Surg Endosc (2014) 28:1096–1102 DOI 10.1007/s00464-013-3277-9

and Other Interventional Techniques

Revised sleeve gastrectomy: another option for weight loss failure after sleeve gastrectomy Patrick Noel • Marius Nedelcu • David Nocca Anne-Sophie Schneck • Jean Gugenheim • Antonio Iannelli • Michel Gagner

Received: 8 August 2013 / Accepted: 11 October 2013 / Published online: 30 October 2013  Springer Science+Business Media New York 2013

Abstract Introduction Laparoscopic sleeve gastrectomy (LSG) is becoming a very common bariatric procedure, based on several advantages it carries over more complex bariatric procedures such as gastric bypass or duodenal switch (DS), and a better quality of life over gastric banding. However, in the long-term follow-up, weight loss failure and intractable severe reflux after primary LSG can necessitate further surgical interventions, and revisional sleeve gastrectomy (ReSG) can represent an option to correct these. Methods From October 2008 to June 2013, 36 patients underwent an ReSG for progressive weight regain, insufficient weight, or severe gastroesophageal reflux in ‘La Casamance’ Private Hospital. All patients with weight loss failure after primary LSG underwent radiological evaluation. If Gastrografin swallow showed a huge unresected fundus or an upper gastric pouch dilatation, or if the

Patrick Noel and Marius Nedelcu contributed equally to this study. P. Noel  M. Nedelcu Hoˆpital Prive La Casamance, Aubagne, France M. Nedelcu (&)  D. Nocca Centre Hospitalier Re´gional Universitaire Montpellier, 80 Avenue Augustin Fliche, 34295 Montpellier, France e-mail: [email protected] A.-S. Schneck  J. Gugenheim  A. Iannelli Hoˆpital Archet, Universite´ de Nice, Nice, France M. Gagner Hoˆpital Du Sacre Cœur, Montreal, QC, Canada


computed tomography (CT) scan volumetry revealed a gastric tube superior to 250 cc, ReSG was proposed. Results Thirty-six patients (34 women, two men; mean age 41.3 years) with a body mass index (BMI) of 39.9 underwent ReSG. Thirteen patients (36.1 %) had their original LSG surgery performed at another hospital and were referred to us for weight loss failure. Twenty-four patients (66.6 %) out of 36 had a history of gastric banding with weight loss failure. Thirteen patients (36.1 %) were super-obese (BMI [ 50) before primary LSG. The LSG was realized for patients with morbid obesity with a mean BMI of 47.1 (range 35.4–77.9). The mean interval time from the primary LSG to ReSG was 34.5 months (range 9–67 months). The indication for ReSG was insufficient weight loss for 19 patients (52.8 %), weight regain for 15 patients (41.7 %), and 2 patients underwent ReSG for invalidating gastroesophageal reflux disease. In 24 cases the Gastrografin swallow results were interpreted as primary dilatation, and in the remaining 12 cases results were interpreted as secondary dilatation. The CT scan volumetry was realized in 21 cases, and it has revealed a mean gastric volume of 387.8 cc (range 275–555 cc). All 36 cases were completed by laparoscopy with no intraoperative incidents. The mean operative time was 43 min (range 29–70 min), and the mean hospital stay was 3.9 days (range 3–16 days). One perigastric hematoma was recorded. The mean BMI decreased to 29.2 (range 20.24–37.5); the mean percentage of excess weight loss was 58.5 % (±25.3) (p \ 0.0004) for a mean follow-up of 20 months (range 6–56 months). Conclusions The ReSG may be a valid option for failure of primary LSG for both primary or secondary dilatation. Long-term results of ReSG are awaited to prove efficiency. Further prospective clinical trials are required to compare the outcomes of ReSG with those of Roux en Y Gastric Bypass or DS for weight loss failure after LSG.

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Revised sleeve gastrectomy

The laparoscopic sleeve gastrectomy (LSG) was introduced in the early 2000s as the first step of a bariatric procedure, carried out only for super-obese, high-risk patients, in order to reduce the high morbidity of laparoscopic duodenal switch (DS) [1] or Roux en Y Gastric Bypass (RYGBP) [2]. Starting 2004–2005, the LSG has been proposed as a standalone procedure. Given the initial excellent weight loss results as well as the several advantages that LSG carries over more complex bariatric procedures such as gastric bypass or DS, and a better quality of life over gastric banding, it has gained wide popularity as a sole bariatric procedure [3]. Indeed, the actual trends for this procedure are growing exponentially, from 480 cases in 2005 to 13,557 cases in 2011, and LSG has become the most common bariatric procedure in France compared with gastric banding (7,600 cases) or RYGBP (9,500 cases) (Fig. 1). However, in the long-term follow-up, weight loss failure and intractable severe reflux can necessitate further surgical interventions in some cases. Which surgical strategy to adopt in case of failure of the LSG? This question represents controversy in the literature and is still a matter of debate. Some authors have reported good results with conversion of the sleeve gastrectomy to RYGBP [2], but other authors prefer DS [1] to ensure a more important and durable weight loss. There are numerous articles on the efficacy of the LSG, but only few publications with limited data exist on the revisional sleeve gastrectomy (ReSG) as an option for LSG failure [4–8]. The aim of this study is to evaluate our early experience with ReSG.

Methods From October 2008 to June 2013, all patients who underwent an ReSG for LSG failure—defined as progressive

Fig. 1 Laparoscopic sleeve gastrectomy frequency—evolution of bariatric surgery in France


weight regain, insufficient weight loss at 18 months after surgery [\50 % of the excess weight loss (EWL)] or symptomatic gastroesophageal reflux disease (GERD) (persistent heartburn despite maximum proton pomp inhibitor treatment with mild esophagitis on upper endoscopy) were included in this study. All procedures were performed laparoscopically at Casamance Private Hospital, Aubagne, France, by the same surgeon (PN), who performed 1,279 LSGs during the same period. After multidisciplinary team assessments, each patient with failure of LSG had an upper gastrointestinal (GI) series. This evaluation has evolved in time to the present algorithm. If the barium swallow shows a huge unresected fundus or an upper gastric pouch dilatation, the ReSG was proposed as a revisional strategy. If the barium swallow test was negative for the upper-part sleeve dilatation, or inconclusive, a computed tomography (CT) scan volumetry followed. The residual gastric volume was measured by filling the gastric remnant with carbon dioxide, as follows. The patient had first drunk a sodium bicarbonate solution (4 g in 10 cl of water) and then a tartaric acid solution (4 g in 10 cl of water). Low-dose CT acquisitions were made 30 and 60 s after the tartaric acid intake. The volume was measured using Myrian software (Microsoft Inc., Redwood City, CA, USA) and expressed in cubic centimeters (cc). If the volumetry was superior to 250 cc, the ReSG was taken into consideration. If it was inferior to 250 cc, patients were referred to the nutritionist for assessment of their eating habits, and to the psychiatrist for assessment of eating disorders. Only patients for whom psychiatric and nutritional clearance was obtained were further considered for other procedures such as laparoscopic RYGBP or laparoscopic DS depending on patient characteristics (postoperative commitment to follow-up of the first procedure; patient’s employment; family support). During this period, 12 RYGBPs and nine DS were performed for a residual gastric volume inferior to 250 cc. Data were extracted from a prospective held database and included demographic [age, gender, mean body mass index (BMI) before LSG and ReSG, and time interval between the two procedures], postoperative morbidity, mortality, and weight loss. The history of the weight loss evolution and the previous bariatric procedures were recorded for each patient. The radiological studies were reviewed and the dilatation was classified as primary or secondary. A primary dilation was defined as an upper posterior gastric pouch incompletely dissected during the initial procedure. The mechanisms involved are the learning curve or difficult cases (super–super-obesity) with poor posterior exposure, and incomplete visualization of the left crus of the diaphragm (Fig. 2). A secondary dilation was defined as a homogeneous dilated gastric tube of more than 250 ml in volume at CT scan volumetry, seen later during



follow-up. The mechanism involved is the narrowing of the gastric incisura during the primary operation, with consequent gastric upstream dilation of the remnant stomach, patient’s eating habits, natural history of LSG, use of a large calibration bougie, a planned second procedure or the combination of these mechanisms (Fig. 3). The efficiency of ReSG was analysed for patients with a minimum follow-up of 6 months. Eleven patients operated on between January 2013 and June 2013 were excluded from the analysis of the weight loss after ReSG. Results are expressed as mean ± standard deviation. A p value\0.05 was considered to be significant. Differences in weight loss comparing the results of LSG and ReSG were analyzed using the Mann–Whitney U test. Statistical analysis was performed using the SSPS statistical package, version 11.5 (SSPS, Inc., Chicago, IL, USA). Surgical technique The pneumoperitoneum was created using a Veress needle inserted in the left hypochondrium. Only three trocars were used. Two cases necessitated one additional port for liver retraction. Any intraperitoneal attachment between the left lobe of the liver and the anterior gastric surface was carefully dissected. The greater curvature was dissected next to expose the previous staple line. All adhesions were divided between the stomach and the pancreas, taking care not to injure the splenic artery. Once mobilization of the stomach was completed as previously described [9], the anesthesiologist inserted a 36F orogastric bougie (MidSleeve) to reach the pylorus, and different applications of a linear stapler Echelon 60–4.1 mm (Ethicon Endo-Surgery

Fig. 2 Primary dilatation—contrast with air fluid level below the diaphragm showing upper posterior gastric pouch incompletely dissected during the initial procedure


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Inc., Cincinnati, OH, USA) were fired. A methylene blue test was performed. A drain was left in place along the staple line. No nasogastric tube was used in the postoperative period.

Results Preoperative work-up data Thirty-six patients (34 women, two men; mean age 41.3 years) with an average BMI of 39.9 (±1.34), undergoing ReSG in our department, were enrolled in the current study. Thirteen (36.1 %) had their original LSG surgery performed at another hospital and were subsequently referred to us for weight loss failure. The remaining 23 patients had had the primary LSG done in our department [10]. Prior to the primary LSG, 24 patients (66.6 %) out of 36 had already had a gastric banding with weight loss failure. Four patients have had multiple gastric band procedures for technical failures. Thirteen patients (36.1 %) were superobese (BMI [ 50) before LSG, and three patients (8.3 %) were super–super-obese (BMI [ 60). The LSG was realized for patients with morbid obesity with a mean BMI of 47.1 (±1.33; range 35.4–77.9). The mean interval time from the primary LSG to ReSG was 34.5 months (range 9–67 months). The indication for ReSG was insufficient weight loss for 19 patients (52.8 %), weight regain for 15 patients

Fig. 3 Secondary dilatation—uniform dilatation of the gastric tube

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(41.7 %) and two patients underwent ReSG for symptomatic GERD. Both patients were GERD symptom-free at 10 and 36 months follow-up, respectively. The analysis of barium swallow showed primary dilatation (upper gastric pouch) in 24 cases, and in the remaining 12 cases the radiological findings were compatible with a secondary dilatation (gastric tube dilatation). The CT scan volumetry (21 cases) revealed a mean gastric volume of 387.76 cc (range 275–555 cc). Intraoperative data and postoperative outcomes All 36 cases were completed by laparoscopy with no intraoperative complications. The mean operative time was 43 min (range 29–70 min), and the mean hospital stay was 3.9 days (range 3–16 days). In the immediate postoperative period, one complication was recorded—patient 12 developed a perigastric hematoma on postoperative day 2, identified by CT scan, with vomiting. An endoscopic stent was inserted and the patient was discharged on a liquid diet. At 4 weeks the CT scan and upper endoscopy were normal and the stent was removed. Postoperative follow-up We have analyzed the weight loss results for 24 patients operated on from October 2008 to December 2012. Followup was accomplished for 21 patients (91.6 %); two patients were lost from follow-up. A 53-year-old woman diagnosed with uterine cancer 4 months after the ReSG was excluded from the group submitted to the weight loss analysis. The mean BMI before the primary LSG was 44.1 (±1.33; range 35.4–55.1). The minimal BMI recorded after the primary LSG was 32.5 (±1.32; range 21.9–43.4), and the mean percentage of EWL (%EWL) was 53.4 % (±24. 3) at a mean follow-up of 14.5 months. The ReSG was performed after a mean follow-up of 35.1 months. The mean BMI and %EWL were 29.2 (range 20.2–37.5) and 58.5 % (±25.3), respectively (p \ 0.0004) at a mean

Fig. 4 Weight loss (mean and standard deviation)—before/after primary LSG and before/after ReSG. BMI body mass index, LSG laparoscopic sleeve gastrectomy, ReSG revisional sleeve gastrectomy


follow-up of 19.9 months (range 6–56 months); four patients achieved an ideal body weight. The mean and standard deviations of these groups are illustrated in Fig. 4.

Discussion The problem of insufficient weight loss and weight regain after LSG is an issue, as for other bariatric procedures. LSG is generally considered a straightforward procedure, but the surgical technique is one of the major determinants of the success of this procedure. One of the key points is the removal of the entire gastric fundus. The left crus of the diaphragm must be systematically visualized, the posterior attachments of the stomach released, and hiatal hernias closed primarily. The particularity of our technique is that the posterior aspect of the fundus is repeatedly grasped with forceps operated by the right hand, while releasing the stapler with the left hand, and pulled laterally before the stapler is definitively clamped and fired [10]. Possible explanations for LSG failure include dilatation of the residual stomach, calibration of the stomach with an excessively large gastric bougie [11] and incomplete section of the gastric fundus (from where ghrelin is secreted) [12]. Himpens et al. [13] reported a 3-year follow-up %EWL of 77.5 % and a 6-year %EWL of 53.3 % with patients receiving only sleeve gastrectomy. Their conclusion was that weight regain and de novo gastroesophageal reflux symptoms (21 %) appear between the third and sixth postoperative year. In our opinion, some of the patients had undissected fundus or upper gastric dilatation which could explain some of the failures. We must mention that this study was conducted on patients operated on between November 2001 and October 2002 when the learning curve for LSG may also be incriminated for some of the negative results, due to incomplete left crus exposure and full posterior fundic dissection. For the LSG, the risk of dilatation in time with weight loss failure was a constant source of debate. Facing 24 patients with primary dilatation (upper gastric pouch), this question came up rapidly in our minds: ‘‘Has this part of the stomach undergone secondary dilatation or was it incompletely dissected from the beginning?’’. The answer remains unknown; a prospective randomized study based on CT scan volumetry would be needed. With the development of CT scan gastric volumetry it will be easier to differentiate between secondary and primary dilation as the former provides useful details such as the position of the staple line and the integrity of the angle of Hiss that are in favor of primary dilation. In the literature, Braghetto et al. [14] reported data on 15 LSG patients undergoing CT scan gastric volumetry on postoperative day 3 and, repeatedly, at 24–36 months after



surgery, and found that the mean gastric volume had increased from 108 to 250 ml. Interestingly, no patient experienced weight regain, and the authors concluded that the gastric capacity increase lately after LSG sleeve gastrectomy even when a narrow gastric tubulization is done. Langer et al. [15] prospectively studied 23 patients (15 morbidly obese, 8 super-obese) by upper GI contrast studies and found that, at a mean follow-up of 20 months, dilation occurred in only one patient, while weight regain after initial successful weight loss occurred in three more patients. Yehoshua et al. [16] investigated the role of the intraluminal pressure in the process of dilation of the gastric tube. The mean volume of the entire stomach before surgery was 1553 cc (600–2 000 cc) and that of the sleeved stomach was 129 cc (90–220 cc). Results showed that the sleeve has a higher pressure [when filled with saline, mean pressure of 43 mmHg (range 32–58 mmHg)] compared with the removed stomach, which had a mean pressure of 26 mmHg (12–47 mmHg). Their conclusion was that the notably higher pressure in the sleeve reflects its markedly lesser distensibility compared with that of the whole stomach and of the removed fundus. The ReSG or resleeve gastrectomy is a relatively new procedure; literature data is sparse and very limited groups of patients were analyzed. Gagner and Rogula [4] reported the first repeated sleeve gastrectomy in a case report of a 47-year-old woman with a lifelong history of morbid obesity [BMI 64 kg/m2 (170 kg)]. She was operated on in January 2000 with a laparoscopic BPD/DS with a 100 ml gastric pouch, 150 cm of alimentary limb, and 100 cm of common channel. She lost most of her excess weight within 17 months after surgery and regained weight up to 77 kg and a BMI of 29 kg/m2. Upper GI series showed a markedly dilated gastric pouch, and her second surgery consisted of a laparoscopic repeated sleeve gastrectomy. No postoperative complications occurred, and at 10 months after surgery her weight was 61 kg with a BMI of 22. Another two cases of ReSG were presented by Baltasar et al. [5], with subsequent increased weight loss. In their experience, isolated ReSG represents an option in case of weight loss failure after LSG if the dilatation of the stomach is larger than 4 cm in diameter on GI series study. Recently, three case series reported the feasibility of the ReSG technique in selected patients. Dapri et al. [6] compared seven patients who underwent ReSG with 19 patients who underwent DS. The results of this study were biased by the patient’s selection according to different eating behavior patterns and by the heterogeneous groups (the maximum BMI of the ReSG was 68.9 kg/m2 vs. no super-obese patients in the other group). In our experience, the loss of satiety described by the patient is crucial to alerting about a possible dilatation, but the indication for


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the type of redo surgery is taken based also on the radiological data. Regarding the safety of these procedures, in the ReSG group, Dapri et al. recorded one early gastric leak that required treatment for 58 days and more than one endoscopic stent placement. In a multicentric study (October 2005–April 2010), Iannelli et al. [7] selected a group of 13 patients with ReSG for progressive weight loss failure after LSG associated with the persistence of the gastric fundus on upper gastrointestinal series. The mean BMI dropped from 44.6 to 32.3, with no morbidity associated with this procedure. Rebibo et al. [8] reported the largest series of 15 ReSGs found in the literature compared with a group of 30 primary LSG. At 12 months’ follow-up, %EWL was similar for both groups—66 % in the ReSG group and 77 % in the primary LSG group. Two patients in the ReSG group developed a gastric fistula, one of whom died. The risk of fistula after ReSG has also been reported by Trelles et al. [17]. In our experience of 36 ReSGs, no gastric fistula has occurred in this group of patient, and there is no associated mortality. After extensive analysis of %EWL for every patient in our study following primary LSG and ReSG, we identified only five cases (patients 1, 2, 3, 7, and 21 [Fig. 5]) with insufficient weight loss after ReSG. The last case (patient 21) had only 7 months of follow-up, and the remaining cases occured at the beginning of our experience. In our opinion, weight loss after both ReSG and primary LSG depends on the learning curve and are technically dependent. For primary LSG, incomplete removal of the gastric fundus seems to be the most reliable hypothesis causing weight regain. In some cases of incomplete removal of the fundus, a small unrecognized hiatal hernia may be associated with this. In the presence of a hiatal hernia, a transthoracic stomach may be missed while performing an LSG. We advise an intraoperative exploration of the esophageal hiatus whenever a hiatal hernia is suspected, and we can avoid undisected fundus and repair the crura when necessary. This hypothesis has been sustained by Soricelli et al. [18]. To avoid unnecessary dissection, Heacock et al. [19] tried to improve the preoperative diagnostic accuracy of hiatal hernia by using the right anterior oblique (RAO) esophagram technique instead of the commonly used upright technique, and comparing it with the gold standard of intraoperative detection. They analyzed a total of 388 patients who underwent preoperative esophagrams (69 upright, 388 RAO). For upright esophagram, sensitivity was 50 % and specificity was 97 %. For RAO esophagram, sensitivity was 70 % and specificity was 77 %. Use of the RAO technique for preoperative esophagram is more sensitive for the diagnosis of hiatal hernia than upright esophagram. The undisected fundus represents a risk factor for reflux disease, and the ReSG with hiatal hernia repair can be a

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Fig. 5 ReSG learning curve—individual representation of weight loss evolution. BMI body mass index, LSG laparoscopic sleeve gastrectomy, ReSG revisional sleeve gastrectomy

valid option of treatment, as shown by Parikh and Gagner [20]. In our experience, we had two patients who had complete remission of the reflux symptomatology after ReSG. Literature data on the effect of LSG for GERD are contradictory. Petersen et al. [21] recently reported, on 37 patients undergoing LSG, that the lower esophageal sphincter pressure increased significantly after surgery, independently of weight loss. The stationary esophageal manometry for lower sphincter showed a pressure of 11 mmHg preoperatively, which increased significantly to 24 mmHg in the postoperative period. Compared with the malabsorptive procedures, resleeve gastrectomy offers several advantages, such as: • • • •

increasing restriction and decreasing gastric output; lesser dumping syndrome by preserving of the pylorus; decreased risks of anemia, osteoporosis, protein and vitamin deficiency (except B12 and thiamine level); lesser operating time.

Conclusions Re-LSG is a feasible and safe surgical approach for weight regain post-LSG and is best applied when the gastric pouch is too large or when the gastric tube is dilated after the original LSG. This dilatation may, in the long term, be responsible for weight regain, weight loss insufficiency or reflux disease. Long-term results of ReSG are awaited to prove efficiency. Further prospective, randomized clinical trials are required to compare the outcomes of ReSG with those of RYGBP or DS for weight loss failure after LSG.

Disclosures Patrick Noel, Marius Nedelcu, David Nocca, AnneSophie Schneck, Antonio Iannelli, and Jean Gugenheim have no conflicts of interest or financial ties to disclose. Michel Gagner has received honorarium for speaking engagements from Ehicon Endosurgery, Covidien, MID, Transenterix, Gore.

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Revised sleeve gastrectomy: another option for weight loss failure after sleeve gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) is becoming a very common bariatric procedure, based on several advantages it carries over more complex bariatri...
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