Antonio D’Urso, MD, Silvana Perretta, MD, Michel Vix, MD, Ludovic Marx, MD, Bernard Dallemagne, MD, Jacques Marescaux, MD, Didier Mutter, MD. IRCAD-NHC-IHU Department of Digestive and Endocrine Surgery, University of Strasbourg France.
Increasing experience with laparoscopic adjustable gastric banding (LAGB) demonstrated a high rate of complications and inadequate weight loss. Revisional laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) have been reported to be safe and effective in selected patients after LAGB removal. This study aims at evaluating the outcomes of revisional weight loss surgery (RWLS) after LAGB removal at our bariatric tertiary center.
Methods and procedure:
We retrospectively evaluated the feasibility and efficacy of performing concomitant single-stage or delayed two stages laparoscopic band removal and LSG or RYGB on all-comers who had a failed laparoscopic adjustable gastric band (LABG) and analyzed the impact of the reason for revision surgery on outcomes.
From January 2009 to September 2013, all patients who underwent LAGB removal were retrospectively analyzed. All procedures were performed by surgeons with extensive experience in bariatric surgery. Patient demographics, reason for band removal, interval between removal and RWLS, type of RWLS, complications, length of hospital stay, and percent of excess weight loss (%EWL) were collected.
During the study period, 111 (100 women, age = 41 ±8 years, 11 men, age 42± 4.7 years) patients underwent LAGB removal. Sixty-eight patients (61.3 %), presented with weight regain or inadequate weight loss. In the remaining 43 patients (38.7 %) indications for removal included: dysphagia (14 patients, 12.6%), GERD (10 patients, 9 %), gastric erosion (4 patients, 3.6 %), problems related to the access port (4 patient, 3.6%), epigastric pain and vomiting (9 patients 8.1%), diagnosis of gastric ectopic pancreas (1 patient 0.9%) and 1 removal upon patient’s request (0.9%). A total of 56 patients (50.4 %) with a BMI of 42.5 ± 4.7 kg/m2 successfully underwent RWLS (31 RYGB, 25 LSG). Five patients underwent simultaneous band removal and LSG. In the remaining patients RWLS was undertaken approximately 4 months (2 weeks-13 months) after LAGB. No conversion to an open approach was required. Median hospital stay was 5.7 (3-15) days. There was no major morbidity and no mortality. Early complications occurred in 4 patients after two-stage (7.14 %) revisional LSG, including 1 gastric fistula successfully treated by endoscopic stenting, one peri-gastric hematoma requiring surgical drainage, 1 urinary infection ; Six (10.7 %) late complications occurred: 4 incisional hernias, 1 laparoscopic exploration for internal hernia after RYGB, 1 dysphagia after SLG. Mean follow-up time was 17.4 (range, 6-60 ± 10.8) months. Overall mean EWL at 3, 6, and 12, months was 22.9 ± 7.4, 46.6 ± 15.9, and 58.2 % ± 18.2 respectively. At a mean follow-up of 12 months, %EWL was 76.8± 15.3 %, for RYGB and 56.7±16.3 for LSG. At 12 months 57.7% of patients achieved a BMI < 33.
Over 1/3 of patients who underwent LAGB removal were likely to present with mechanical/symptomatic/functional complications other than unsuccessful weight loss. Bariatric revisional surgery can be performed safely in experienced hands in selected patients even as a single-stage procedure with good surgical outcomes and satisfactory short-term weight loss results.