failure? Surg Obes Relat Dis. 2013;9(5):660–6. Nesset EM, Kendrick ML, Houghton SG, et al. A two-decade spectrum of revisional bariatric surgery at a tertiary referral center. Surg Obes Relat Dis. 2007;3(1):25–30. Spyropoulos C, Kehagias I, Panagiotopoulos S, et al. Revisional bariatric surgery: 13-year experience from a tertiary institution. Arch Surg. 2010;145(2):173–7.
