REVIEW ARTICLE

Revisional Surgery After Laparoscopic Sleeve Gastrectomy Manuel Ferrer-Ma´rquez, PhD, Ricardo Belda-Lozano, PhD, a M Jose´ Solvas-Salmero´n, BSc, and Manuel Ferrer-Ayza, PhD

Abstract: The recent increase in the frequency of bariatric surgery, especially laparoscopic sleeve gastrectomy, is associated with an increase in the frequency of revisional bariatric surgery. The causes of this are numerous but can be summarized as: (1) late fistulae (2) stenosis; (3) gastroesophageal reflux; and (4) weight regain (by increasing or not increasing the gastric volume). We present below a review of the clinical features, diagnosis, and treatment of them. Key Words: sleeve gastrectomy, revisional surgery, gastric stenosis, gastric leak, weight regain

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evisional bariatric surgery is the reintervention performed on an obese patient after a failure in a previous surgical technique. The recent increase in the frequency of bariatric surgery, especially laparoscopic sleeve gastrectomy (LSG), is associated with an increase in the frequency of revisional bariatric surgery. The fact that LSG has been erroneously considered as simple and easily reproducible has led many surgeons to perform it. From a laparoscopic point of view, it might seem to be a more acceptable surgery if compared with gastric bypass or biliopancreatic diversion. However, its complications can be even more serious than those from other techniques.1 Revisional surgery treats certain complications that occur 30 days after primary surgery. There are many causes, but we can focus on those significantly affecting the quality of life of the affected patient: (1) late fistulae; (2) stenosis; (3) gastroesophageal reflux; and (4) weight regain (by increasing or not increasing the gastric volume). Each one of them has a specific clinical feature that lets us identify the diagnosis, but a failure in the surgical technique is common in all of them. If we continually argue that performing bariatric surgery requires a well-trained team, in both theoretical knowledge and surgical technique (either by laparoscopy or, if necessary, open surgery), it is needless to say that this training is also required to perform revisional surgery. Hence, when treating a patient requiring this type of surgery, it is advisable to refer said patient to an experienced, accredited center.

LATE FISTULAE A late fistula is the most feared complication of LSG as it poses a difficult challenge and carries a wide range of therapeutic options for the surgeon and a prolonged hospital stay for the patient. The incidence rate of leakage after LSG ranges Received for publication March 15, 2014; accepted September 1, 2014. From the Torreca´rdenas Hospital, Almerı´ a, Spain. The author declares no conflicts of interest. Reprints: Manuel Ferrer-Ma´rquez, PhD, Torreca´rdenas Hospital, Almerı´ a, Spain (e-mail: [email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.

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from 0% to 20%. Most leaks appear in the proximal third of the stomach, close to the gastroesophageal junction.1,2 The causes are numerous. It seems that, because of gastric emptying difficulties, they are more likely to occur in patients presenting distal stenosis. Yehoshua et al3 showed that a combination of low gastric tube compliance and high intraluminal pressure seems to be the main cause of fistulae at this level. Gastric fistulae are secondary to variations in the normal acute healing process. Among local risk factors are impaired suture line healing, inadequate blood flow, infection, and poor oxygenation with subsequent ischemia. There are authors who suggest that rather than being caused by staple failure and staple line dehiscence, most fistulae occur because of ischemia in the gastric wall near the staple line. This may be caused by dissection of the greater curvature when the LigaSure or Ultracision systems are used. They usually occur when the patient is at home and, although they tend to appear during the first 10 days after surgery, they occasionally show belatedly. The signs and symptoms of the patients who develop a fistula are similar to those of patients with other types of abdominal infections. The clinical presentation of gastric leaks ranges from the patient being completely asymptomatic (identified by radiologic examination), to the presentation of peritonitis, septic shock, multiorgan failure, and death. It is noteworthy that most of the patients do not complain of abdominal pain, but they usually attend the emergency room with fever and dyspnea. The management of these types of fistulae is not easy. Although stabilizing the patient early and controlling the fistula is possible, it remains difficult to permanently stop the leak. The patient’s condition is the main indicator for management. Any patients presenting hemodynamic instability will obviously require urgent drainage of the collection, either radiologically guided or by laparoscopic reintervention. The major inflammatory component and frequent presence of nearby abscesses make closing a late fistula impossible. In these cases, the best option is to wash out the cavity and install a drain. Once the acute process is solved, the next step should be conservative treatment by parenteral or enteral nutrition, high-dose proton pump inhibitors, and the use of broad spectrum antibiotics. Enteral nutrition should be started as soon as possible during treatment as appropriate nutrition is needed to support the closure of the defect. When a fistula does not resolve after 4 weeks or there is no clear decrease in size, several conservative options exist. Some authors have successfully used sealants (biological glues) applied under endoscopy with controversial results. In recent years, most authors have supported the use of flexible coated stents as a second step.4 A temporary “fistula bypass” is thus obtained, allowing the maintenance of enteral nutrition until closure. Most authors recommend a period of 6 to 8 weeks as the optimal time to withdraw the stent (Fig. 1). In cases of patients who do not respond to any of these procedures, we should consider acting on the distal stenosis

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Revisional Surgery After LSG

FIGURE 2. Gastroesophageal transit in which stenosis after laparoscopic sleeve gastrectomy is shown. FIGURE 1. Placing a coated stent.

(if it exists) by endoscopic dilation. When none of these options solves the problem, a surgical procedure is required. We should avoid a simple closure of the fistula as it often fails because of the poor condition of the tissues around the infected area. The aim should be to decrease intragastric pressure; hence, most authors recommend a conversion of the technique into gastric bypass. Other authors5 describe the fistula diversion in a Roux-en-Y intestinal loop. The performance of a total gastrectomy is the last option.1,6

STENOSIS Stenosis is another possible complication that may occur after LSG. It may appear acutely after surgery but usually appears chronically. Its incidence ranges between 0.1% and 3.9% and in most cases it is a short segment located in the body (near the incisura angularis and less frequently at a proximal level) (Fig. 2). Among the possible causes of stenosis are edema or postoperative hematomas, suture reinforcement, an excessively small bougie size, or suture line angulations, which create a torsion that facilitates the stenosis itself. During surgery, we must be extremely careful when performing gastric section. Before performing the section, we should repeatedly check that the Faucher tube remains properly placed. Any incorrect movement of the Faucher tube may confuse the surgeon and create a stenosis by tubulization. Some authors recommend setting the gastric tube to the omentum to avoid the risk of torsion. In terms of symptoms, the patient may have difficulty in passing food, regurgitation, nausea, and vomiting or Copyright

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dysphagia. The symptoms of the patient could be indicative of this complication, which is diagnosed by performing a gastroesophageal transit or an upper endoscopy. Therapeutic options will depend on the time of appearance. Acute stenosis after surgery can, occasionally, be treated conservatively with intestinal rest, parenteral nutrition, and surveillance. In the absence of other pathologies (fistulae, abscesses, y), the stenosis could disappear spontaneously without needing intervention. However, chronic stenosis will usually require some type of—either endoscopic or surgical—intervention. In this case, the options for treatment will depend on the length of the stenosis. In those cases of short stenosis located in the body of the gastric tube, endoscopic or interventional radiology dilations usually have a good result in one or more sessions. The use of a stent has also been described to control this complication, but it is usually less well-tolerated by the patient. Long stenotic segments or those in which the dilator treatment fails, however, require surgical intervention. Among the possible surgical techniques, Dapri et al7 described the extramucosal laparoscopic seromyotomy for the treatment of stenosis (performed with electrocautery from 1 cm proximal to 1 cm distal to the stenotic area) with good results. Another possibility described is performing a strictureplasty (longitudinal section of the stenosis and transverse suture).8 The best, and the most often-performed, option is probably the conversion to gastric bypass9,10 (Fig. 3).

REFLUX In relation to resolving symptoms related to gastroesophageal reflux, gastric bypass has proved highly efficient. However, the role of LSG remains controversial because of

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FIGURE 3. Therapeutic algorithm in the stenosis.

the heterogeneity of the studies and the large variability of the surgical technique.11 The use of LSG in patients with gastroesophageal reflux is generally not recommended, especially in those with Barrett’s esophagus.12 In any case, we can find controversy in the literature as there are both studies that report an increase of reflux after sleeve gastrectomy and studies that show the opposite effect.13 Sleeve gastrectomy may contribute to the clinical features of reflux through the following mechanisms:  Anatomic alteration of the angle of Hiss.14  Decreased gastric compliance.3  Increased intragastric pressure and relative hypotension of the lower esophageal sphincter. It is important to note that these mechanisms are characteristic of LSG as their proper operation essentially depends on the restriction produced. These alterations are especially common during the first postoperative year. As the volume of gastric remnant progressively increases with age, we consider it possible for

the reflux to improve for up to 3 years after surgery,14 with a certain degree of dilation occurring. Further, indirectly, weight loss improves the clinical condition of treated patients.15 Therefore, we should not rush into the indication of the surgery, with it being preferable to start treatment with proton pump inhibitors during this time.12 The excessive increase of intragastric pressure may be mediated by a gastric stenosis, which frequently occurs at the level of the incisura angularis. If the barium transit—in the preoperative study of the patient—shows this stricture, then a nonsurgical approach by endoscopic dilations can be performed.16 The role of torsion of the gastric remnant in the increase of gastric pressure has yet to be thoroughly studied. If there is neither clinical improvement after dilation nor stenosis that justifies the reflux, the ideal technique is Roux-en-Y gastric bypass. This procedure will enable a low pressure system,17 allowing an improvement of the patient’s clinical situation in most cases (Fig. 4). Sleeve reconstruction,16 although published with good results by some authors, is not generally recommended

FIGURE 4. Therapeutic algorithm after reflux.

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as it does not solve pressure problems from a theoretical view.

WEIGHT REGAIN LSG was considered a revisable technique from its inceptions, as it was conceived as a first step in high surgical risk patients toward subsequent surgeries (gastric bypass or duodenal switch). In addition, restrictive procedures tend to lead to a weight regain over time, especially if patients have some risk factors (age above 45 y, body mass index >50 kg/m2, maintenance of eating habits, lack of follow-up in a medical center). Deitel and Greeinstein18 suggest using the percentage of excess body mass index loss to assess the results. Therefore, it is considered an excellent result if it exceeds 65%; good, if it is between 50% and 65%; and failure, when it is under 50%. Weight regain may occur under 2 circumstances.

Patients Without Increased Gastric Volume This is uncommon (< 10%), and usually occurs in patients with eating disorders who follow a highly caloric soft or liquid diet. The ideal revisional surgery is a malabsorptive technique such as a duodenal switch or a gastric bypass. The increased production of ghrelin by the small intestine as a compensation for the resection of the gastric fundus has a poorly understood role in the failure of the technique.19

Patients With Increased Gastric Volume An increased gastric residual volume after LSG is a risk factor associated with weight regain.20 There are even authors who do not observe failure in long series if it is not associated with sleeve dilation. The origin of this dilation may lie in technical failures (calibration probe too thick, the antrum or fundus do not fit to the probe, resected stomach volume under 500 mL) or a progressive dilation occurring over time. The latter is the result of an excessive pressure on the gastric remnant caused by excessive food intake, repeated vomiting, or distal obstruction. In addition, there may be differences in the properties of the gastric wall, enabling a larger dilation in some patients than others.20 These circumstances overlap and interrelate to each other. For example, it has been shown that narrower initial volumes of the sleeve are difficult to dilate compared with those of a larger volume. Although many people think that the classic surgical aphorism “when the restriction fails, the solution is not more restriction” is still valid, several authors suggest the utility of performing a resleeve gastrectomy either as a first step to a duodenal switch or as an isolated revision technique. However, these studies are limited by the number of patients and the lack of long-term results.21 Malabsorptive surgeries, such as gastric bypass or duodenal switch, have been studied as second-time surgeries in the case of patients at a high surgical risk and show adequate efficiency and safety.22 Therefore, their use as revisional surgeries for weight regain is widely accepted. REFERENCES 1. Ma´rquez MF, Ayza MF, Lozano RB, et al. Gastric leak after laparoscopic sleeve gastrectomy. Obes Surg. 2010;20:1306–1311.

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2. Burgos AM, Braghetto I, Csendes A, et al. Gastric leak after laparoscopic-sleeve gastrectomy for obesity. Obes Surg. 2009;19:1672–1677. 3. Yehoshua RT, Eidelman LA, Stein M, et al. Laparoscopic sleeve gastrectomy—volume and pressure assessment. Obes Surg. 2008;18:1083–1088. 4. Eubanks S, Edwards CA, Fearing NM, et al. Use of endoscopic stents to treat anastomotic complications after bariatric surgery. J Am Coll Surg. 2008;206:935–938. 5. Baltasar A, Bou R, Bengochea M, et al. Use of a Roux limb to correct esophagogastric junction fistulas after sleeve gastrectomy. Obes Surg. 2007;17:1408–1410. 6. Lacy A, Ibarzabal A, Obarzabal A, et al. Revisional surgery after sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech. 2010;20:351–356. 7. Dapri G, Cadie`re GB, Himpens J. Laparoscopic seromyotomy for long stenosis after sleeve gastrectomy with or without duodenal switch. Obes Surg. 2009;19:495–499. 8. Zundel N, Hernandez JD, Galvao Neto M, et al. Strictures after laparoscopic sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech. 2010;20:154–158. 9. Parikh A, Alley JB, Peterson RM, et al. Management options for symptomatic stenosis after laparoscopic vertical sleeve gastrectomy in the morbidly obese. Surg Endosc. 2012;26:738–746. 10. Burgos AM, Csendes A, Braghetto I. Gastric stenosis after laparoscopic sleeve gastrectomy in morbidly obese patients. Obes Surg. 2013;23:1481–1486. 11. Mahawar KK, Jennings N, Balupuri S, et al. Sleeve gastrectomy and gastro-oesophageal reflux disease: a complex relationship. Obes Surg. 2013;23:987–991. 12. Rosenthal RJ, Diaz AA, Arvidsson D, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis. 2012;8:8–19. 13. Laffin M, Chau J, Gill RS, et al. Sleeve gastrectomy and gastroesophageal reflux disease. J Obes. 2013;2013:741097. 14. Himpens J, Dapri G, Cadie`re GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg. 2006;16:1450–1456. 15. Falk GW. Obesity and gastroesophageal reflux disease: another piece of the puzzle. Gastroenterology. 2008;134:1620–1622. 16. Daes J, Jimenez ME, Said N, et al. Laparoscopic sleeve gastrectomy: symptoms of gastroesophageal reflux can be reduced by changes in surgical technique. Obes Surg. 2012;22: 1874–1879. 17. Pallati PK, Shaligram A, Shostrom VK, et al. Improvement in gastroesophageal reflux disease symptoms after 17rious bariatric procedures: review of the Bariatric Outcomes Longitudinal Database. Surg Obes Relat Dis. 2014;10:502–507. 18. Deitel M, Greenstein RJ. Recommendations for reporting weight loss. Obes Surg. 2003;13:159–160. 19. Karamanakos SN, Vagenas K, Kalfarentzos F, et al. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Ann Surg. 2008;247:401–407. 20. Deguines J-B, 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;9:660–666. 21. Weiner RA, Weiner S, Pomhoff I, et al. Laparoscopic sleeve gastrectomy—influence of sleeve size and resected gastric volume. Obes Surg. 2007;17:1297–1305. 22. Moszkowicz D, Rau C, Guenzi M, et al. Laparoscopic omegaloop gastric bypass for the conversion of failed sleeve gastrectomy: early experience. J Visc Surg. 2013;150:373–378.

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Revisional surgery after laparoscopic sleeve gastrectomy.

The recent increase in the frequency of bariatric surgery, especially laparoscopic sleeve gastrectomy, is associated with an increase in the frequency...
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