Single Stage Conversion of Laparoscopic Adjustable Gastric Band(LAGB) to Modified Laparoscopic Duodenal Switch (DS)

Andrew R Brownlee, MD, Yuriy Dudiy, MD, Kelsey Gibson, Erica Bromberg, BA, Mitchell Roslin, MD, FACS. Lenox Hill Hospital.

 Introduction: Re-operative bariatric surgery carries a higher risk of complication and it is generally accepted that long-term outcomes are worse. Common indications for revision following LAGB are adverse symptoms and failure to lose weight. It remains controversial whether conversion to stapled bariatric procedure should be staged, with band removal preceding reconstruction, and what is the ideal conversion procedure.

Methods: Between 2008 and present, 30 single-stage LAGB removal to laparoscopic DS procedures were performed by a single surgeon. The technique involved band and port removal with full dissection and separation of the overlying plication. The gastric sleeve was created over 42F bougie and over sewn with 2-0 PDS without use of buttress material. The duodenal enteral anastomosis was hand sewn with creation of a 175cm alimentary limb, and 125cm common channel, making total intestinal length exposed to food 3m. Synchronous cholecystectomy was performed.

Results: The mean pre-operative BMI was 45.5 (range 35.5-61), the mean age was 47.4 (range 24-70), with 21 females and 9 males. All procedures were completed laparoscopically. The mean OR time was 220 minutes (range 170-349)
There were no mortalities. Two complications required surgery. A leak of the duodenal-enteral anastomosis on POD 2 requiring open exploration and repair. This patient was discharged without further issue on POD 12. Another patient was noted to have cystic duct leak from a synchronous cholecystectomy and was treated with laparoscopy and re-clipping of the cystic duct and was discharged on POD 6. There were no leaks of the sleeve gastrectomy.

To date, follow-up is available for 28 of 30 patients. Greater than 6-month follow-up is available for 24 patients. Of these, the mean pre-operative BMI was 45(35.6-57.7). The mean post-operative BMI was 28.2(19.2-39). In total, there was a mean loss of excess BMI of 84% with a mean follow-up 25.2 months (6-69). Twelve patients have reached 2-year follow-up. Their mean pre-op BMI was 45.0 with a current BMI of 29.1(80% loss of excess BMI). Six patients have reached 3-year follow-up with a mean pre-op BMI of 48 and a current BMI of 28.6(85% loss of excess BMI). This data is shown in Table 1. One patient had severe complaints of GERD and was subsequently converted to RYGB. No patient required revision or parenteral nutrition for nutrient deficiency.

Conclusions: Single stage conversion to DS provides impressive lasting weight loss in patients that have failed a previous bariatric procedure with complication rates comparable to reports of other stapling procedures. Lengthening the total intestinal length of the alimentary and common channels to 3 M with 1.25 common channel mitigates the risk of protein deficiency and excess BMI weight loss.

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