Indications for Conversion from Sleeve Gastretomy to Roux-en-Y Gastric Bypass

Thomas J Buddensick, MD, Michael Kammerer, MD, Alec Beekley, MD, David Tichansky, MD. Thomas Jefferson University

Introduction: As sleeve gastrectomy (LSG) continues to grow in popularity, a noticeable subset of patients has evolved that undergo revisional surgery after LSG; specifically conversion to roux-en-Y gastric bypass (RYGB). Knowledge of the indications for conversion may allow for earlier identification of patients in need of revision.  We present our subset of patients who underwent this procedure over a 30-month time period.

Methods: A retrospective review of a prospectively maintained bariatric surgery database was performed on a single institution’s data from patients undergoing surgery between 2013 and 2015.  Medical history, weight loss and surgical indications were reviewed in all patients undergoing conversion from LSG to RYGB.

Results: Four patients underwent conversion from LSG to RYGB during the reviewed time period. Indications were severe gastroesophageal reflux (n=3) and weight regain (n=1). All patients with gastroesophageal reflux were found to have a hiatal hernia at re-exploration. One of these had undergone a hiatal hernia repair at initial operation. All hernias were repaired at subsequent operation. One of these patients was found to have severe angulation in the sleeve with proximal gastritis that likely contributed to reflux symptoms. Two of the three patients who underwent conversion for gastroephageal reflux underwent post conversion upper endoscopy. These evaluations were performed at four and seven months respectively and showed no evidence of esophagitis or recurrent hiatal hernia. The patient requiring conversion due to weight regain had a BMI of 52 prior to LSG.  Maximal weight loss was reached at 15 months with a BMI nadir of 37.  At the time of conversion, 26 months postoperatively, BMI was 42.  In this patient, upper gastrointestinal series and endoscopy revealed a dilated sleeve more than twice its original diameter which was confirmed intraoperatively. At 12 months post conversion, BMI was 38.

Conclusions: In our series, severe gastroesophageal reflux and weight regain were the indications for conversion from LSG to RYGB. Of the two, severe reflux seems to be more common and was associated with recurrent or previously unrecognized hiatal hernia.

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