Surgery for Obesity and Related Diseases 11 (2015) 612–620
Original article
Worthy or not? Six-year experience of revisional bariatric surgery from an Asian center of excellence Anirudh Vij, M.D.a, Kirubakaran Malapan, M.D.a, Ching-Chung Tsai, M.D.b, Kuo-Chung Hung, M.D.c, Po-Chi Chang, M.D.a,d, Chih-Kun Huang, M.D.a,d,* a
Bariatric and Metabolic International Surgery Centre, E-Da Hospital, Taiwan, Republic of China b Department of Pediatrics, E-Da Hospital, Taiwan, Republic of China c Department of Anesthesia, E-Da Hospital, Taiwan, Republic of China d Department of General Surgery, E-Da Hospital, Taiwan, Republic of China Received September 13, 2013; accepted April 28, 2014
Abstract
Background: Revisional bariatric surgery (RBS) is increasing. The various primary operations with their distinctive complications make this group of patients quite heterogeneous, and treatment has to be individualized. There are concerns regarding the safety profile and efficacy of these procedures. The objective of the present study was to analyze the indications, safety, and efficacy of RBS at a high-volume Asian center and provide insight into the different treatment options. Methods: Of a total of 1578 bariatric surgeries from July 2006 to June 2012, 52 patients underwent revisional bariatric procedures. The primary operations included 6 different procedures. The indications for surgery were grouped into weight loss failure (n ¼ 21) or complications related to the primary operation (n ¼ 31). The revisional operations performed were conversion to another procedure (n ¼ 22), revision of existing anatomy (n ¼ 29), or reversal to normal anatomy (n ¼ 1). Results: 96% of revisional surgeries were performed laparoscopically. The median operating time was 72 minutes (25–240 min), and the median duration of hospital stay was 4 days (3–25 d). The mean body mass index for weight loss failure decreased significantly from 36.3 to 29.6 kg/m2 after 1 year of revisional surgery (P o .01). However, revision of RYGB was only associated with a body mass index loss of 3.2 kg/m2 and percentage of excess weight loss of 31.8%. More than 90% of the patients with complications had complete resolution of their preoperative symptoms. There were 3 major complications with an overall morbidity rate of 5.8%. There was no mortality. Conclusions: RBS is well-tolerated, with satisfactory early outcomes, in high-volume centers. However, larger studies with longer follow-up periods are needed to determine the long-term efficacy of these procedures. (Surg Obes Relat Dis 2015;11:612–620.) r 2015 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
Keywords:
Revisional surgery; Bariatric; Morbid obesity
There is a global pandemic of obesity [1]. Bariatric surgery has proved to be the most effective treatment for * Correspondence: Chih Kun Huang, M.D., No.1, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City, Taiwan 82445 Republic of China. E-mail: [email protected]
clinically severe obesity and its associated co-morbidities [2]. The number of bariatric surgeries has increased almost 10-fold over the past decade in the Asia Pacific region because of the increased demand and acceptance of these procedures [3]. Most primary bariatric surgeries (PBS) are successful. However, a revisional surgery rate of 5%–50%, depending
http://dx.doi.org/10.1016/j.soard.2014.04.033 1550-7289/r 2015 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
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on the primary procedure performed, has been described in the literature [4]. Weight loss failure (WLF) is a common indication for revisional surgery, which is often observed for all procedures [5]. Patients may also require revision for complications unique to the initial surgery. For instance, band and port site–related problems are often observed after laparoscopic adjustable gastric banding (LAGB), whereas reflux, staple line dehiscence, and stomal stenosis are common after vertical banded gastroplasty (VBG) [6,7]. Laparoscopic sleeve gastrectomy (LSG) may lead to gastrointestinal reflux disease (GERD) and stricture [8,9], whereas complications of gastrojejunal anastomosis are commonly observed after laparoscopic Roux-en-Y gastric bypass (LRYGB) [10–12]. With the increased number of bariatric surgeries, surgeons in Asia are increasingly encountering such problems. Because this is a heterogeneous population, it is appropriate to mention that their treatment has to be individualized. WLF or complications related to restrictive procedures have had good outcomes after conversion to RYGB [13] or biliopancreatic diversion with duodenal switch (BPD-DS) [14]. Other studies have described band replacement in cases of band/port site complications after LAGB or resleeving for weight regain after LSG [15]. Anastomotic complications after RYGB may require revision of gastrojejunostomy, whereas WLF may be addressed by either augmenting restriction by pouch/stoma reduction or increasing malabsorption with limb lengthening [16–18]. The dense adhesions, scarring, and ischemic tissues that result from multiple stapler lines make revisional bariatric surgery (RBS) technically challenging and increase patients’ predisposition to complications; the outcomes of RBS are generally inferior to those of PBS [4–7]. The objective of the present study was to analyze the indications, safety profile, and efficacy of RBS performed over the past 6 years at an Asian center of excellence to provide an insight into the different treatment options.
(Covidien–Endo GIA; staple height 4.8 mm) and, more recently, black cartridges (staple height 5 mm) to minimize the incidence of leak in the thickened tissues. Drainage tubes were usually used, and a Gastrografin study was not routinely performed after surgery. Particular mention is made of the surgical technique for 2 patients with intractable anemia after primary RYGB who were converted to sleeve gastrectomy. This was a complex procedure performed by first disconnecting the roux limb from the gastric pouch by linear stapler. The previous jejunojejunal anastomosis was taken down, followed by a side-to-side anastomosis between the biliopancreatic and alimentary limbs, restoring intestinal continuity. This was followed by gastrolysis of the remnant stomach and a sleeve gastrectomy over a 36F bougie. Lastly, a hand-sewn gastrogastric anastomosis was completed between the gastric pouch and the newly created sleeve of stomach. The patient data included demographic characteristics and investigations, operative parameters, postoperative events, and overall outcomes including weight loss and resolution of complications. The %EWL was calculated with the standard formula, using an ideal BMI equal to 22 kg/m2 as per Asian standards. The patients undergoing RBS were grouped by surgical indication into 2 groups: (1) weight loss failure (WLF), defined as excess weight loss (EWL) of o50% at 2 years or weight gain 415% from baseline after PBS; and (2) complications, defined as those causing chronic intractable (but not life-threatening) symptoms not amenable to medical management and impairing the patient’s quality of life. Only those patients with a follow-up period of 46 months after RBS were included for analysis. Patients who underwent emergency reoperation for life-threatening complications, such as leaks, abscesses, perforation, or hemorrhage, and patients who underwent reoperation for internal/incisional hernias after PBS were excluded from the study.
Methods
Statistical methods
The bariatric surgery database at the authors’ institution was retrospectively reviewed. A period of 6 years spanning July 2006 to June 2012 was chosen for the analysis. The indications for PBS were based on the Asian Pacific Bariatric Surgery Society Guidelines: BMI 432 kg/m2 with associated co-morbidity and BMI 437 kg/m2 with or without co-morbidities. The preoperative workup included assessment of psychiatric condition, diet, percentage of excess weight loss (%EWL), nutritional deficiencies and changes in anatomy by upper gastrointestinal (UGI) endoscopy, diatrizoic acid (Gastrografin) study, and computed tomography (CT) of the abdomen, as required. Adhesions encountered during surgery were tackled by sharp dissection with scissors and electrocautery hook. Stapling was usually done using green loads
Patient data were entered into the BMI Surgery Centre Clinical database, which is a customized computer database (built using Access [Microsoft Inc., Redmond, WA]). Descriptive results for continuous variables are presented as mean ⫾ standard deviation. The categorical data are presented as counts and percentages. Results A total of 1578 PBS, including restrictive and combined procedures, were performed at the authors’ center during the 6-year study period. Fifty-two RBS patients were identified, 43 of whom had undergone PBS at the authors’ center and 9 of whom were referrals from outside hospitals. The primary surgeries performed were RYGB (n = 25), SG
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(n = 10), VBG (n = 6), AGB (n = 4), adjustable gastric banded plication (n = 4), and mini gastric bypass (MGB; n = 3). There were 4 open surgeries (2 VBG, 1 RYGB, and 1 MGB). The remaining surgeries (92.3%) were performed laparoscopically. All the revisional bariatric surgeries were performed by a single surgeon with an overall experience of more than 2000 primary bariatric operations. The revisional surgeries were first attempted 2 years after starting the bariatric program, after gaining experience of approximately 500 primary bariatric operations. The center was the first one in Asia to get ICE accreditation, in 2008, after which a fellowship program was started. A number of primary operations were subsequently performed by the trainee surgeons enrolled in the fellowship under supervision of the corresponding author. The indications for RBS were documented WLF in 21 patients (40.4%) and PBS-related complications in 31 patients (59.6%; Fig. 1). The mean age of patients was 36 years (range, 16–61 yr). There were 38 women (71.7%) and 15 men (28.3%).The patients underwent RBS after a median time interval of 24 months (range, 3–72 mo). The median operating time and postoperative length of hospital stay for RBS was 72 minutes (range, 25–240 min) and 4 days (range, 3–25 d), respectively.
Effect of RBS on WLF A total of 21 patients required RBS for WLF (Table 1). All patients with prior restrictive procedures were converted to RYGB, except 1 LSG patient who underwent additional plication of the gastric tube. Revision of the gastric pouch and/or gastrojejunostomy (GJ) stoma was performed in all 8 patients with primary RYGB. The mean BMI at the time of initial surgery, at revisional surgery, and at 1-year postrevision was 38.8, 36.3, and 29.6 kg/m2, respectively (P o .01 for pre- and postrevisional BMI). The median time to revision was 36 months (range, 24–72 mo), and the median follow-up period after RBS was 12 months (range, 6–24 mo). A total of 13 patients (61.9%) were available for the 1-year follow-up examination. The incidence of preoperative co-morbidities before the index operation in patients with WLF was diabetes mellitus, hypertension, and hyperlipidemia in 61.9%, 33.3%, and 47.6%, respectively. The rate of the respective comorbidities before revisional surgery was 47.6% , 23.8%, and 42.8%, which decreased to 14%, 9.5%, and 4.8% 1 year after revisional surgery. A difference in the weight loss pattern was observed between patients undergoing restrictive PBS and those undergoing primary RYGB (Fig. 2). The mean initial
RYGB (n=8)
Pouch/Stoma revision RYGB (n=4)
LSG (n=5) Plicaon (n=1)
Primary Bariatric surgery (n=52)
Weight loss failure (n=21) VBG (n=5)
RYGB
LAGB (n=2)
RYGB
MGB (n=1)
RYGB
RYGB (n=1) GJ complicaons (n=12) GJ revision (n=11)
Proximalisaon (n=4) Malnutrion (n=6) Sleeve (n=2)
Complicaons (n=31)
Band/tubing failure (n=3)
Band Replacement (n=3) Replicaon (n=1)
Fundal herniaon (n=3)
Sleeve (n=1)
Reversal (n=1)
Miscellaneous (n=7)
RYGB
Fig. 1. Revisional surgical procedures for patients with different primary bariatric operations. Abbreviations: RYGB ¼ Roux-en-Y gastric bypass; LSG ¼ laparoscopic sleeve gastrectomy; VBG ¼ vertical banded gastroplasty; LABG ¼ laparoscopic adjustable gastric banding; MGB ¼ mini-gastric bypass; GJ ¼ gastrojejunostomy.
Abbreviations: F ¼ female; M ¼ male; BMI ¼ body mass index; RYGB ¼ Roux–en-Y gastric bypass; LSG ¼ laparoscopic sleeve gastrectomy; VBG ¼ vertical banded gastroplasty; P/C ¼ ; lap ¼ ; LAGB ¼ laparoscopic adjustable gastric banding; MGB ¼ mini gastric bypass.
None None RYGB RYGB 24 54 16.7 3.1 51.5 39.6 LAGB MGB
2 1
34.5 55
0:2 1:0
49.5 50
33.2 36.5
Leak (1) 72 (60–72) 9.1 30 40.8 42 VBG
5
36
5:0
30.1 LSG
5
31
5:0
34.2
26.5
4.9
36 (28–46)
None
None
Pouch revision (3) Stoma revision (3) Combined (2) RYGB (4) Plication (1) RYGB 33.1 RYGB
8
41.5
7:1
39.2
30
3.2
34 (12–48)
Complication Mean final BMI (1 yr) Pre-revisional BMI (Mean) Initial BMI (Mean) Gender (F:M) Median age Number of patients Primary surgery
Table 1 Revisional bariatric surgery outcomes for weight loss failure after different primary procedures
Mean BMI loss (1 yr)
Median time to revision (mo)
Revisional surgery
Management
P/C drainage þ lap repair
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615
prerevisional and 1-year postrevisional BMI in the 2 groups was 38.5 and 39.2 (P ¼ .81), 38.1 and 33.1 (P ¼ .2), and 29.2 and 30 (P ¼ .41), respectively. There was 1 major complication in a case of VBG conversion to RYGB. The patient presented with an intraabdominal abscess on postoperative day 8. After an initial unsuccessful attempt at percutaneous drainage, diagnostic laparoscopy was performed, which revealed a small perforation in the excluded stomach that was repaired laparoscopically. A jejunostomy feeding tube was placed for nutrition, and the patient made an uneventful recovery. Effect of RBS on complications PBS-related complications accounted for 31 RBS cases performed in the present study (Table 2). Complications related to the GJ, such as stricture (n ¼ 5), marginal ulcer (n ¼ 2), and dumping syndrome (n ¼ 4), were the most common (11 of 31 cases, 35%) cause for revision in this group. Both stricture and marginal ulcers were treated by revision of the GJ anastomosis with a single-layer hand-sewn technique. Bilateral truncal vagotomy was performed in both cases of marginal ulcer to decrease acid secretion. All patients with dumping syndrome underwent resizing of the dilated GJ (43 cm) to 1.5 cm in diameter. Malabsorption was the next most common complication (6 of 31 cases, 19.4%), which presented as chronic diarrhea in 4 patients and intractable iron deficiency anemia in 2 patients; the former group underwent a common channel lengthening, whereas conversion to enhance iron absorption was performed in the latter. Three patients who underwent laparoscopic adjustable gastric banded plication (LAGBP) [19] presented with vomiting and dysphagia and had evidence of gross fundal dilation on radiographic studies. The cause was suture breakage at the fundus with slippage of the band. The first patient underwent re-plication of the fundus, the second was converted to a LSG because of a thinned and ischemic fundus, and the third patient underwent reversal of plication with the band left in situ to maintain weight. Two patients who underwent LAGB and 1 who underwent LAGBP with Primary surgery
Revisional surgery
41
39.2
39 37
38.1
38.5
Restricve primary surgery
35.2
35
33.1
33 31
30.9
29 27
30.1
32.6
30.3
30 29.2
Primary RYGB
27
25 Inial BMI
1 yr
2 yr
Pre 6 months 1 yr BMI revisional BMI BMI
Fig. 2. Body mass index change in patients with weight loss failure. Abbreviations: RYGB ¼ Roux-en-Y gastric bypass; BMI ¼ body mass index.
616
Primary surgery
Symptoms (primary surgery)
Number of patients
Median age
F: M
RYGB
1.GJ Complications a. Stricture b. Dumping c. Marginal ulcer 2.Malabsorption
11
33
4:7 41.3
5 4 2 4
3. Anaemia 1.GERD 2.Stricture 1.Fundal dilation
2.Tubing breakage 1.Bile reflux 2. Marginal ulcer Band slippage Mesh erosion
LSG LAGBP
MGB LAGB VBG
Initial BMI
Pre-revisional BMI
Final BMI
Mean time to Revisional revision (mo) procedure
25.4
25.9
23
43.5
2:2 46.4
27.3
25.2
30
2 3 2 3
35 39
0:2 47.7 2:3 36.8
33 27.5
32.6 23.9
21
2:1 43.1
38.5
33.2
55 6 38 7
1 1 1 2 1
36 44 39 19 24
0:1 0:1 1:0 0:2 1:0
34.5 32 30 26.5 38.3
32.1 29.1 27.5 26 32.7
30 30 36 9 72
37.6 37 57.5 42.1 45.4
Symptom resolution (Y/N)
Complication
Management
a. Redo b. Resizing c. Redo Limb revision
Y Y(1); N(3) Y Y
Sleeve RYGB Seromyotomy Revision (1) Reversal (1) Sleeve (1) Revision RYGB RYGB Revision RYGB
Y Y Y Y Y Y Y Y Y Y Y
GJ leak Laparoscopy None None Jejuno-jejunostomy Laparotomy leak None None None None
None None None None None
Abbreviations: F ¼ female; M ¼ male; BMI ¼ body mass index; Y ¼ yes; N ¼ no; RYGB ¼Roux–en-Y gastric bypass; GJ ¼ gastrojejunostomy; LSG ¼ laparoscopic sleeve gastrectomy; GERD ¼ ; LAGBP ¼ laparoscopic adjustable gastric banded plication; MGB ¼ mini gastric bypass; LAGB ¼ laparoscopic adjustable gastric banding; VBG ¼ vertical banded gastroplasty.
A. Vij et al. / Surgery for Obesity and Related Diseases 11 (2015) 612–620
Table 2 Revisional bariatric surgery outcomes for complications related to the primary bariatric surgeries
Six-Year Experience of Revisional Bariatric Surgery / Surgery for Obesity and Related Diseases 11 (2015) 612–620
band-related complications (1 patient with slippage, 2 patients with tubing breakage) underwent band replacement. One patient who had previously undergone VBG with mesh erosion and chronic GI hemorrhage was converted to RYGB. Chronic GERD was found in 3 patients who had undergone LSG and were converted to RYGB. Laparoscopic seromyotomy was performed for 2 patients with long-segment stricture at the incisura angularis. Two patients who underwent MGB, 1 with bile reflux and the other with marginal ulcer, were also converted to RYGB. Overall, 28 of 31 patients (90.3%) had complete resolution of their preoperative symptoms after RBS. No recurrence was reported during the 14-month follow-up period. Three of 4 patients with dumping syndrome reported partial symptomatic improvement after surgery but continued to experience occasional postprandial hypoglycemia. There were 2 major complications in the patients studied. One patient had anastomotic failure after revisional surgery for GJ stricture that was repaired laparoscopically. Another patient developed a jejunal obstruction with leak because of the dense adhesion that resulted from limb revision for malabsorption. After exploratory laparotomy with adhesiolysis, resection of the previous anastomosis with a second jejunojejunostomy was performed by single-layer hand-sewn technique. Discussion Concomitant with the growing number of PBS, there is an increased incidence of patients requiring revisional surgeries. The overall rate of RBS reported in the literature varies from o5% to 450% [4–7]. This wide disparity can be explained by the different rates of RBS described for the various primary procedures. A low RBS rate of 2.76% was observed in the present study. This may be attributed to the fact that primary RYGB, traditionally associated with low revisional rates, was performed in almost 60% of the patients in the present study, whereas procedures with higher failure rates like LAGB and VBG were few in comparison. The study period did not include the first 50 surgeries performed at the authors’ institution, during which the surgeons were less familiar with the techniques and had experienced a larger number of technical complications. Patients who required reoperation for emergencies and with incisional or internal hernia were excluded from this study. Lastly, the median follow-up period for patients undergoing PBS during the study period was o3 years, and it is possible that more revisions will be required in the future. In patients who underwent RBS for WLF, the mean change in BMI 12 months after RBS was a loss of 6.32 kg/m2. More than 90% of the patients with complications had complete resolution of their preoperative symptoms after RBS. These results corroborate those of previous studies that have found RBS to be effective [13]. There was no mortality in this study. There were 3 major complications, resulting in an overall morbidity rate of
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5.8%. Although previous reports have associated RBS with high morbidity and mortality, recent studies, including the present study, report an improvement in outcomes [4,13]. Because of the authors’ considerable experience with laparoscopic PBS, revisional surgery was successfully performed with the same technique in most patients. Laparoscopic surgery offered specific benefits to the RBS patients, such as a magnified view of the tissues and improved accessibility to difficult areas like the hiatus, in addition to general advantages like earlier recovery and shorter hospital stay. Moreover, with its use, the risk of postoperative adhesions and wound-related complications, which are of particular concern in revisional surgery, was decreased. Although comparative data are lacking, the present results suggest that laparoscopic approaches have advantages over open approaches in RBS. WLF is a common indication for RBS [4–6,16–18] and accounted for 40% of cases. It was more commonly observed in patients with restrictive primary surgeries than in those with RYGB [5] (LAGB, 4%; LSG, 1.37%; RYGB, .83%; MGB and VBG, data not available). The workup before RBS for WLF included a dietary assessment to calculate to quantify the volume of food intake and preoperative endoscopy and Gastrografin study to estimate the pouch size and diameter of the GJ stoma. Most patients with restrictive surgeries had regained weight because of maladaptive eating behaviors without demonstrable anatomic abnormalities [7,20]. This was corrected by repeated counseling sessions by a trained dietician. Some patients also required psychological/psychiatric assessment and medical treatment to normalize the food habits. The majority of such patients were able to control their food intake and achieve an acceptable weight loss. Only a few (o10%) ultimately required RBS as a result of dietary noncompliance and WLF, and they underwent conversion to RYGB. The mean percentage of EWL loss was 57% after 1 year, which is similar to that in previous reports. The BMI for the WLF group decreased by a mean of 6.32 kg/m2 within 1 year after the second procedure. These data provide strong evidence regarding the need for and efficacy of RBS in this group of patients. Although RYGB has been described as the revisional procedure of choice in these situations [13], others have reported successful resleeve or replacement of band after LSG and LAGB failure, respectively [14,15,21]. The latter procedures are simpler to perform with less morbidity, but the published results are poorer than those after RYGB in terms of EWL [14]. Furthermore, RYGB helps to modify eating behavior through the effects of dumping, a phenomenon not observed after restrictive surgeries. However, this approach may entail the risk of recurrent failure after such procedures. Weight loss outcomes after RYGB have shown an inverse correlation with the volume of the gastric pouch and the GJ stoma diameter [22]. The gastric pouch was considered enlarged if it measured 46 cm long and/or
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45 cm wide. A GJ stoma measuring 42 cm in diameter was considered dilated. These measurements were made at preoperative endoscopy with an articulating measuring instrument introduced through the working channel. An enlarged pouch size and/or stoma diameter was found in all WLF patients after RYGB (.83%), which was managed by pouch/stoma resizing [16,23]. Pouch resizing was done by vertical firing of linear stapler from the lateral aspect on to a 36F bougie placed within the pouch and across the GJ anastomosis. A dilated GJ alone was tackled by transverse firing of a linear stapler partially across the anastomosis with the bougie in place. The pouch size and stoma diameter for this group was reconstructed to 25 mL and 2 cm, respectively. The mean BMI loss and %EWL loss was 3.2 kg/m2 and 31.8% at the 1-year follow-up examination compared with the prerevisional values, respectively, which are comparable to earlier studies [16,23]. Though pouch resizing has been reported to be a valuable option in the short term for weight loss failure, the long-term efficacy of this procedure needs to be determined. Recently, endoscopic techniques for the management of dilated gastric pouches or GJ stomas have also shown some benefit, but the overall results have been disappointing [23]. Others have described malabsorptive procedures for WLF after RYGB, such as conversion to distal RYGB [17] or BPD-DS [18], but they have a higher morbidity with long-term nutritional consequences. Problems related to the gastrojejunal anastomosis were the most common cause for RBS among patients with complications. Marginal ulcer (.6%–16%) and GJ stricture (4.7%–27%) are variably reported after RYGB and are related to patient factors and surgical technique [10,11]. A liner stapled GJ was performed, with hand-sewn closure of the enterotomy, creating a stoma of 1.5-cm diameter, and an overall stricture rate of 2.5% was encountered in the present series. There was no anatomic abnormality (i.e., gastrogastric fistula, excessively large pouch, etc.) in any patient studied, and hence, the exact etiology of ulceration/stricture remains uncertain. All strictures at the first instance were managed by repeated sessions of endoscopic dilation (usually 3–4 sessions at intervals of 2 wk each). Only extremely tight strictures that did not allow passage of an endoscope or complicated strictures (i.e., those associated with ulcers/bleeding/not responding to 4 sessions of dilation) underwent revisional surgery and accounted .5% of primary RYGB cases. Previously, a high stricture rate has been reported after revisional surgery for marginal ulcer after RYGB [10]. This was attributed to the use of circular staplers for reconstruction. In the present study, revision of the gastrojejunostomy with intracorporeal hand-sewn anastomosis using absorbable suture material was performed to avoid stricture. Although a bilateral truncal vagotomy was also performed in the 2 patients with marginal ulcers to decrease acid output, its benefit in preventing recurrence is controversial [10].
Dumping syndrome is common after RYGB (15%–50% of cases) [25]. Medically refractory symptoms have been managed by surgical or endoscopic reduction of the GJ anastomosis, reconversion to normal anatomy, and even partial pancreatectomy [25,26]. Dumping syndrome was diagnosed in patients based on the oral glucose tolerance test and Sigstad’s scoring system. Hypoglycemic symptoms were found 41 hour after the meal, suggestive of late dumping syndrome, and such symptoms were seen transiently in approximately 20% of our patients. Most were managed successfully by dietary modification and pharmacotherapy, and only 4 patients (.42%) with severe symptoms required revisional surgery. A dilated GJ anastomosis (43 cm) was noted on UGI endoscopy, and the stoma was resized laparoscopically with a linear stapler. All 4 patients with suspected late dumping experienced improvement after this procedure, but only 1 had complete symptom resolution in the follow-up period. The partial response may be explained by the fact that besides rapid intestinal transit, patients with late dumping have increased postprandial insulin and glucagon-like peptide-1 secretion. They also exhibit an enhanced sensitivity to these hormones as a result of changes in the entero-insular axis and the “incretin effect,” which may not completely respond to mechanical intervention alone [27]. One patient with persistent symptoms after revision (not included in the study) recently underwent conversion to LSG, and the preliminary tests, including oral glucose tolerance tests, indicated marked improvement in insulin resistance. Zurita et al. have similarly converted 2 cases of RYGB to LSG for intractable dumping syndrome with complete symptomatic resolution at the 1-year follow-up examination [26]. However, others have documented a significant increase in the dumping syndrome score after LSG, which is thought to be secondary to the rapid gastric emptying after this surgery [28]. The ideal treatment option for dumping syndrome remains debatable and further analysis is needed. A long length of bypassed small bowel has been associated with a high incidence of protein calorie malnutrition in patients undergoing RYGB who may require revisional surgery [29]. The authors encountered 4 patients with diarrhea and malnutrition after RYGB (.42%) with standard limb lengths in 2 patients (100 cm both limbs) and a long biliopancreatic limb (200 cm) in 2 patients. They all underwent common channel lengthening at the expense of the biliopancreatic limb, which was reduced to 40 cm. There was complete symptom resolution with increment in mean albumin levels by 1.2 mg/dL without evidence of excessive weight regain in the follow-up period. In addition, 2 patients (.2%) with primary RYGB had intractable anemia and underwent conversion to sleeve gastrectomy with a mean increase of 2 gm/dL in their hemoglobin levels 1 year after revisional surgery. An increased incidence of erosive esophagitis and GERD symptoms after LSG related to anatomic changes and the de
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novo development of hiatal hernia has been reported in a previous study [8]. In the present study, a relative stricture in the distal stomach was found in 2 patients, whereas evidence of a new hiatal hernia was found in the third patient. RYGB has been found to be effective for morbidly obese patients with severe GERD and, in comparison, the present patients also experienced immediate and sustained relief of symptoms after conversion [30]. Two patients who underwent LSG developed chronic long-segment strictures at the level of the incisura angularis, and these patients were managed with a laparoscopic seromyotomy [9]. Both patients reported symptom resolution during the follow-up period. The present study had a number of limitations of note. It was a retrospective study, with a relatively short mean follow-up period of 14 months. Because the median time to undergo RBS was 32 months, a longer follow-up period should be assessed in future work. The number of patients in each group was too small to make firm recommendations regarding the most appropriate procedure. Despite these limitations, this study outlines the different surgical problems encountered in RBS and provides insight into the options available for management of these problems. Conclusions Laparoscopic RBS is well tolerated, with satisfactory early outcomes for the management of WLF and the resolution of complications after PBS. A variety of surgical options are available, but the treatment needs to be tailored based on the primary surgery and presenting symptoms. Larger patient studies with longer-term follow-up periods are required to develop firm recommendations.24 Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. Acknowledgments The authors thank Ms. Ivy Huang for her sincere contribution to the collection and analysis of data for the manuscript. References [1] WHO. Global Health Observatory: Obesity: situations and trends. Available from: http://www.who.int/gho/ncd/risk_factors/obesity_text/en/. [2] Sjöström L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351:2683–93. [3] Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23:427–36. [4] Radtka JF 3rd, Puleo FJ, Wang L, Cooney RN. Revisional bariatric surgery: who, what, where, and when? Surg Obes Relat Dis 2010;6: 635–42.
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[5] Kellogg TA. Revisional bariatric surgery. Surg Clin North Am 2011;91:1353–71. [6] Gagner M, Gumbs AA. Gastric banding: conversion to sleeve, bypass, or DS. Surg Endosc 2007;21:1931–5. [7] Marsk R, Jonas E, Gartzios H, Stockeld D, Granström L, Freedman J. High revision rates after laparoscopic vertical banded gastroplasty. Surg Obes Relat Dis 2009;5:94–8. [8] Tai CM, Huang CK. Increase in gastroesophageal reflux disease symptoms and erosive esophagitis 1 year after laparoscopic sleeve gastrectomy among obese adults. Surg Endosc 2013;27: 1260–6. [9] Dapri G, Cadière GB, Himpens J. Laparoscopic seromyotomy for long stenosis after sleeve gastrectomy with or without duodenal switch. Obes Surg 2009;19:495–9. [10] Patel RA, Brolin RE, Gandhi A. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2009;5: 317–22. [11] Carrodeguas L, Szomstein S, Zundel N, Lo Menzo E, Rosenthal R. Gastrojejunal anastomotic strictures following laparoscopic Roux-enY gastric bypass surgery: analysis of 1291 patients. Surg Obes Relat Dis 2006;2:92–7. [12] Fernandez-Esparrach G, Lautz DB, Thompson CC. Peroral endoscopic Anastomotic reduction improves intractable dumping syndrome in Roux-en-Y gastric bypass patients. Surg Obes Relat Dis 2010;6:36–40. [13] Coakley BA, Deveney CW, Spight DH, et al. Revisional bariatric surgery for failed restrictive procedures. Surg Obes Relat Dis 2008;4: 581–6. [14] 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. [15] Ardestani A, Lautz DB, Tavakkolizadeh A. Band revision versus Roux-en-Y gastric bypass conversion as salvage operation after laparoscopic adjustable gastric banding. Surg Obes Relat Dis 2011;7: 33–7. [16] Iannelli A, Schneck AS, Hébuterne X, Gugenheim J. Gastric pouch resizing for Roux-en-Y gastric bypass failure in patients with a dilated pouch. Surg Obes Relat Dis 2013;9:260–7. [17] Rawlins ML, Teel D 2nd, Hedgcorth K, Maguire JP. Revision of Roux-en-Y gastric bypass to distal bypass for failed weight loss. Surg Obes Relat Dis 2011;7:45–9. [18] Parikh M, Pomp A, Gagner M. Laparoscopic conversion of failed gastric bypass to duodenal switch: technical considerations and preliminary outcomes. Surg Obes Relat Dis 2007;3: 611–8. [19] Huang CK, Lo CH, Shabbir A, Tai CM. Novel bariatric technology: laparoscopic adjustable gastric banded plication: technique and preliminary results. Surg Obes Relat Dis 2012;8:41–5. [20] Iannelli A, Schneck AS, Noel P, Ben Amor I, Krawczykowski D, Gugenheim J. Re-sleeve gastrectomy for failed laparoscopic sleeve gastrectomy: a feasibility study. Obes Surg 2011;21:832–5. [21] Iannelli A, Amato D, Addeo P, et al. Laparoscopic conversion of vertical banded gastroplasty into Roux-en-Y gastric bypass. Obes Surg 2008;18:43–6. [22] Heneghan HM, Yimcharoen P, Brethauer SA, et al. Influence of pouch and stoma size on weight loss after gastric bypass. Surg Obes Relat Dis 2012;8:408–15. [23] Müller MK, Wildi S, Scholz T, et al. Laparoscopic pouch resizing and redo of gastro-jejunal anastomosis for pouch dilatation following gastric bypass. Obes Surg 2005;15:1089–95. [24] Dakin GF, Eid G, Mikami D, et al. Endoluminal revision of gastric bypass for weight regain—a systematic review. Surg Obes Relat Dis 2013;9:335–42. [25] Fernandez-Esparrach G, Lautz DB, Thompson CC. Peroral endoscopic anastomotic reduction improves intractable dumping syndrome
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in Roux-en-Y gastric bypass patients. Surg Obes Relat Dis 2010;6: 36–40. [26] Zurita LC, Tabari, Hong D. Laparoscopic conversion of laparoscopic Roux-en-Y gastric bypass to laparoscopic sleeve gastrectomy for intractable dumping syndrome and excessive weight loss. Surg Obes Relat Dis 2013;9:e34–7. [27] Laferrere B, Teixeira J, McGinty J, et al. Effect of weight loss by gastric bypass surgery versus hypocaloric diet on glucose and incretin levels in patients with type 2 diabetes. J Clin Endocrinol Metab 2008;93:2479–85.
[28] Papamargaritis D, Koukoulis G, Sioka E, et al. Dumping symptoms and incidence of hypoglycaemia after provocation test at 6 and 12 months after laparoscopic sleeve gastrectomy. Obes Surg 2012;22:1600–6. [29] Sugerman JH, Kellum JM, DeMaria EJ. Conversion of proximal to distal gastric bypass for failed gastric for super obesity. J Gastrointest Surg 1997;1:517–25. [30] Braghetto I, Korn O, Csendes A, Gutiérrez L, Valladares H, Chacon M. Laparoscopic treatment of obese patients with gastroesophageal reflux disease and Barrett's esophagus: a prospective study. Obes Surg 2012;22:764–72.
Original article
Worthy or not? Six-year experience of revisional bariatric surgery from an Asian center of excellence Anirudh Vij, M.D.a, Kirubakaran Malapan, M.D.a, Ching-Chung Tsai, M.D.b, Kuo-Chung Hung, M.D.c, Po-Chi Chang, M.D.a,d, Chih-Kun Huang, M.D.a,d,* a
Bariatric and Metabolic International Surgery Centre, E-Da Hospital, Taiwan, Republic of China b Department of Pediatrics, E-Da Hospital, Taiwan, Republic of China c Department of Anesthesia, E-Da Hospital, Taiwan, Republic of China d Department of General Surgery, E-Da Hospital, Taiwan, Republic of China Received September 13, 2013; accepted April 28, 2014
Abstract
Background: Revisional bariatric surgery (RBS) is increasing. The various primary operations with their distinctive complications make this group of patients quite heterogeneous, and treatment has to be individualized. There are concerns regarding the safety profile and efficacy of these procedures. The objective of the present study was to analyze the indications, safety, and efficacy of RBS at a high-volume Asian center and provide insight into the different treatment options. Methods: Of a total of 1578 bariatric surgeries from July 2006 to June 2012, 52 patients underwent revisional bariatric procedures. The primary operations included 6 different procedures. The indications for surgery were grouped into weight loss failure (n ¼ 21) or complications related to the primary operation (n ¼ 31). The revisional operations performed were conversion to another procedure (n ¼ 22), revision of existing anatomy (n ¼ 29), or reversal to normal anatomy (n ¼ 1). Results: 96% of revisional surgeries were performed laparoscopically. The median operating time was 72 minutes (25–240 min), and the median duration of hospital stay was 4 days (3–25 d). The mean body mass index for weight loss failure decreased significantly from 36.3 to 29.6 kg/m2 after 1 year of revisional surgery (P o .01). However, revision of RYGB was only associated with a body mass index loss of 3.2 kg/m2 and percentage of excess weight loss of 31.8%. More than 90% of the patients with complications had complete resolution of their preoperative symptoms. There were 3 major complications with an overall morbidity rate of 5.8%. There was no mortality. Conclusions: RBS is well-tolerated, with satisfactory early outcomes, in high-volume centers. However, larger studies with longer follow-up periods are needed to determine the long-term efficacy of these procedures. (Surg Obes Relat Dis 2015;11:612–620.) r 2015 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
Keywords:
Revisional surgery; Bariatric; Morbid obesity
There is a global pandemic of obesity [1]. Bariatric surgery has proved to be the most effective treatment for * Correspondence: Chih Kun Huang, M.D., No.1, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City, Taiwan 82445 Republic of China. E-mail: [email protected]
clinically severe obesity and its associated co-morbidities [2]. The number of bariatric surgeries has increased almost 10-fold over the past decade in the Asia Pacific region because of the increased demand and acceptance of these procedures [3]. Most primary bariatric surgeries (PBS) are successful. However, a revisional surgery rate of 5%–50%, depending
http://dx.doi.org/10.1016/j.soard.2014.04.033 1550-7289/r 2015 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
Six-Year Experience of Revisional Bariatric Surgery / Surgery for Obesity and Related Diseases 11 (2015) 612–620
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on the primary procedure performed, has been described in the literature [4]. Weight loss failure (WLF) is a common indication for revisional surgery, which is often observed for all procedures [5]. Patients may also require revision for complications unique to the initial surgery. For instance, band and port site–related problems are often observed after laparoscopic adjustable gastric banding (LAGB), whereas reflux, staple line dehiscence, and stomal stenosis are common after vertical banded gastroplasty (VBG) [6,7]. Laparoscopic sleeve gastrectomy (LSG) may lead to gastrointestinal reflux disease (GERD) and stricture [8,9], whereas complications of gastrojejunal anastomosis are commonly observed after laparoscopic Roux-en-Y gastric bypass (LRYGB) [10–12]. With the increased number of bariatric surgeries, surgeons in Asia are increasingly encountering such problems. Because this is a heterogeneous population, it is appropriate to mention that their treatment has to be individualized. WLF or complications related to restrictive procedures have had good outcomes after conversion to RYGB [13] or biliopancreatic diversion with duodenal switch (BPD-DS) [14]. Other studies have described band replacement in cases of band/port site complications after LAGB or resleeving for weight regain after LSG [15]. Anastomotic complications after RYGB may require revision of gastrojejunostomy, whereas WLF may be addressed by either augmenting restriction by pouch/stoma reduction or increasing malabsorption with limb lengthening [16–18]. The dense adhesions, scarring, and ischemic tissues that result from multiple stapler lines make revisional bariatric surgery (RBS) technically challenging and increase patients’ predisposition to complications; the outcomes of RBS are generally inferior to those of PBS [4–7]. The objective of the present study was to analyze the indications, safety profile, and efficacy of RBS performed over the past 6 years at an Asian center of excellence to provide an insight into the different treatment options.
(Covidien–Endo GIA; staple height 4.8 mm) and, more recently, black cartridges (staple height 5 mm) to minimize the incidence of leak in the thickened tissues. Drainage tubes were usually used, and a Gastrografin study was not routinely performed after surgery. Particular mention is made of the surgical technique for 2 patients with intractable anemia after primary RYGB who were converted to sleeve gastrectomy. This was a complex procedure performed by first disconnecting the roux limb from the gastric pouch by linear stapler. The previous jejunojejunal anastomosis was taken down, followed by a side-to-side anastomosis between the biliopancreatic and alimentary limbs, restoring intestinal continuity. This was followed by gastrolysis of the remnant stomach and a sleeve gastrectomy over a 36F bougie. Lastly, a hand-sewn gastrogastric anastomosis was completed between the gastric pouch and the newly created sleeve of stomach. The patient data included demographic characteristics and investigations, operative parameters, postoperative events, and overall outcomes including weight loss and resolution of complications. The %EWL was calculated with the standard formula, using an ideal BMI equal to 22 kg/m2 as per Asian standards. The patients undergoing RBS were grouped by surgical indication into 2 groups: (1) weight loss failure (WLF), defined as excess weight loss (EWL) of o50% at 2 years or weight gain 415% from baseline after PBS; and (2) complications, defined as those causing chronic intractable (but not life-threatening) symptoms not amenable to medical management and impairing the patient’s quality of life. Only those patients with a follow-up period of 46 months after RBS were included for analysis. Patients who underwent emergency reoperation for life-threatening complications, such as leaks, abscesses, perforation, or hemorrhage, and patients who underwent reoperation for internal/incisional hernias after PBS were excluded from the study.
Methods
Statistical methods
The bariatric surgery database at the authors’ institution was retrospectively reviewed. A period of 6 years spanning July 2006 to June 2012 was chosen for the analysis. The indications for PBS were based on the Asian Pacific Bariatric Surgery Society Guidelines: BMI 432 kg/m2 with associated co-morbidity and BMI 437 kg/m2 with or without co-morbidities. The preoperative workup included assessment of psychiatric condition, diet, percentage of excess weight loss (%EWL), nutritional deficiencies and changes in anatomy by upper gastrointestinal (UGI) endoscopy, diatrizoic acid (Gastrografin) study, and computed tomography (CT) of the abdomen, as required. Adhesions encountered during surgery were tackled by sharp dissection with scissors and electrocautery hook. Stapling was usually done using green loads
Patient data were entered into the BMI Surgery Centre Clinical database, which is a customized computer database (built using Access [Microsoft Inc., Redmond, WA]). Descriptive results for continuous variables are presented as mean ⫾ standard deviation. The categorical data are presented as counts and percentages. Results A total of 1578 PBS, including restrictive and combined procedures, were performed at the authors’ center during the 6-year study period. Fifty-two RBS patients were identified, 43 of whom had undergone PBS at the authors’ center and 9 of whom were referrals from outside hospitals. The primary surgeries performed were RYGB (n = 25), SG
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(n = 10), VBG (n = 6), AGB (n = 4), adjustable gastric banded plication (n = 4), and mini gastric bypass (MGB; n = 3). There were 4 open surgeries (2 VBG, 1 RYGB, and 1 MGB). The remaining surgeries (92.3%) were performed laparoscopically. All the revisional bariatric surgeries were performed by a single surgeon with an overall experience of more than 2000 primary bariatric operations. The revisional surgeries were first attempted 2 years after starting the bariatric program, after gaining experience of approximately 500 primary bariatric operations. The center was the first one in Asia to get ICE accreditation, in 2008, after which a fellowship program was started. A number of primary operations were subsequently performed by the trainee surgeons enrolled in the fellowship under supervision of the corresponding author. The indications for RBS were documented WLF in 21 patients (40.4%) and PBS-related complications in 31 patients (59.6%; Fig. 1). The mean age of patients was 36 years (range, 16–61 yr). There were 38 women (71.7%) and 15 men (28.3%).The patients underwent RBS after a median time interval of 24 months (range, 3–72 mo). The median operating time and postoperative length of hospital stay for RBS was 72 minutes (range, 25–240 min) and 4 days (range, 3–25 d), respectively.
Effect of RBS on WLF A total of 21 patients required RBS for WLF (Table 1). All patients with prior restrictive procedures were converted to RYGB, except 1 LSG patient who underwent additional plication of the gastric tube. Revision of the gastric pouch and/or gastrojejunostomy (GJ) stoma was performed in all 8 patients with primary RYGB. The mean BMI at the time of initial surgery, at revisional surgery, and at 1-year postrevision was 38.8, 36.3, and 29.6 kg/m2, respectively (P o .01 for pre- and postrevisional BMI). The median time to revision was 36 months (range, 24–72 mo), and the median follow-up period after RBS was 12 months (range, 6–24 mo). A total of 13 patients (61.9%) were available for the 1-year follow-up examination. The incidence of preoperative co-morbidities before the index operation in patients with WLF was diabetes mellitus, hypertension, and hyperlipidemia in 61.9%, 33.3%, and 47.6%, respectively. The rate of the respective comorbidities before revisional surgery was 47.6% , 23.8%, and 42.8%, which decreased to 14%, 9.5%, and 4.8% 1 year after revisional surgery. A difference in the weight loss pattern was observed between patients undergoing restrictive PBS and those undergoing primary RYGB (Fig. 2). The mean initial
RYGB (n=8)
Pouch/Stoma revision RYGB (n=4)
LSG (n=5) Plicaon (n=1)
Primary Bariatric surgery (n=52)
Weight loss failure (n=21) VBG (n=5)
RYGB
LAGB (n=2)
RYGB
MGB (n=1)
RYGB
RYGB (n=1) GJ complicaons (n=12) GJ revision (n=11)
Proximalisaon (n=4) Malnutrion (n=6) Sleeve (n=2)
Complicaons (n=31)
Band/tubing failure (n=3)
Band Replacement (n=3) Replicaon (n=1)
Fundal herniaon (n=3)
Sleeve (n=1)
Reversal (n=1)
Miscellaneous (n=7)
RYGB
Fig. 1. Revisional surgical procedures for patients with different primary bariatric operations. Abbreviations: RYGB ¼ Roux-en-Y gastric bypass; LSG ¼ laparoscopic sleeve gastrectomy; VBG ¼ vertical banded gastroplasty; LABG ¼ laparoscopic adjustable gastric banding; MGB ¼ mini-gastric bypass; GJ ¼ gastrojejunostomy.
Abbreviations: F ¼ female; M ¼ male; BMI ¼ body mass index; RYGB ¼ Roux–en-Y gastric bypass; LSG ¼ laparoscopic sleeve gastrectomy; VBG ¼ vertical banded gastroplasty; P/C ¼ ; lap ¼ ; LAGB ¼ laparoscopic adjustable gastric banding; MGB ¼ mini gastric bypass.
None None RYGB RYGB 24 54 16.7 3.1 51.5 39.6 LAGB MGB
2 1
34.5 55
0:2 1:0
49.5 50
33.2 36.5
Leak (1) 72 (60–72) 9.1 30 40.8 42 VBG
5
36
5:0
30.1 LSG
5
31
5:0
34.2
26.5
4.9
36 (28–46)
None
None
Pouch revision (3) Stoma revision (3) Combined (2) RYGB (4) Plication (1) RYGB 33.1 RYGB
8
41.5
7:1
39.2
30
3.2
34 (12–48)
Complication Mean final BMI (1 yr) Pre-revisional BMI (Mean) Initial BMI (Mean) Gender (F:M) Median age Number of patients Primary surgery
Table 1 Revisional bariatric surgery outcomes for weight loss failure after different primary procedures
Mean BMI loss (1 yr)
Median time to revision (mo)
Revisional surgery
Management
P/C drainage þ lap repair
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615
prerevisional and 1-year postrevisional BMI in the 2 groups was 38.5 and 39.2 (P ¼ .81), 38.1 and 33.1 (P ¼ .2), and 29.2 and 30 (P ¼ .41), respectively. There was 1 major complication in a case of VBG conversion to RYGB. The patient presented with an intraabdominal abscess on postoperative day 8. After an initial unsuccessful attempt at percutaneous drainage, diagnostic laparoscopy was performed, which revealed a small perforation in the excluded stomach that was repaired laparoscopically. A jejunostomy feeding tube was placed for nutrition, and the patient made an uneventful recovery. Effect of RBS on complications PBS-related complications accounted for 31 RBS cases performed in the present study (Table 2). Complications related to the GJ, such as stricture (n ¼ 5), marginal ulcer (n ¼ 2), and dumping syndrome (n ¼ 4), were the most common (11 of 31 cases, 35%) cause for revision in this group. Both stricture and marginal ulcers were treated by revision of the GJ anastomosis with a single-layer hand-sewn technique. Bilateral truncal vagotomy was performed in both cases of marginal ulcer to decrease acid secretion. All patients with dumping syndrome underwent resizing of the dilated GJ (43 cm) to 1.5 cm in diameter. Malabsorption was the next most common complication (6 of 31 cases, 19.4%), which presented as chronic diarrhea in 4 patients and intractable iron deficiency anemia in 2 patients; the former group underwent a common channel lengthening, whereas conversion to enhance iron absorption was performed in the latter. Three patients who underwent laparoscopic adjustable gastric banded plication (LAGBP) [19] presented with vomiting and dysphagia and had evidence of gross fundal dilation on radiographic studies. The cause was suture breakage at the fundus with slippage of the band. The first patient underwent re-plication of the fundus, the second was converted to a LSG because of a thinned and ischemic fundus, and the third patient underwent reversal of plication with the band left in situ to maintain weight. Two patients who underwent LAGB and 1 who underwent LAGBP with Primary surgery
Revisional surgery
41
39.2
39 37
38.1
38.5
Restricve primary surgery
35.2
35
33.1
33 31
30.9
29 27
30.1
32.6
30.3
30 29.2
Primary RYGB
27
25 Inial BMI
1 yr
2 yr
Pre 6 months 1 yr BMI revisional BMI BMI
Fig. 2. Body mass index change in patients with weight loss failure. Abbreviations: RYGB ¼ Roux-en-Y gastric bypass; BMI ¼ body mass index.
616
Primary surgery
Symptoms (primary surgery)
Number of patients
Median age
F: M
RYGB
1.GJ Complications a. Stricture b. Dumping c. Marginal ulcer 2.Malabsorption
11
33
4:7 41.3
5 4 2 4
3. Anaemia 1.GERD 2.Stricture 1.Fundal dilation
2.Tubing breakage 1.Bile reflux 2. Marginal ulcer Band slippage Mesh erosion
LSG LAGBP
MGB LAGB VBG
Initial BMI
Pre-revisional BMI
Final BMI
Mean time to Revisional revision (mo) procedure
25.4
25.9
23
43.5
2:2 46.4
27.3
25.2
30
2 3 2 3
35 39
0:2 47.7 2:3 36.8
33 27.5
32.6 23.9
21
2:1 43.1
38.5
33.2
55 6 38 7
1 1 1 2 1
36 44 39 19 24
0:1 0:1 1:0 0:2 1:0
34.5 32 30 26.5 38.3
32.1 29.1 27.5 26 32.7
30 30 36 9 72
37.6 37 57.5 42.1 45.4
Symptom resolution (Y/N)
Complication
Management
a. Redo b. Resizing c. Redo Limb revision
Y Y(1); N(3) Y Y
Sleeve RYGB Seromyotomy Revision (1) Reversal (1) Sleeve (1) Revision RYGB RYGB Revision RYGB
Y Y Y Y Y Y Y Y Y Y Y
GJ leak Laparoscopy None None Jejuno-jejunostomy Laparotomy leak None None None None
None None None None None
Abbreviations: F ¼ female; M ¼ male; BMI ¼ body mass index; Y ¼ yes; N ¼ no; RYGB ¼Roux–en-Y gastric bypass; GJ ¼ gastrojejunostomy; LSG ¼ laparoscopic sleeve gastrectomy; GERD ¼ ; LAGBP ¼ laparoscopic adjustable gastric banded plication; MGB ¼ mini gastric bypass; LAGB ¼ laparoscopic adjustable gastric banding; VBG ¼ vertical banded gastroplasty.
A. Vij et al. / Surgery for Obesity and Related Diseases 11 (2015) 612–620
Table 2 Revisional bariatric surgery outcomes for complications related to the primary bariatric surgeries
Six-Year Experience of Revisional Bariatric Surgery / Surgery for Obesity and Related Diseases 11 (2015) 612–620
band-related complications (1 patient with slippage, 2 patients with tubing breakage) underwent band replacement. One patient who had previously undergone VBG with mesh erosion and chronic GI hemorrhage was converted to RYGB. Chronic GERD was found in 3 patients who had undergone LSG and were converted to RYGB. Laparoscopic seromyotomy was performed for 2 patients with long-segment stricture at the incisura angularis. Two patients who underwent MGB, 1 with bile reflux and the other with marginal ulcer, were also converted to RYGB. Overall, 28 of 31 patients (90.3%) had complete resolution of their preoperative symptoms after RBS. No recurrence was reported during the 14-month follow-up period. Three of 4 patients with dumping syndrome reported partial symptomatic improvement after surgery but continued to experience occasional postprandial hypoglycemia. There were 2 major complications in the patients studied. One patient had anastomotic failure after revisional surgery for GJ stricture that was repaired laparoscopically. Another patient developed a jejunal obstruction with leak because of the dense adhesion that resulted from limb revision for malabsorption. After exploratory laparotomy with adhesiolysis, resection of the previous anastomosis with a second jejunojejunostomy was performed by single-layer hand-sewn technique. Discussion Concomitant with the growing number of PBS, there is an increased incidence of patients requiring revisional surgeries. The overall rate of RBS reported in the literature varies from o5% to 450% [4–7]. This wide disparity can be explained by the different rates of RBS described for the various primary procedures. A low RBS rate of 2.76% was observed in the present study. This may be attributed to the fact that primary RYGB, traditionally associated with low revisional rates, was performed in almost 60% of the patients in the present study, whereas procedures with higher failure rates like LAGB and VBG were few in comparison. The study period did not include the first 50 surgeries performed at the authors’ institution, during which the surgeons were less familiar with the techniques and had experienced a larger number of technical complications. Patients who required reoperation for emergencies and with incisional or internal hernia were excluded from this study. Lastly, the median follow-up period for patients undergoing PBS during the study period was o3 years, and it is possible that more revisions will be required in the future. In patients who underwent RBS for WLF, the mean change in BMI 12 months after RBS was a loss of 6.32 kg/m2. More than 90% of the patients with complications had complete resolution of their preoperative symptoms after RBS. These results corroborate those of previous studies that have found RBS to be effective [13]. There was no mortality in this study. There were 3 major complications, resulting in an overall morbidity rate of
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5.8%. Although previous reports have associated RBS with high morbidity and mortality, recent studies, including the present study, report an improvement in outcomes [4,13]. Because of the authors’ considerable experience with laparoscopic PBS, revisional surgery was successfully performed with the same technique in most patients. Laparoscopic surgery offered specific benefits to the RBS patients, such as a magnified view of the tissues and improved accessibility to difficult areas like the hiatus, in addition to general advantages like earlier recovery and shorter hospital stay. Moreover, with its use, the risk of postoperative adhesions and wound-related complications, which are of particular concern in revisional surgery, was decreased. Although comparative data are lacking, the present results suggest that laparoscopic approaches have advantages over open approaches in RBS. WLF is a common indication for RBS [4–6,16–18] and accounted for 40% of cases. It was more commonly observed in patients with restrictive primary surgeries than in those with RYGB [5] (LAGB, 4%; LSG, 1.37%; RYGB, .83%; MGB and VBG, data not available). The workup before RBS for WLF included a dietary assessment to calculate to quantify the volume of food intake and preoperative endoscopy and Gastrografin study to estimate the pouch size and diameter of the GJ stoma. Most patients with restrictive surgeries had regained weight because of maladaptive eating behaviors without demonstrable anatomic abnormalities [7,20]. This was corrected by repeated counseling sessions by a trained dietician. Some patients also required psychological/psychiatric assessment and medical treatment to normalize the food habits. The majority of such patients were able to control their food intake and achieve an acceptable weight loss. Only a few (o10%) ultimately required RBS as a result of dietary noncompliance and WLF, and they underwent conversion to RYGB. The mean percentage of EWL loss was 57% after 1 year, which is similar to that in previous reports. The BMI for the WLF group decreased by a mean of 6.32 kg/m2 within 1 year after the second procedure. These data provide strong evidence regarding the need for and efficacy of RBS in this group of patients. Although RYGB has been described as the revisional procedure of choice in these situations [13], others have reported successful resleeve or replacement of band after LSG and LAGB failure, respectively [14,15,21]. The latter procedures are simpler to perform with less morbidity, but the published results are poorer than those after RYGB in terms of EWL [14]. Furthermore, RYGB helps to modify eating behavior through the effects of dumping, a phenomenon not observed after restrictive surgeries. However, this approach may entail the risk of recurrent failure after such procedures. Weight loss outcomes after RYGB have shown an inverse correlation with the volume of the gastric pouch and the GJ stoma diameter [22]. The gastric pouch was considered enlarged if it measured 46 cm long and/or
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45 cm wide. A GJ stoma measuring 42 cm in diameter was considered dilated. These measurements were made at preoperative endoscopy with an articulating measuring instrument introduced through the working channel. An enlarged pouch size and/or stoma diameter was found in all WLF patients after RYGB (.83%), which was managed by pouch/stoma resizing [16,23]. Pouch resizing was done by vertical firing of linear stapler from the lateral aspect on to a 36F bougie placed within the pouch and across the GJ anastomosis. A dilated GJ alone was tackled by transverse firing of a linear stapler partially across the anastomosis with the bougie in place. The pouch size and stoma diameter for this group was reconstructed to 25 mL and 2 cm, respectively. The mean BMI loss and %EWL loss was 3.2 kg/m2 and 31.8% at the 1-year follow-up examination compared with the prerevisional values, respectively, which are comparable to earlier studies [16,23]. Though pouch resizing has been reported to be a valuable option in the short term for weight loss failure, the long-term efficacy of this procedure needs to be determined. Recently, endoscopic techniques for the management of dilated gastric pouches or GJ stomas have also shown some benefit, but the overall results have been disappointing [23]. Others have described malabsorptive procedures for WLF after RYGB, such as conversion to distal RYGB [17] or BPD-DS [18], but they have a higher morbidity with long-term nutritional consequences. Problems related to the gastrojejunal anastomosis were the most common cause for RBS among patients with complications. Marginal ulcer (.6%–16%) and GJ stricture (4.7%–27%) are variably reported after RYGB and are related to patient factors and surgical technique [10,11]. A liner stapled GJ was performed, with hand-sewn closure of the enterotomy, creating a stoma of 1.5-cm diameter, and an overall stricture rate of 2.5% was encountered in the present series. There was no anatomic abnormality (i.e., gastrogastric fistula, excessively large pouch, etc.) in any patient studied, and hence, the exact etiology of ulceration/stricture remains uncertain. All strictures at the first instance were managed by repeated sessions of endoscopic dilation (usually 3–4 sessions at intervals of 2 wk each). Only extremely tight strictures that did not allow passage of an endoscope or complicated strictures (i.e., those associated with ulcers/bleeding/not responding to 4 sessions of dilation) underwent revisional surgery and accounted .5% of primary RYGB cases. Previously, a high stricture rate has been reported after revisional surgery for marginal ulcer after RYGB [10]. This was attributed to the use of circular staplers for reconstruction. In the present study, revision of the gastrojejunostomy with intracorporeal hand-sewn anastomosis using absorbable suture material was performed to avoid stricture. Although a bilateral truncal vagotomy was also performed in the 2 patients with marginal ulcers to decrease acid output, its benefit in preventing recurrence is controversial [10].
Dumping syndrome is common after RYGB (15%–50% of cases) [25]. Medically refractory symptoms have been managed by surgical or endoscopic reduction of the GJ anastomosis, reconversion to normal anatomy, and even partial pancreatectomy [25,26]. Dumping syndrome was diagnosed in patients based on the oral glucose tolerance test and Sigstad’s scoring system. Hypoglycemic symptoms were found 41 hour after the meal, suggestive of late dumping syndrome, and such symptoms were seen transiently in approximately 20% of our patients. Most were managed successfully by dietary modification and pharmacotherapy, and only 4 patients (.42%) with severe symptoms required revisional surgery. A dilated GJ anastomosis (43 cm) was noted on UGI endoscopy, and the stoma was resized laparoscopically with a linear stapler. All 4 patients with suspected late dumping experienced improvement after this procedure, but only 1 had complete symptom resolution in the follow-up period. The partial response may be explained by the fact that besides rapid intestinal transit, patients with late dumping have increased postprandial insulin and glucagon-like peptide-1 secretion. They also exhibit an enhanced sensitivity to these hormones as a result of changes in the entero-insular axis and the “incretin effect,” which may not completely respond to mechanical intervention alone [27]. One patient with persistent symptoms after revision (not included in the study) recently underwent conversion to LSG, and the preliminary tests, including oral glucose tolerance tests, indicated marked improvement in insulin resistance. Zurita et al. have similarly converted 2 cases of RYGB to LSG for intractable dumping syndrome with complete symptomatic resolution at the 1-year follow-up examination [26]. However, others have documented a significant increase in the dumping syndrome score after LSG, which is thought to be secondary to the rapid gastric emptying after this surgery [28]. The ideal treatment option for dumping syndrome remains debatable and further analysis is needed. A long length of bypassed small bowel has been associated with a high incidence of protein calorie malnutrition in patients undergoing RYGB who may require revisional surgery [29]. The authors encountered 4 patients with diarrhea and malnutrition after RYGB (.42%) with standard limb lengths in 2 patients (100 cm both limbs) and a long biliopancreatic limb (200 cm) in 2 patients. They all underwent common channel lengthening at the expense of the biliopancreatic limb, which was reduced to 40 cm. There was complete symptom resolution with increment in mean albumin levels by 1.2 mg/dL without evidence of excessive weight regain in the follow-up period. In addition, 2 patients (.2%) with primary RYGB had intractable anemia and underwent conversion to sleeve gastrectomy with a mean increase of 2 gm/dL in their hemoglobin levels 1 year after revisional surgery. An increased incidence of erosive esophagitis and GERD symptoms after LSG related to anatomic changes and the de
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novo development of hiatal hernia has been reported in a previous study [8]. In the present study, a relative stricture in the distal stomach was found in 2 patients, whereas evidence of a new hiatal hernia was found in the third patient. RYGB has been found to be effective for morbidly obese patients with severe GERD and, in comparison, the present patients also experienced immediate and sustained relief of symptoms after conversion [30]. Two patients who underwent LSG developed chronic long-segment strictures at the level of the incisura angularis, and these patients were managed with a laparoscopic seromyotomy [9]. Both patients reported symptom resolution during the follow-up period. The present study had a number of limitations of note. It was a retrospective study, with a relatively short mean follow-up period of 14 months. Because the median time to undergo RBS was 32 months, a longer follow-up period should be assessed in future work. The number of patients in each group was too small to make firm recommendations regarding the most appropriate procedure. Despite these limitations, this study outlines the different surgical problems encountered in RBS and provides insight into the options available for management of these problems. Conclusions Laparoscopic RBS is well tolerated, with satisfactory early outcomes for the management of WLF and the resolution of complications after PBS. A variety of surgical options are available, but the treatment needs to be tailored based on the primary surgery and presenting symptoms. Larger patient studies with longer-term follow-up periods are required to develop firm recommendations.24 Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. Acknowledgments The authors thank Ms. Ivy Huang for her sincere contribution to the collection and analysis of data for the manuscript. References [1] WHO. Global Health Observatory: Obesity: situations and trends. Available from: http://www.who.int/gho/ncd/risk_factors/obesity_text/en/. [2] Sjöström L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351:2683–93. [3] Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23:427–36. [4] Radtka JF 3rd, Puleo FJ, Wang L, Cooney RN. Revisional bariatric surgery: who, what, where, and when? Surg Obes Relat Dis 2010;6: 635–42.
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