Surgery for Obesity and Related Diseases ] (2014) 00–00
Original article
Laparoscopic sleeve gastrectomy as a revisional procedure for failed laparoscopic gastric banding with a “2-step approach”: a multicenter study Gianfranco Silecchia, M.D., Ph.D.a,*, Mario Rizzello, M.D., Ph.D.a, Francesco De Angelis, M.D.a, Luigi Raparelli, M.D., Ph.D.a, Francesco Greco, M.D.c, Nicola Perrotta, M.D.b, Maria Antonietta Lerose, M.D.a, Fabio Cesare Campanile, M.D., F.A.C.S.c a
Division of General Surgery, Department of Medico-Surgical Sciences and Biotechnology, “Sapienza” University of Rome, Latina, Italy b Division of General Surgery, Hospital of Villa d’Agri, Villa d’Agri Potenza, Italy c Division of General Surgery , Hospital Andosilla, Civita Castellana - Viterbo, Italy Received August 7, 2013; accepted October 29, 2013
Abstract
Background: Laparoscopic sleeve gastrectomy (LSG) has been proposed as an alternative revisional procedure for failed/complicated gastric banding. This is a retrospective cohort study of a prospectively maintained database of revisional LSG after band removal for insufficient weight loss and/ or band-related complications, using a 2-step approach. The outcomes were compared with a control group of primary LSG. The study was conducted at a university hospital (Sapienza University of Rome-Polo Pontino, Icot, Latina, Italy) and 2 community general hospitals (Hospital Andosilla Civita Castellana, Viterbo, Italy and Hospital Villa D'Agri, Potenza, Italy). Methods: A total of 76 revisional LSG procedures was recorded; a control group of 279 LSG patients was selected. The primary endpoint was to compare the perioperative complication rate between the revisional versus the control group. Secondary endpoints were operative time, conversion rate, postoperative length of stay and percentage excess weight loss (%EWL) at 6, 12, and 24 months. Results: The indications for band removal were inadequate weight loss (47 patients), slippage (10 patients), erosion (7 patients), and pouch dilation (12 patients). All procedures were completed laparoscopically. The median operative time was 78 minutes for the revision LSG and 65 minutes for the control LSG (P o .05). In the revision group, the overall complication rate was 17.1%, and the median postoperative length of stay was 4 days; in the control group, the overall complication rate was 10.7%, and the median postoperative length of stay was 3. No complications requiring reoperation or readmission occurred in the revision group. In the control group, there were 5 cases of major complications. All the patients completed the follow-up. A total of 56 patients in the revision group and 184 patients in the control group were followed-up for at least 24 months. The %EWL at 6, 12, and 24 months was 46.5%, 66.4%, and 78.5%, respectively, in the revision group, and 49.8%, 78.2%, and 78%, respectively, in the control group. Conclusion: Results confirmed that LSG, performed in 2 steps, is an effective revision procedure for failed or complicated laparoscopic adjustable gastric banding with good perioperative outcomes and 2-year weight loss. (Surg Obes Relat Dis 2014;]:00–00.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Gastric banding; Sleeve gastrectomy; Morbid obesity; Weight regain; Revisional surgery; Bariatric surgery; Laparoscopy
* Correspondence: Gianfranco Silecchia, M.D., Ph.D., Division of General Surgery, Via F. Faggiana 1668 04100 Latina (Italy). E-mail: [email protected]
Laparoscopic adjustable gastric banding (LAGB) was a popular bariatric restrictive procedure in the early 1990s. It was associated with good short-term results in terms of postoperative morbidity rate, mortality, weight loss, and
1550-7289/13/$ – see front matter r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.10.017
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G. Silecchia et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
improving co-morbidities. However, the failure to reach or maintain an adequate weight loss has been reported in 40%–60% of patients [1–3]. Insufficient weight loss, weight regain, hardware-related problems (slippage, intragastric migration), motility disorders (esophageal dilation), and/or psychological intolerance are among the causes that often necessitate band removal and the decision to undergo another bariatric procedure. Laparoscopic Roux-en-Y gastric bypass (LRYGB) had been proposed as an effective revision procedure after failed or complicated gastric banding. The removal of the band is accomplished in 1 stage with the revision gastric bypass, but if gastric erosion is present, then the LRYGB is usually postponed and performed later in a second operation (the 2-stage approach). In those series, perioperative complication rates appear to be higher than in primary LRYGB [4–6]. Recently, laparoscopic sleeve gastrectomy (LSG) has been proposed as an alternative revision procedure for failed or complicated gastric banding [6]. Most bariatric surgeons perform the revision procedure in 1 stage. The short-term weight loss of revisional sleeve gastrectomy (after gastric banding) is comparable to the weight loss obtained in the non-revisional sleeve gastrectomy (primary LSG) in patients never operated on before; however, the perioperative complication rate after 1-stage revision LSG appears to be higher than in primary LSG [7–12]. To reduce the complication rate, some authors have proposed performing the revisional LSG several weeks after removal of the gastric band (the 2-stage approach) [13–15], to allow time for the regression of the fibrous capsule and scarring that is commonly found at the gastric band site. The present study is a retrospective review of a multicenter prospectively maintained database of 2-step revision LSG for insufficient weight loss, weight regain, or band-related major complication. Patients and methods
Fig. 1. Study flow-chart.
data included patient demographic characteristics, previous medical history, weight, height, obesity-related co-morbidities, dates of surgery and postoperative office evaluations, weight and evolution of the co-morbid conditions at each office evaluation, medication use, hospital stay duration, duration of surgery, and complications. BMI, ideal weight, excess weight, and excess weight loss were calculated. From January 2008 to December 2011, 3 bariatric surgeons in 3 different hospitals performed a 2-step revision LSG on 76 consecutive patients. Revisional surgery was indicated for inadequate LAGB excess weight loss (% EWL o30%), long-term weight regain, and/or food intolerance in patients with an intact anatomy (confirmed by upper gastrointestinal radiologic series and endoscopy) and LAGB-related complications (Table 1). A total of 279 LSG patients, who had procedures performed in the same interval period as the primary procedure, were selected as the control group according to the criteria specified in Fig. 1. Six patients with severe GERD symptoms and /or esophagitis class B or superior (Los Angeles classification) at upper gastrointestinal endoscopy were not considered for
Study design This cohort study retrospectively analyzed the data collected prospectively in a database used for clinical follow-up (retrospective cohort study). The database was adopted by the above-mentioned centers in 2007 and, since then, has been used for clinical purposes; the data were collected by the authors during the follow-up. The collected Table 1 Revisional group characteristics Band duration, (months) median
51 (1–112)
Indication for laparoscopic adjustable gastric band removal Inadequate weight loss Slippage Erosion Pouch dilation Interval band-removal–Sleeve (months)
47 10 7 12 5
(61.8%) (13.1%) (9.2%) (15.7%) (1–39)
Table 2 Demographic characteristics Characteristic
Revisional LSG
Number 76 Gender Male 16 (21%) Female 60 (79%) Age, year (median) 45.5 (22–70) Preoperative weight, 119.5 (83–245) kg (median) Preoperative BMI, 43.9 (32.6–74.9) kg/m² (median) Co-morbidities Diabetes type II 13 (17.1%) Hypertension 15 (19%) OSAS 9 (11.8%)
Primary LSG
P
279 70 209 41 126
(24.1%) (74.9%) (19–71) (75–213)
44.6 (31.2–63.6)
.2 .0007 .7 .8
43 (15.4%) 52 (18%) 24 (8.6%)
LSG ¼ laparoscopic sleeve gastrectomy; OSAS ¼ obstructive sleep apnea syndrome.
Laparoscopic Sleeve Gastrectomy after Gastric Banding / Surgery for Obesity and Related Diseases ] (2014) 00–00
LSG; they were referred for a LRYGB and, therefore, are not included in the study groups. The demographic parameters of the patients are reported in Table 2. The primary endpoint was to evaluate the perioperative (30-day) complication rate. Complications were classified on the basis of Clavien criteria [16]. Secondary endpoints were operative time, intraoperative complications, conversion to open surgery, postoperative hospital stay, and %EWL at 6, 12, and 24 months follow-up. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS), version 15.0 (SPSS, Inc., Chicago, IL). Continuous variables were expressed as the median and range, and qualitative variables were expressed as a percentage. Statistical analysis was performed using χ2 with a Fisher's exact test when needed and the Mann-Whitney nonparametric test for categorical and continuous variables, respectively. All tests were 2-tailed, and statistical significance was considered for P values o.05. Surgical procedures The surgical technique (described below) for band removal and sleeve gastrectomy was standardized and adopted by participating surgeons. The perioperative management was similar in all centers. All participating surgeons were experts in laparoscopic bariatric surgery, experienced in revisional surgery, and well over their learning curve for the procedures taken into consideration. Gastric band removal. A 5-mm trocar was placed midway between the xiphoid process and the umbilicus for a 301 optical system. Two trocars were placed at the midclavicular line on the right and left side, 5 cm distal to the costal margin (10-mm trocar on the left side and 5-mm trocar on the right side). Fundic gastric adhesions to the liver and to the left diaphragm were divided to mobilize the fundus completely. Gastrogastric sutures were removed to restore the normal anatomy. The band was then cut and removed. A radiologic water soluble iodinated contrast swallow study was obtained on the first postoperative day, to rule out gastric leak. Patients were started on a clear liquids diet on the same day. After 1 month, a barium swallow was performed to evaluate the gastric anatomy. In case of band erosion, the prosthesis was removed, endoscopically in 2 cases and by laparoscopy in 5 cases as previously described [17]. After band removal, a low calorie diet (1000–1200 kcal) was prescribed until revisional surgery was accomplished. LSG: Revisional surgery was planned at least 2 months after band removal. Four ports were inserted. The LSG was performed according to the technique described by Ren et al. [18]. The division of the gastric greater curvature vascular supply started 6 cm from the pylorus and proceeded upward to the angle of His; ultrasound dissection (Harmonic Scalpel, Ethicon Endo-Surgery, a Johnson &
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Johnson Company, Cincinnati, OH) or radiofrequency (LigaSure, 5 mm Blunt Tip, Covidien, Mansfield, MA) were used. The gastroesophageal junction was always assessed, and a hiatal hernia, if found, was repaired. The LSG was created using a linear stapler (Echelon Flex Endopath, Ethicon Endo-Surgery, a Johnson & Johnson Company, Cincinnati, OH). The stapler was applied next to a 42 Fr bougie placed next to the lesser curve. The stomach was transected, and a gastric pouch of 80–100 mL created. In the case of a primary LSG, 2 sequential green cartridges were used for the transection of antrum, followed by 2 or 3 sequential yellow cartridges for the gastric corpus and fundus. The staple line was reinforced with Seamguard (W. L. Gore & Associates, Inc., Newark, DE) for all but the first cartridge. For revision LSG, only green reinforced (Seamguard) cartridges were used. An intraoperative methylene blue test was performed, and a 19 Fr drain was placed alongside the transected stomach. On the second postoperative day, a radiologic control (contrast swallow study) and another methylene test were performed. Clear liquids were begun, and the patient was discharged on the third or fourth postoperative day. A protein soft diet was prescribed for 4 weeks. Results Upon univariate analysis, the 2 groups (revision LSG versus primary LSG) did not differ significantly in terms of age, gender, and body mass index (Table 2). There were no conversions to laparotomy. The median interval time between gastric band removal and revision LSG was 5 months (range: 1–39). The median operative time for band removal (first step) was 47 minutes without any significant differences between those with an intact anatomy (patients with insufficient weight loss or regain) and those whose band was removed for complications. The median LSG operative time was higher for revision than primary surgery (78 versus 65 minutes, P o .05). There were no postoperative deaths. After band removal, there were no postoperative complications, and all patients were discharged on the first postoperative day. After revision LSG, an overall complication rate of 17.1% and a median hospital stay of 4 days were registered. In the control group, the perioperative complication rate was 10.7%, and median postoperative hospital stay was 3 days. Neither major complications (Clavien III–IV) nor reoperations occurred in the revision group. In the control group, there were 5 major postoperative complications (3 Clavien III and 2 Clavien IV) (Table 3). There was no relation between postoperative complications and previous band erosion or slippage. All patients completed the follow-up (no drop out). The %EWL was 46.5%, 66.4%, and 78.5% in the revision group and 49.8%, 78.2%, and 78% in the primary group at 6, 12, and 24 months, respectively (P ¼ .03, P o .001, and
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Table 3 Laparoscopic sleeve gastrectomy postoperative complications
Patients (Number) Complications Clavien classification
Reoperation
Revisional LSG
Primary LSG
76 13 (17.1%) I ¼ 9* II ¼ 4† IIIa ¼ 0 IIIb ¼ 0 IV ¼ 0 –
279 27 (10.7%) I ¼ 5* II ¼ 17† IIIa ¼ 0 IIIb ¼ 3‡ IV ¼ 2§ 1 bleeding, 1 leak, 1 trocar hernia
P n.s. (4.05)
n.s. (.43)
LSG ¼ laparoscopic sleeve gastrectomy; n.s. ¼ nonsignificant. * Anemia and transient food intolerance. † Transient dysphagia, leukocytosis, fever, and anemia. ‡ Leak, bleeding, and trocar hernia. § Leak and bleeding.
P o .3, respectively) (Fig. 2). A total of 56 patients in the revision group and 184 patients in the control group were followed-up for at least 24 months. Discussion LAGB is associated with high failure and late complication rates that require removal of the band in up to 50% of patients [1–2]. In a prospective cohort of 500 cases, a 13% incidence of major complications was observed; the rate of major and minor complications was 4.1 and 2.1 interventions per 100 person-years, respectively. In patients with a follow-up longer than 5 years, the cumulative prevalence of major complications reached 24% (perigastric technique). The most common complications that led to reoperation were pouch dilation and band erosion (37% and 20%, respectively) [3]. For those complications, several solutions have been proposed: replacement or repositioning of the band, conversion to LRYGB, or conversion to biliopancreatic diversion. LRYGB is often considered the bariatric procedures of choice. The results of this procedure with regard to weight loss and the improvement/resolution of co-morbidities are satisfactory [4,5]. However, the early complication rate is higher than in the primary LRYGB (0%–23%). LSG has been gaining popularity as a primary bariatric procedure. 90 80 p=0,3
70 60
p=0,001
50 40
(n=186)
Primary LSG
(n=56)
Revisional
p=0,0365
30 20
6 Months
12 Months
24 Months
LSG: Laparoscopic Sleeve Gastrectomy EWL: Excess weight loss
Fig. 2. %EWL modifications.
International consensus conferences have underlined its safety and effectiveness as a stand-alone bariatric operation [19]. Recently, indications for LSG have been widened to those patients with failed or complicated LAGB. During recent years, some studies have reported good results in terms of safety and efficacy after conversion from LAGB to LSG [6–12]. Generally, revisions were accomplished in 1 stage, except in the case of band erosion (Table 4). The short-term results of these series seem to be comparable to those obtained after primary LSG. However, the complication rate of revision LSG when performed in 1 stage are controversial. Rebibo et al. reported that the prevalence of gastric fistula in the removal gastric banding (RGB) þ LSG group was higher than the LSG group [11]. The result was not statistically significant (4.3% versus 3.4%, P ¼ .56); however, the series was too small to achieve the power needed to show the difference [20]. In the RGBþLSG group, the authors observed a total of 4 patients (8.6%) with Clavien grade III complications, 3 of whom required a reintervention (6.5%). Yazbek et al. observed that complications were more severe and associated with a higher need for conversion or reoperation [6]. Recently, the results obtained after band removal and concomitant LSG versus LRYGB show comparable %EWL at 2 years. However, the reported complication rate was higher in the LRYGB group than in the LSG group (20.8% versus 7.1%, respectively) [21]. Similarly, Moon et al. reported higher readmission and reoperation rate in an LRYGB group [22]. Some authors have suggested performing LSG as a second operation, weeks after band removal, to reduce perioperative morbidity (Table 5). Achonolu et al. maintained that, although band removal and LSG were feasible in a single operation, the complication rate was higher than after 2 separate operations [12]. The concern is the scar
Table 4 Published studies on laparoscopic sleeve gastrectomy as a revisional procedure in a single stage Author
Bernante et al. [14] Lalor et al. [29] Tucker et al. [28] Acholonu et al. [12] Frezza et al. [23] Jacobs et al. [24] * Goiten et al. [7] * Berende et al. [27] Yazbek et al. [6] Rebibo et al. [11] Moon et al. [22] Khoursheed et al. [21] Alqahtani et al. [26] *
Year Patients Major complication Reoperation
2006 2008 2008 2009 2009 2010 2010 2011 2012 2012 2012 2013 2013
8 13 10 13 10 26 26 15 90 46 13 42 56
Bleeding
Leak
0 0 0 0 0 0 3.8% 20% 4.4% 2.1% 0 2.3% 0
0 15.3% 0 7.6% 0 3.8% 7.6% 33.3% 5.5% 4.3% 0 0 0
0 15.3% 0 7.6% 0 0 0 0 5.5% 6.5% 0 0 0
Series with both 2-stage and 1-stage procedures. The outcomes of only the patients who underwent the 1-stage procedure are reported here.
Laparoscopic Sleeve Gastrectomy after Gastric Banding / Surgery for Obesity and Related Diseases ] (2014) 00–00 Table 5 Published studies on laparoscopic sleeve gastrectomy as a revisional procedure in 2 stages Author
Year
Patients
Major complication Bleeding
Dapri et al. [15] Iannelli et al. [13] Uglioni et al. [25] Goiten et al. [7]* Berende et al. [27]* Present study
2009 2009 2009 2010 2011 2013
27 36 29 20 13 76
3.7% 0 0 0 7.6% 1.31%
Leak 0 2.7% 3.4% 0 0 0
* Series with both 2-stage and 1-stage procedures. The outcomes of only the patients who underwent the 2-stage procedure are reported here.
tissue beneath the gastric band can make the gastric wall less pliable. The reactive “capsule" can be responsible for ischemic changes that might accentuate the local inflammatory reaction and cause dense adhesions with surrounding structures (i.e., the liver). The persistence of a band “outlet” after prosthesis removal does not allow an easy, safe, and smooth insertion of a 440 Fr orogastric bougie. This impaired “local condition” can contribute to an increased risk of complications when a concomitant LSG is performed. The results of the present study confirmed that a 2step approach may avoid the increased frequency of major complications related to revision surgery. A few weeks after gastric band removal, the peri-prosthesis inflammatory reaction improved and the stomach regained its physiologic shape, and its wall was pliable again, which might explain the decrease in major complications. The 2-stage approach allows construction of a correctly sized gastric sleeve; it might explain the good 2-year weight loss results that were comparable to the control group. In the present series, revisional surgery was planned at least 2 months after band removal; however, often a longer interval (up to 39 months) was required by the patient. At the beginning, one of the surgeons agreed to perform the LSG earlier than planned, in 5 cases after a normal barium swallow. The intense scarring found at this early stage made the operation more difficult, and no other patients were operated earlier than 8 weeks after band removal. Moreover, the interval allowed a discussion with the patients regarding the possible options for revision and reevaluation by the multidisciplinary team. A longer hospital stay and operative times occurred in the revision group. The higher overall complication rate (17.1% versus 10.7%, P 4 .05) observed in the revision group was mainly due to minor complication (Clavien I and II); 5 major complications (Clavien III and IV) were found in the primary group (3 of them required a reoperation), but none in the revision group. No variation of the standard technique was made, and no technical pitfalls could be related to the complication described. Limitations of the present study include its retrospective design and small sample size. However, the availability of a
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prospective database and the previous strict standardization of the technique add strength to the study design. Randomized, prospective control trials (1-stage versus 2-stage) with a larger number of patients will be needed to confirm results. Moreover, a longer follow-up of these patients submitted to revisional surgery will also be necessary. However, the value of the present report lies in the evidence of encouraging results coming from a multicenter setting. Furthermore, to the authors' knowledge, the present study is the largest published series of revision LSG after gastric banding performed in 2 stages. Conclusion Despite its limitations, the present study confirmed that LSG is a well-tolerated and effective revisional procedure for a failed and/or complicated LAGB with low perioperative major complications and 2-year %EWL comparable to a primary procedure (78.5%). Furthermore, a 2-stage approach does not seem to be burdened by the increase in postoperative complications described in some series performed in a single stage. The results of this multicenter study, with 3 different bariatric teams and 24 months follow-up, encourage the adoption of a 2-stage approach when a sleeve gastrectomy is chosen for revision after a failed gastric banding. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Himpens J, Cadière GB, Bazi M, Vouche M, Cadière B, Dapri G. Long-term outcomes of laparoscopic adjustable gastric banding. Arch Surg 2011;146:802–7. [2] Mittermair RP, Obermüller S, Perathoner A, Sieb M, Aigner F, Margreiter R. Results and complications after Swedish adjustable gastric banding—10 years experience. Obes Surg 2009;19:1636–41. [3] Silecchia G, Bacci V, Bacci S, et al. Reoperation after laparoscopic adjustable gastric banding: analysis of a cohort of 500 patients with long-term follow-up. Surg Obes Relat Dis 2008;4:430–6. [4] Gagner M, Gumbs AA. Gastric banding: conversion to sleeve, bypass, or DS. Surg Endosc 2007;21:1931–5. [5] Spivak H, Beltran OR, Slavchev P, Wilson EB. Laparoscopic revision from LAP-BAND to gastric bypass. Surg Endosc 2007;21:1388–92. [6] Yazbek T, Safa N, Denis R, Atlas H, Garneau PY. Laparoscopic sleeve gastrectomy (LSG)—a good bariatric option for failed laparoscopic adjustable gastric banding (LAGB): a review of 90 patients. Obes Surg 2013;23:300–5. [7] Goitein D, Feigin A, Segal-Lieberman G, Goitein O, Papa MZ, Zippel D. Laparoscopic sleeve gastrectomy as a revisional option after gastric band failure. Surg Endosc 2011;25:2626–30. [8] Foletto M, Prevedello L, Bernante P, et al. Sleeve gastrectomy as revisional procedure for failed gastric banding or gastroplasty. Surg Obes Relat Dis 2010;6:146–51. [9] Elnahas A, Graybiel K, Farrokhyar F, Gmora S, Anvari M, Hong D. Revisional surgery after failed laparoscopic adjustable gastric banding: a systematic review. Surg Endosc 2013;27:740–5.
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[10] Gagnière J, Slim K, Launay-Savary MV, Raspado O, Flamein R, Chipponi J. Previous gastric banding increases morbidity and gastric leaks after laparoscopic sleeve gastrectomy for obesity. J Visc Surg 2011;148:205–9. [11] Rebibo L, Mensah E, Verhaeghe P, et al. Simultaneous gastric band removal and sleeve gastrectomy: a comparison with front-line sleeve gastrectomy. Obes Surg 2012;22:1420–6. [12] Acholonu E, McBean E, Court I, Bellorin O, Szomstein S, Rosenthal RJ. Safety and short-term outcomes of laparoscopic sleeve gastrectomy as a revisional approach for failed laparoscopic adjustable gastric banding in the treatment of morbid obesity. Obes Surg 2009;19:1612–6. [13] Iannelli A, Schneck AS, Ragot E, et al. Laparoscopic sleeve gastrectomy as revisional procedure for failed gastric banding and vertical banded gastroplasty. Obes Surg 2009;19:1216–20. [14] Bernante P, Foletto M, Busetto L, et al. Feasibility of laparoscopic sleeve gastrectomy as a revision procedure for prior laparoscopic gastric banding. Obes Surg 2006;16:1327–30. [15] Dapri G, Cadière GB, Himpens J. Feasibility and technique of laparoscopic conversion of laparoscopic gastric banding to sleeve gastrectomy. Surg Obes Relat Dis 2009;5:72–6. [16] Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–13. [17] Silecchia G, Perrotta N, Boru C, et al. Role of a minimally invasive approach in the management of laparoscopic adjustable gastric banding postoperative complications. Arch Surg 2004;139:1225–30. [18] Ren CJ, Patterson E, Gagner M. Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients. Obes Surg 2000;10:514–23. [19] Deitel M, Gagner M, Erikson AL, Crosby RD. Third International Summit: current status of sleeve gastrectomy. Surg Obes Relat Dis 2011;7:749–59.
[20] Campanile FC, Silecchia G. Simultaneous gastric band removal and sleeve gastrectomy complication rate. Obes Surg 2013;23:393–4. [21] Khoursheed M, Al-Bader I, Mouzannar A, et al. Sleeve gastrectomy or gastric bypass as revisional bariatric procedures: retrospective evaluation of outcomes. Surg Endosc 2013;27:4277–83. [22] Moon RC, Teixeira AF, Jawad MA. Conversion of failed laparoscopic adjustable gastric banding: sleeve gastrectomy or Roux-en-Y gastric bypass? Surg Obes Relat Dis. Epub 2013 Apr 17. [23] Frezza EE, Jaramillo-de la Torre EJ, Calleja Enriquez C, Gee L, Wachtel MS, Lopez Corvala JA. Laparoscopic sleeve gastrectomy after gastric banding removal: a feasibility study. Surg In nov 2009;16:68–72. [24] Jacobs M, Gomez E, Romero R, Jorge I, Fogel R, Celaya C. Failed restrictive surgery: is sleeve gastrectomy a good revisional procedure? Obes Surg 2011;21:157–60. [25] Uglioni B, Wölnerhanssen B, Peters T, Christoffel-Courtin C, Kern B, Peterli R. Midterm results of primary vs. secondary laparoscopic sleeve gastrectomy (LSG) as an isolated operation. Obes Surg 2009;19:401–6. [26] Alqahtani AR, Elahmedi M, Alamri H, Mohammed R, Darwish F, Ahmed AM. Laparoscopic removal of poor outcome gastric banding with concomitant sleeve gastrectomy. Obes Surg 2013;23:782–7. [27] Berende CA, de Zoete JP, Smulders JF, Nienhuijs SW. Laparoscopic sleeve gastrectomy feasible for bariatric revision surgery. Obes Surg 2012;22:330–4. [28] Tucker O, Sucandy I, Szomstein S, Rosenthal RJ. Revisional surgery after failed laparoscopic adjustable gastric banding. Surg Obes Relat Dis 2008;4:740–7. [29] Lalor PF, Tucker ON, Szomstein S, Rosenthal RJ. Complications after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2008;4: 33–8.
Original article
Laparoscopic sleeve gastrectomy as a revisional procedure for failed laparoscopic gastric banding with a “2-step approach”: a multicenter study Gianfranco Silecchia, M.D., Ph.D.a,*, Mario Rizzello, M.D., Ph.D.a, Francesco De Angelis, M.D.a, Luigi Raparelli, M.D., Ph.D.a, Francesco Greco, M.D.c, Nicola Perrotta, M.D.b, Maria Antonietta Lerose, M.D.a, Fabio Cesare Campanile, M.D., F.A.C.S.c a
Division of General Surgery, Department of Medico-Surgical Sciences and Biotechnology, “Sapienza” University of Rome, Latina, Italy b Division of General Surgery, Hospital of Villa d’Agri, Villa d’Agri Potenza, Italy c Division of General Surgery , Hospital Andosilla, Civita Castellana - Viterbo, Italy Received August 7, 2013; accepted October 29, 2013
Abstract
Background: Laparoscopic sleeve gastrectomy (LSG) has been proposed as an alternative revisional procedure for failed/complicated gastric banding. This is a retrospective cohort study of a prospectively maintained database of revisional LSG after band removal for insufficient weight loss and/ or band-related complications, using a 2-step approach. The outcomes were compared with a control group of primary LSG. The study was conducted at a university hospital (Sapienza University of Rome-Polo Pontino, Icot, Latina, Italy) and 2 community general hospitals (Hospital Andosilla Civita Castellana, Viterbo, Italy and Hospital Villa D'Agri, Potenza, Italy). Methods: A total of 76 revisional LSG procedures was recorded; a control group of 279 LSG patients was selected. The primary endpoint was to compare the perioperative complication rate between the revisional versus the control group. Secondary endpoints were operative time, conversion rate, postoperative length of stay and percentage excess weight loss (%EWL) at 6, 12, and 24 months. Results: The indications for band removal were inadequate weight loss (47 patients), slippage (10 patients), erosion (7 patients), and pouch dilation (12 patients). All procedures were completed laparoscopically. The median operative time was 78 minutes for the revision LSG and 65 minutes for the control LSG (P o .05). In the revision group, the overall complication rate was 17.1%, and the median postoperative length of stay was 4 days; in the control group, the overall complication rate was 10.7%, and the median postoperative length of stay was 3. No complications requiring reoperation or readmission occurred in the revision group. In the control group, there were 5 cases of major complications. All the patients completed the follow-up. A total of 56 patients in the revision group and 184 patients in the control group were followed-up for at least 24 months. The %EWL at 6, 12, and 24 months was 46.5%, 66.4%, and 78.5%, respectively, in the revision group, and 49.8%, 78.2%, and 78%, respectively, in the control group. Conclusion: Results confirmed that LSG, performed in 2 steps, is an effective revision procedure for failed or complicated laparoscopic adjustable gastric banding with good perioperative outcomes and 2-year weight loss. (Surg Obes Relat Dis 2014;]:00–00.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Gastric banding; Sleeve gastrectomy; Morbid obesity; Weight regain; Revisional surgery; Bariatric surgery; Laparoscopy
* Correspondence: Gianfranco Silecchia, M.D., Ph.D., Division of General Surgery, Via F. Faggiana 1668 04100 Latina (Italy). E-mail: [email protected]
Laparoscopic adjustable gastric banding (LAGB) was a popular bariatric restrictive procedure in the early 1990s. It was associated with good short-term results in terms of postoperative morbidity rate, mortality, weight loss, and
1550-7289/13/$ – see front matter r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.10.017
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G. Silecchia et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
improving co-morbidities. However, the failure to reach or maintain an adequate weight loss has been reported in 40%–60% of patients [1–3]. Insufficient weight loss, weight regain, hardware-related problems (slippage, intragastric migration), motility disorders (esophageal dilation), and/or psychological intolerance are among the causes that often necessitate band removal and the decision to undergo another bariatric procedure. Laparoscopic Roux-en-Y gastric bypass (LRYGB) had been proposed as an effective revision procedure after failed or complicated gastric banding. The removal of the band is accomplished in 1 stage with the revision gastric bypass, but if gastric erosion is present, then the LRYGB is usually postponed and performed later in a second operation (the 2-stage approach). In those series, perioperative complication rates appear to be higher than in primary LRYGB [4–6]. Recently, laparoscopic sleeve gastrectomy (LSG) has been proposed as an alternative revision procedure for failed or complicated gastric banding [6]. Most bariatric surgeons perform the revision procedure in 1 stage. The short-term weight loss of revisional sleeve gastrectomy (after gastric banding) is comparable to the weight loss obtained in the non-revisional sleeve gastrectomy (primary LSG) in patients never operated on before; however, the perioperative complication rate after 1-stage revision LSG appears to be higher than in primary LSG [7–12]. To reduce the complication rate, some authors have proposed performing the revisional LSG several weeks after removal of the gastric band (the 2-stage approach) [13–15], to allow time for the regression of the fibrous capsule and scarring that is commonly found at the gastric band site. The present study is a retrospective review of a multicenter prospectively maintained database of 2-step revision LSG for insufficient weight loss, weight regain, or band-related major complication. Patients and methods
Fig. 1. Study flow-chart.
data included patient demographic characteristics, previous medical history, weight, height, obesity-related co-morbidities, dates of surgery and postoperative office evaluations, weight and evolution of the co-morbid conditions at each office evaluation, medication use, hospital stay duration, duration of surgery, and complications. BMI, ideal weight, excess weight, and excess weight loss were calculated. From January 2008 to December 2011, 3 bariatric surgeons in 3 different hospitals performed a 2-step revision LSG on 76 consecutive patients. Revisional surgery was indicated for inadequate LAGB excess weight loss (% EWL o30%), long-term weight regain, and/or food intolerance in patients with an intact anatomy (confirmed by upper gastrointestinal radiologic series and endoscopy) and LAGB-related complications (Table 1). A total of 279 LSG patients, who had procedures performed in the same interval period as the primary procedure, were selected as the control group according to the criteria specified in Fig. 1. Six patients with severe GERD symptoms and /or esophagitis class B or superior (Los Angeles classification) at upper gastrointestinal endoscopy were not considered for
Study design This cohort study retrospectively analyzed the data collected prospectively in a database used for clinical follow-up (retrospective cohort study). The database was adopted by the above-mentioned centers in 2007 and, since then, has been used for clinical purposes; the data were collected by the authors during the follow-up. The collected Table 1 Revisional group characteristics Band duration, (months) median
51 (1–112)
Indication for laparoscopic adjustable gastric band removal Inadequate weight loss Slippage Erosion Pouch dilation Interval band-removal–Sleeve (months)
47 10 7 12 5
(61.8%) (13.1%) (9.2%) (15.7%) (1–39)
Table 2 Demographic characteristics Characteristic
Revisional LSG
Number 76 Gender Male 16 (21%) Female 60 (79%) Age, year (median) 45.5 (22–70) Preoperative weight, 119.5 (83–245) kg (median) Preoperative BMI, 43.9 (32.6–74.9) kg/m² (median) Co-morbidities Diabetes type II 13 (17.1%) Hypertension 15 (19%) OSAS 9 (11.8%)
Primary LSG
P
279 70 209 41 126
(24.1%) (74.9%) (19–71) (75–213)
44.6 (31.2–63.6)
.2 .0007 .7 .8
43 (15.4%) 52 (18%) 24 (8.6%)
LSG ¼ laparoscopic sleeve gastrectomy; OSAS ¼ obstructive sleep apnea syndrome.
Laparoscopic Sleeve Gastrectomy after Gastric Banding / Surgery for Obesity and Related Diseases ] (2014) 00–00
LSG; they were referred for a LRYGB and, therefore, are not included in the study groups. The demographic parameters of the patients are reported in Table 2. The primary endpoint was to evaluate the perioperative (30-day) complication rate. Complications were classified on the basis of Clavien criteria [16]. Secondary endpoints were operative time, intraoperative complications, conversion to open surgery, postoperative hospital stay, and %EWL at 6, 12, and 24 months follow-up. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS), version 15.0 (SPSS, Inc., Chicago, IL). Continuous variables were expressed as the median and range, and qualitative variables were expressed as a percentage. Statistical analysis was performed using χ2 with a Fisher's exact test when needed and the Mann-Whitney nonparametric test for categorical and continuous variables, respectively. All tests were 2-tailed, and statistical significance was considered for P values o.05. Surgical procedures The surgical technique (described below) for band removal and sleeve gastrectomy was standardized and adopted by participating surgeons. The perioperative management was similar in all centers. All participating surgeons were experts in laparoscopic bariatric surgery, experienced in revisional surgery, and well over their learning curve for the procedures taken into consideration. Gastric band removal. A 5-mm trocar was placed midway between the xiphoid process and the umbilicus for a 301 optical system. Two trocars were placed at the midclavicular line on the right and left side, 5 cm distal to the costal margin (10-mm trocar on the left side and 5-mm trocar on the right side). Fundic gastric adhesions to the liver and to the left diaphragm were divided to mobilize the fundus completely. Gastrogastric sutures were removed to restore the normal anatomy. The band was then cut and removed. A radiologic water soluble iodinated contrast swallow study was obtained on the first postoperative day, to rule out gastric leak. Patients were started on a clear liquids diet on the same day. After 1 month, a barium swallow was performed to evaluate the gastric anatomy. In case of band erosion, the prosthesis was removed, endoscopically in 2 cases and by laparoscopy in 5 cases as previously described [17]. After band removal, a low calorie diet (1000–1200 kcal) was prescribed until revisional surgery was accomplished. LSG: Revisional surgery was planned at least 2 months after band removal. Four ports were inserted. The LSG was performed according to the technique described by Ren et al. [18]. The division of the gastric greater curvature vascular supply started 6 cm from the pylorus and proceeded upward to the angle of His; ultrasound dissection (Harmonic Scalpel, Ethicon Endo-Surgery, a Johnson &
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Johnson Company, Cincinnati, OH) or radiofrequency (LigaSure, 5 mm Blunt Tip, Covidien, Mansfield, MA) were used. The gastroesophageal junction was always assessed, and a hiatal hernia, if found, was repaired. The LSG was created using a linear stapler (Echelon Flex Endopath, Ethicon Endo-Surgery, a Johnson & Johnson Company, Cincinnati, OH). The stapler was applied next to a 42 Fr bougie placed next to the lesser curve. The stomach was transected, and a gastric pouch of 80–100 mL created. In the case of a primary LSG, 2 sequential green cartridges were used for the transection of antrum, followed by 2 or 3 sequential yellow cartridges for the gastric corpus and fundus. The staple line was reinforced with Seamguard (W. L. Gore & Associates, Inc., Newark, DE) for all but the first cartridge. For revision LSG, only green reinforced (Seamguard) cartridges were used. An intraoperative methylene blue test was performed, and a 19 Fr drain was placed alongside the transected stomach. On the second postoperative day, a radiologic control (contrast swallow study) and another methylene test were performed. Clear liquids were begun, and the patient was discharged on the third or fourth postoperative day. A protein soft diet was prescribed for 4 weeks. Results Upon univariate analysis, the 2 groups (revision LSG versus primary LSG) did not differ significantly in terms of age, gender, and body mass index (Table 2). There were no conversions to laparotomy. The median interval time between gastric band removal and revision LSG was 5 months (range: 1–39). The median operative time for band removal (first step) was 47 minutes without any significant differences between those with an intact anatomy (patients with insufficient weight loss or regain) and those whose band was removed for complications. The median LSG operative time was higher for revision than primary surgery (78 versus 65 minutes, P o .05). There were no postoperative deaths. After band removal, there were no postoperative complications, and all patients were discharged on the first postoperative day. After revision LSG, an overall complication rate of 17.1% and a median hospital stay of 4 days were registered. In the control group, the perioperative complication rate was 10.7%, and median postoperative hospital stay was 3 days. Neither major complications (Clavien III–IV) nor reoperations occurred in the revision group. In the control group, there were 5 major postoperative complications (3 Clavien III and 2 Clavien IV) (Table 3). There was no relation between postoperative complications and previous band erosion or slippage. All patients completed the follow-up (no drop out). The %EWL was 46.5%, 66.4%, and 78.5% in the revision group and 49.8%, 78.2%, and 78% in the primary group at 6, 12, and 24 months, respectively (P ¼ .03, P o .001, and
G. Silecchia et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
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Table 3 Laparoscopic sleeve gastrectomy postoperative complications
Patients (Number) Complications Clavien classification
Reoperation
Revisional LSG
Primary LSG
76 13 (17.1%) I ¼ 9* II ¼ 4† IIIa ¼ 0 IIIb ¼ 0 IV ¼ 0 –
279 27 (10.7%) I ¼ 5* II ¼ 17† IIIa ¼ 0 IIIb ¼ 3‡ IV ¼ 2§ 1 bleeding, 1 leak, 1 trocar hernia
P n.s. (4.05)
n.s. (.43)
LSG ¼ laparoscopic sleeve gastrectomy; n.s. ¼ nonsignificant. * Anemia and transient food intolerance. † Transient dysphagia, leukocytosis, fever, and anemia. ‡ Leak, bleeding, and trocar hernia. § Leak and bleeding.
P o .3, respectively) (Fig. 2). A total of 56 patients in the revision group and 184 patients in the control group were followed-up for at least 24 months. Discussion LAGB is associated with high failure and late complication rates that require removal of the band in up to 50% of patients [1–2]. In a prospective cohort of 500 cases, a 13% incidence of major complications was observed; the rate of major and minor complications was 4.1 and 2.1 interventions per 100 person-years, respectively. In patients with a follow-up longer than 5 years, the cumulative prevalence of major complications reached 24% (perigastric technique). The most common complications that led to reoperation were pouch dilation and band erosion (37% and 20%, respectively) [3]. For those complications, several solutions have been proposed: replacement or repositioning of the band, conversion to LRYGB, or conversion to biliopancreatic diversion. LRYGB is often considered the bariatric procedures of choice. The results of this procedure with regard to weight loss and the improvement/resolution of co-morbidities are satisfactory [4,5]. However, the early complication rate is higher than in the primary LRYGB (0%–23%). LSG has been gaining popularity as a primary bariatric procedure. 90 80 p=0,3
70 60
p=0,001
50 40
(n=186)
Primary LSG
(n=56)
Revisional
p=0,0365
30 20
6 Months
12 Months
24 Months
LSG: Laparoscopic Sleeve Gastrectomy EWL: Excess weight loss
Fig. 2. %EWL modifications.
International consensus conferences have underlined its safety and effectiveness as a stand-alone bariatric operation [19]. Recently, indications for LSG have been widened to those patients with failed or complicated LAGB. During recent years, some studies have reported good results in terms of safety and efficacy after conversion from LAGB to LSG [6–12]. Generally, revisions were accomplished in 1 stage, except in the case of band erosion (Table 4). The short-term results of these series seem to be comparable to those obtained after primary LSG. However, the complication rate of revision LSG when performed in 1 stage are controversial. Rebibo et al. reported that the prevalence of gastric fistula in the removal gastric banding (RGB) þ LSG group was higher than the LSG group [11]. The result was not statistically significant (4.3% versus 3.4%, P ¼ .56); however, the series was too small to achieve the power needed to show the difference [20]. In the RGBþLSG group, the authors observed a total of 4 patients (8.6%) with Clavien grade III complications, 3 of whom required a reintervention (6.5%). Yazbek et al. observed that complications were more severe and associated with a higher need for conversion or reoperation [6]. Recently, the results obtained after band removal and concomitant LSG versus LRYGB show comparable %EWL at 2 years. However, the reported complication rate was higher in the LRYGB group than in the LSG group (20.8% versus 7.1%, respectively) [21]. Similarly, Moon et al. reported higher readmission and reoperation rate in an LRYGB group [22]. Some authors have suggested performing LSG as a second operation, weeks after band removal, to reduce perioperative morbidity (Table 5). Achonolu et al. maintained that, although band removal and LSG were feasible in a single operation, the complication rate was higher than after 2 separate operations [12]. The concern is the scar
Table 4 Published studies on laparoscopic sleeve gastrectomy as a revisional procedure in a single stage Author
Bernante et al. [14] Lalor et al. [29] Tucker et al. [28] Acholonu et al. [12] Frezza et al. [23] Jacobs et al. [24] * Goiten et al. [7] * Berende et al. [27] Yazbek et al. [6] Rebibo et al. [11] Moon et al. [22] Khoursheed et al. [21] Alqahtani et al. [26] *
Year Patients Major complication Reoperation
2006 2008 2008 2009 2009 2010 2010 2011 2012 2012 2012 2013 2013
8 13 10 13 10 26 26 15 90 46 13 42 56
Bleeding
Leak
0 0 0 0 0 0 3.8% 20% 4.4% 2.1% 0 2.3% 0
0 15.3% 0 7.6% 0 3.8% 7.6% 33.3% 5.5% 4.3% 0 0 0
0 15.3% 0 7.6% 0 0 0 0 5.5% 6.5% 0 0 0
Series with both 2-stage and 1-stage procedures. The outcomes of only the patients who underwent the 1-stage procedure are reported here.
Laparoscopic Sleeve Gastrectomy after Gastric Banding / Surgery for Obesity and Related Diseases ] (2014) 00–00 Table 5 Published studies on laparoscopic sleeve gastrectomy as a revisional procedure in 2 stages Author
Year
Patients
Major complication Bleeding
Dapri et al. [15] Iannelli et al. [13] Uglioni et al. [25] Goiten et al. [7]* Berende et al. [27]* Present study
2009 2009 2009 2010 2011 2013
27 36 29 20 13 76
3.7% 0 0 0 7.6% 1.31%
Leak 0 2.7% 3.4% 0 0 0
* Series with both 2-stage and 1-stage procedures. The outcomes of only the patients who underwent the 2-stage procedure are reported here.
tissue beneath the gastric band can make the gastric wall less pliable. The reactive “capsule" can be responsible for ischemic changes that might accentuate the local inflammatory reaction and cause dense adhesions with surrounding structures (i.e., the liver). The persistence of a band “outlet” after prosthesis removal does not allow an easy, safe, and smooth insertion of a 440 Fr orogastric bougie. This impaired “local condition” can contribute to an increased risk of complications when a concomitant LSG is performed. The results of the present study confirmed that a 2step approach may avoid the increased frequency of major complications related to revision surgery. A few weeks after gastric band removal, the peri-prosthesis inflammatory reaction improved and the stomach regained its physiologic shape, and its wall was pliable again, which might explain the decrease in major complications. The 2-stage approach allows construction of a correctly sized gastric sleeve; it might explain the good 2-year weight loss results that were comparable to the control group. In the present series, revisional surgery was planned at least 2 months after band removal; however, often a longer interval (up to 39 months) was required by the patient. At the beginning, one of the surgeons agreed to perform the LSG earlier than planned, in 5 cases after a normal barium swallow. The intense scarring found at this early stage made the operation more difficult, and no other patients were operated earlier than 8 weeks after band removal. Moreover, the interval allowed a discussion with the patients regarding the possible options for revision and reevaluation by the multidisciplinary team. A longer hospital stay and operative times occurred in the revision group. The higher overall complication rate (17.1% versus 10.7%, P 4 .05) observed in the revision group was mainly due to minor complication (Clavien I and II); 5 major complications (Clavien III and IV) were found in the primary group (3 of them required a reoperation), but none in the revision group. No variation of the standard technique was made, and no technical pitfalls could be related to the complication described. Limitations of the present study include its retrospective design and small sample size. However, the availability of a
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prospective database and the previous strict standardization of the technique add strength to the study design. Randomized, prospective control trials (1-stage versus 2-stage) with a larger number of patients will be needed to confirm results. Moreover, a longer follow-up of these patients submitted to revisional surgery will also be necessary. However, the value of the present report lies in the evidence of encouraging results coming from a multicenter setting. Furthermore, to the authors' knowledge, the present study is the largest published series of revision LSG after gastric banding performed in 2 stages. Conclusion Despite its limitations, the present study confirmed that LSG is a well-tolerated and effective revisional procedure for a failed and/or complicated LAGB with low perioperative major complications and 2-year %EWL comparable to a primary procedure (78.5%). Furthermore, a 2-stage approach does not seem to be burdened by the increase in postoperative complications described in some series performed in a single stage. The results of this multicenter study, with 3 different bariatric teams and 24 months follow-up, encourage the adoption of a 2-stage approach when a sleeve gastrectomy is chosen for revision after a failed gastric banding. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Himpens J, Cadière GB, Bazi M, Vouche M, Cadière B, Dapri G. Long-term outcomes of laparoscopic adjustable gastric banding. Arch Surg 2011;146:802–7. [2] Mittermair RP, Obermüller S, Perathoner A, Sieb M, Aigner F, Margreiter R. Results and complications after Swedish adjustable gastric banding—10 years experience. Obes Surg 2009;19:1636–41. [3] Silecchia G, Bacci V, Bacci S, et al. Reoperation after laparoscopic adjustable gastric banding: analysis of a cohort of 500 patients with long-term follow-up. Surg Obes Relat Dis 2008;4:430–6. [4] Gagner M, Gumbs AA. Gastric banding: conversion to sleeve, bypass, or DS. Surg Endosc 2007;21:1931–5. [5] Spivak H, Beltran OR, Slavchev P, Wilson EB. Laparoscopic revision from LAP-BAND to gastric bypass. Surg Endosc 2007;21:1388–92. [6] Yazbek T, Safa N, Denis R, Atlas H, Garneau PY. Laparoscopic sleeve gastrectomy (LSG)—a good bariatric option for failed laparoscopic adjustable gastric banding (LAGB): a review of 90 patients. Obes Surg 2013;23:300–5. [7] Goitein D, Feigin A, Segal-Lieberman G, Goitein O, Papa MZ, Zippel D. Laparoscopic sleeve gastrectomy as a revisional option after gastric band failure. Surg Endosc 2011;25:2626–30. [8] Foletto M, Prevedello L, Bernante P, et al. Sleeve gastrectomy as revisional procedure for failed gastric banding or gastroplasty. Surg Obes Relat Dis 2010;6:146–51. [9] Elnahas A, Graybiel K, Farrokhyar F, Gmora S, Anvari M, Hong D. Revisional surgery after failed laparoscopic adjustable gastric banding: a systematic review. Surg Endosc 2013;27:740–5.
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[10] Gagnière J, Slim K, Launay-Savary MV, Raspado O, Flamein R, Chipponi J. Previous gastric banding increases morbidity and gastric leaks after laparoscopic sleeve gastrectomy for obesity. J Visc Surg 2011;148:205–9. [11] Rebibo L, Mensah E, Verhaeghe P, et al. Simultaneous gastric band removal and sleeve gastrectomy: a comparison with front-line sleeve gastrectomy. Obes Surg 2012;22:1420–6. [12] Acholonu E, McBean E, Court I, Bellorin O, Szomstein S, Rosenthal RJ. Safety and short-term outcomes of laparoscopic sleeve gastrectomy as a revisional approach for failed laparoscopic adjustable gastric banding in the treatment of morbid obesity. Obes Surg 2009;19:1612–6. [13] Iannelli A, Schneck AS, Ragot E, et al. Laparoscopic sleeve gastrectomy as revisional procedure for failed gastric banding and vertical banded gastroplasty. Obes Surg 2009;19:1216–20. [14] Bernante P, Foletto M, Busetto L, et al. Feasibility of laparoscopic sleeve gastrectomy as a revision procedure for prior laparoscopic gastric banding. Obes Surg 2006;16:1327–30. [15] Dapri G, Cadière GB, Himpens J. Feasibility and technique of laparoscopic conversion of laparoscopic gastric banding to sleeve gastrectomy. Surg Obes Relat Dis 2009;5:72–6. [16] Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–13. [17] Silecchia G, Perrotta N, Boru C, et al. Role of a minimally invasive approach in the management of laparoscopic adjustable gastric banding postoperative complications. Arch Surg 2004;139:1225–30. [18] Ren CJ, Patterson E, Gagner M. Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients. Obes Surg 2000;10:514–23. [19] Deitel M, Gagner M, Erikson AL, Crosby RD. Third International Summit: current status of sleeve gastrectomy. Surg Obes Relat Dis 2011;7:749–59.
[20] Campanile FC, Silecchia G. Simultaneous gastric band removal and sleeve gastrectomy complication rate. Obes Surg 2013;23:393–4. [21] Khoursheed M, Al-Bader I, Mouzannar A, et al. Sleeve gastrectomy or gastric bypass as revisional bariatric procedures: retrospective evaluation of outcomes. Surg Endosc 2013;27:4277–83. [22] Moon RC, Teixeira AF, Jawad MA. Conversion of failed laparoscopic adjustable gastric banding: sleeve gastrectomy or Roux-en-Y gastric bypass? Surg Obes Relat Dis. Epub 2013 Apr 17. [23] Frezza EE, Jaramillo-de la Torre EJ, Calleja Enriquez C, Gee L, Wachtel MS, Lopez Corvala JA. Laparoscopic sleeve gastrectomy after gastric banding removal: a feasibility study. Surg In nov 2009;16:68–72. [24] Jacobs M, Gomez E, Romero R, Jorge I, Fogel R, Celaya C. Failed restrictive surgery: is sleeve gastrectomy a good revisional procedure? Obes Surg 2011;21:157–60. [25] Uglioni B, Wölnerhanssen B, Peters T, Christoffel-Courtin C, Kern B, Peterli R. Midterm results of primary vs. secondary laparoscopic sleeve gastrectomy (LSG) as an isolated operation. Obes Surg 2009;19:401–6. [26] Alqahtani AR, Elahmedi M, Alamri H, Mohammed R, Darwish F, Ahmed AM. Laparoscopic removal of poor outcome gastric banding with concomitant sleeve gastrectomy. Obes Surg 2013;23:782–7. [27] Berende CA, de Zoete JP, Smulders JF, Nienhuijs SW. Laparoscopic sleeve gastrectomy feasible for bariatric revision surgery. Obes Surg 2012;22:330–4. [28] Tucker O, Sucandy I, Szomstein S, Rosenthal RJ. Revisional surgery after failed laparoscopic adjustable gastric banding. Surg Obes Relat Dis 2008;4:740–7. [29] Lalor PF, Tucker ON, Szomstein S, Rosenthal RJ. Complications after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2008;4: 33–8.
