Hans J Schmidt, MD1, Edmund W Lee, BA2, Richard C Novack, Jr., MD1, Amit Trivedi, MD1, Sebastian Eid, MD1, Douglas R Ewing, MD1. 1Hackensack University Medical Center, 2Rutgers-New Jersey Medical School
Roux-en-Y gastric bypass (RYGB) performed through open laparotomy was considered the gold standard operation for the treatment of morbid obesity for over two decades. Surgeons versed in the laparoscopic technique may find revisional surgery after open bypass challenging . Moreover, “banded –bypass” was a technique employed by some open surgeons, incorporating mesh band placement around the pouch to prevent dilatation. Obesity is a chronic condition and some patients may fail to lose adequate weight while others regain some or all of the weight that they have lost. Treatments for failure of gastric bypass include revision of the pouch/anastomosis, increasing the length of the roux limb, and conversion to a more radical procedure. While often successful, these procedures can be technically challenging after prior laparotomy and subject to significant intra-abdominal complications. Laparoscopic adjustable gastric band (LAGB) placement has been used as a salvage procedure around the previous RYGB but there is little data in the literature regarding open RYGB or long-term success rates.
We cross referenced our bariatric surgery data base with patients who presented with weight gain after open bypass. All patients had a barium esophagram. Patients with gastrogastic fistula or clealy inadequate fundus reduction were treated with stapled revision. We then focused on that group who underwent open RYGB as the initial procedure and had pouch and/or anastomotic dilatation. Finally, we performed a phone interview with any patient that had not been seen in the office within the past year to inquire about their current condition.
We reviewed 3094 LAGB cases placed since 2001. A total of 31 bands were placed around a RYGB performed as open surgery. Eleven of the 31 patients were “banded-bypass” All 31 band cases were completed laparoscopically with no conversion to open or peri-operative complications. Patients have been followed for an average (mean) of 2 years, with 6 patients being followed for greater than 5 years, the longest being 10 years. Of these 31 bands, 4 (12.9%) have been removed, 3 due to dysphagia. There were no slips or erosions. The average pre-RYGB BMI was 58.4 which decreased to 31.8 post RYGB. At the time of band, the pre-LAGB BMI was 45.7 which decreased to 37.5 at the present time. When looking at the “banded-bypass: sub-group, the pre-RYGB BMI was 61.0 which decreased to 32.2 post-RYGB. Their pre-LAGB BMI was 46.7 which decreased to 39.0 at the present time.
This study shows that LAGB is a safe alternative to complex revisional surgery in patients failing open gastric bypass. It can be performed safely, often as a same day procedure. Long term follow-up demonstrates that the band removal rate is lower then some reported rates for primary LAGB. Furthermore, LAGB around prior open RYGB shows sustainable weight loss results over a period of time, and can be effective even for those subset of patients who had a “banded-bypass” during the initial surgery.