B. Fernando Santos, MD, Jessica B Wallaert, MD, Thadeus L Trus, MD. Dartmouth-Hitchcock Medical Center, Department of Surgery, Lebanon, NH..
INTRODUCTION: Patients who require laparoscopic adjustable gastric band (LAGB) removal are often converted to sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). The impact of band removal on the morbidity and mortality of these salvage bariatric procedures is controversial. We hypothesized that LABG removal with conversion to SG or RYGB would be associated with higher morbidity and mortality compared to primary SG or RYGB.
METHODS: NSQIP data from 2005 to 2011 were analyzed. Patients undergoing LAGB removal and sleeve gastrectomy (BSG) or RYGB (BRYGB) were selected for analysis. Patients undergoing primary SG or RYGB were used as comparison groups. Baseline characteristics and comorbidities were compared between groups using ANOVA for continuous variables and Pearson’s Chi-square or Fisher’s Exact test for categorical variables. The incidence of complications as well as morbidity and mortality was compared between groups. Multivariate analysis was performed to determine which factors were independently associated with mortality. Odds ratios (OR) were calculated with 95% confidence intervals (CI) with p-value < 0.05 considered statistically significant.
RESULTS: A total of 51,609 patients were analyzed, consisting of primary RYGB (n=46,153), BRYGB (495), primary SG (n=4,831), and BSG (n=130) patients. All groups had similar mean age (45 ± 11 years-old). Salvage patients were more commonly female (89% v. 79%) and with lower body-mass index than primary bariatric patients (BMI 42±8 v. 46±8 kg/m2). Unadjusted overall complication rates were lower for primary SG versus RYGB (2.65 v. 3.34%, p = 0.01), but were similar between primary and salvage procedures for both RYGB (3.34%) versus BRYGB (2.63%) and SG (2.65%) versus BSG (3.08%), (p = NS). Unadjusted 30-day mortality was also similar between groups (RYGB 0.16%, BRYGB 0.20%, SG 0.08%, and BSG 0.77%, p = NS). Multivariate analysis of mortality, however, showed that compared to SG, BSG was a significant and independent predictor of mortality (OR = 8.02, 95% CI 1.08-59.34, p = .04). Additional predictors of mortality included age greater than 55 years (OR = 5.47, 95% CI 2.55-12.96, p < .001), female sex (OR = 0.3, 95% CI 0.18 – 0.47, p < .001) and BMI over 51 (OR = 2.21, 95% CI 1.38-3.53, p = .001). Comorbidities associated with increased mortality included renal insufficiency, coronary artery disease, and chronic obstructive pulmonary disease (p< .03 for all).
CONCLUSIONS: Band removal with conversion to RYGB is not associated with higher morbidity or mortality compared to primary RYGB. However, band removal with conversion to sleeve gastrectomy appears to be independently associated with higher mortality and thus may not be the salvage procedure of choice.
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