Surgery for Obesity and Related Diseases ] (2014) 00–00

Editorial comment

Comment on: Revisional sleeve gastrectomy can be a safe and efficacious procedure Laparoscopic adjustable gastric band (LAGB) was once the most popular bariatric procedure in the world. However, inadequate postoperative weight loss and dissatisfaction with postoperative dysphagia have encouraged patients to seek band removal and conversion to another bariatric procedure. However, revisional laparoscopic sleeve gastrectomy (RLSG) after LAGB has been associated with an increased risk of complications such as staple line leak, gastric hemorrhage, or hematoma. In an effort to decrease this complication rate, it is unclear whether to perform this operation as a 1-stage or 2-stage procedure. In a series of 90 patients where it was performed as a 1-stage procedure, the rates of staple line leak and a gastric hemorrhage were 5.5% and 4.4%, respectively [1]. Another series by Berende et al. [2] found a leak rate of 14% and a bleeding rate of 20% for the 1-stage approach. However, with a 2-stage approach major complication rates dropped between 0–3.7% [2–7]. Yet others have attempted to reduce these complications by using surgical adjuncts such as buttress reinforcement agents [8–13]. While the use of these agents has been found to be effective in preventing staple line hemorrhage, the evidence supporting their role in preventing staple line dehiscence is lacking [12,13]. In several studies, complication rates after RLSG have been higher than those seen after primary laparoscopic sleeve gastrectomy (LSG) and therefore call for caution [3,14,15]. It is difficult to explain the inverse phenomena of complication rates in this report between primary and RLSG seen in this series, namely that complication rates were lower in the revisional group than the primary RLSG cohort. Furthermore, no deaths were reported in this series after surgical revisions. This is rather unusual after revisional bariatric surgery. These findings may speak more to the low numbers than to the safety of the procedure. RSLG is more difficult after LAGB for several factors such as thinning out of gastric tissue secondary to capsular scar removal. In addition, band placement at the left crus often causes a dense inflammatory scar reaction in this portion of the stomach, which abuts the crus and is most likely to be the area of leak after RLSG. Dissection around such unfavorable inflammatory tissue does not allow for

easy, safe, and smooth stapling thus contributing to the increased complication rate seen in RLSG [2,7]. As other series have shown, delaying revisional RLSG for up to 12 weeks after removal of the prosthesis allows for the periprosthetic inflammatory reaction to resolve and for the stomach to regain its normal shape, as well as pliability, thereby allowing for construction of an appropriately sized gastric sleeve [2,7]. Reports from other series suggest that this singular act may be the most important factor in the reduced complication rate seen in a series where the 2-stage approach is practiced [2,7]. The published expected percentage of excess body mass index loss after RLSG is 42–46% at 12 months of follow-up [3,4]. Himpens et al. [16] looked at long-term weight loss and found an excess weight loss of 73% and 57% at 3 and 6 years, respectively [16]. In the current series, excess weight loss of 46.5%, 66.4%, and 78.5% were recorded at 6,12, and 24 months, respectively, after RLSG compared with 49.8%, 78.2%, and 78% in patients who underwent primary LSG during the same period [7]. Therefore, despite failing a restrictive procedure patients still demonstrated excellent weight loss when converted to another primarily restrictive procedure. However, weight loss after LSG has been linked to changes of gastrointestinal peptides, shown to be implicated also in metabolic effects and appetite control. Several studies have shown that these gut peptide changes after SG are not seen after LAGB [17–19]. Disease resolution after RLSG is well documented. In the series by Berende et al. [2], disease resolution or improvement occurred in 60% and 40%, respectively. Dysphagia resolved in 82% of patients thus supporting the notion that RLSG confer additional benefits to patients with failed LAGB [2]. The study in this issue by Silecchia et al. [7] has shown us that LSG is an effective procedure for failed LAGB. Because bariatric revision surgery is associated with a higher complication rate than conventional primary procedures, it should be reserved for centers that are experienced with these techniques. In addition, this article nicely demonstrates the safety and efficacy of the 2-stage approach to reduce these complications and achieve optimal weight loss. 1550-7289/r 2014 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.

P. Vemulapalli and E. A. Agaba / Surgery for Obesity and Related Diseases ] (2014) 00–00


Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. Pratibha Vemulapalli, M.D., Emmanuel A. Agaba, M.D. Albert Einstein College of Medicine, New York, NY References [1] Yazbek T, Safa N, Denis R, et al. 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. [2] Berende CA, de Zoete JP, Smulders JF, et al. Laparoscopic sleeve gastrectomy feasible for bariatric revision surgery. Obes Surg 2012;22:330–4. [3] 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. [4] Uglioni B, Wölnerhanssen B, Peters T, et al. Midterm results of primary versus secondary laparoscopic sleeve gastrectomy (LSG) as an isolated operation. Obes Surg 2009;19:401–6. [5] Dapri G, Cadiere GB, Himpens J. Feasibility and technique of laparoscopic conversion of laparoscopic gastric banding to sleeve gastrectomy. Surg Obes Relat Dis 2009;5:72–6. [6] Goitein D, Feigin A, Segal-Lieberman G, et al. Laparoscopic sleeve gastrectomy as a revisional option after gastric band failure. Surg Endosc 2011;25:2626–30. [7] Silecchia G, Rizello M, De Angelis F, et al. Laparoscopic sleeve gastrectomy as a revisional procedure for failed laparoscopic gastric banding with a “2-step approach”: a multicenter study. Surg Obes Relat Dis. Epub 2013 Nov 11.

[8] Foletto M, Prevedello L, Nitti D, et al. Sleeve gastrectomy as revisional procedure for failed gastric banding or gastroplasty. Surg Obes Relat Dis 2010;6:146–51. [9] Spyropoulos C, Kehagias I, Kalfarentzos F, et al. Revisional bariatric surgery: 13-years experience from a tertiary institution. Arch Surg 2010;145:173–7. [10] Gill RS, Switzer N, Driedger M, et al. Laparoscopic sleeve gastrectomy with staple line buttress reinforcement in 116 consecutive morbidly obese patients. Obes Surg 2012;22:560–4. [11] Shikora SA. The use of staple-line reinforcement during laparoscopic gastric bypass. Obes Surg 2004;14:1313–20. [12] Downey DM, Ali S, Goldblatt MI, et al. Gastrointestinal staple line reinforcement. Surg Technol Int 2007;16:55–60. [13] Kasalicky M, Michalsky D, Housova J, et al. Laparoscopic sleeve gastrectomy without an oversewing of the staple line. Obes Surg 2008;18:1257–62. [14] Chen B, Kiriakopoulos A, Tsakayannis D, et al. Reinforcement does not necessarily reduce the rate of staple line leaks after sleeve gastrectomy. A review of the literature and clinical experiences. Obes Surg 2009;19:166–72. [15] Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc 2012;26: 1509–15. [16] Himpens J, Dobbeleir J, Peeters G. Long-term results of laparoscopic sleeve gastrectomy for obesity. Ann Surg 2010;252:319–24. [17] Tsoli M, Chronaiou A, Kehagias I, et al. Hormone changes and diabetes resolution after biliopancreatic diversion and laparoscopic sleeve gastrectomy: a comparative prospective study. Surg Obes Relat Dis 2013;9:667–77. [18] Nannipieri M, Baldi S, Mari A, et al. Roux-en-Y gastric bypass and sleeve gastrectomy: mechanisms of diabetes remission and role of gut hormones. J Clin Endocrinol Metab 2013;98:4391–9. [19] Dimitriadis E, Daskalakis M, Kampa M, et al. Alterations in gut hormones after laparoscopic sleeve gastrectomy: a prospective clinical and laboratory investigational study. Ann Surg 2013;257:647–54.

Revisional sleeve gastrectomy can be a safe and efficacious procedure.

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