Perioperative Risk and Complications of Revisional Bariatric Surgery Compared to Primary Roux-en-Y Gastric Bypass

Linda P Zhang, MD, Wen Hui Tan, MD, Ronald Chang, MD, Valerie Halpin, MD, J. Chris Eagon, MD. Department of Surgery and Section of Minimally Invasive Surgery, Washington University School of Medicine, St Louis, MO.

INTRODUCTION: There have been a growing number of patients requiring revisional bariatric surgery. This study compares the perioperative course and outcomes of revisional versus primary bariatric surgery.

METHODS: All patients who underwent revisional bariatric surgery at our institution from January 1997 to September 2012 were reviewed retrospectively. For each revisional patient with BMI>35 and age<70, a primary Roux-en-Y gastric bypass control patient was matched based on preoperative BMI (+/- 5 units), age (+/- 5 years), sex, and year of surgery (+/-2 years). Patients’ preoperative indications, operative procedure, intraoperative and postoperative course, and complications were analyzed. Statistical analysis was done by Student’s t-test, where p<0.05 indicated significance.

RESULTS: 255 patients underwent revisional bariatric surgery with a resulting Roux-en-Y gastric bypass anatomy while 1,674 patients underwent primary gastric bypass surgery in the same time interval. Of the 255 patients, 172 patients (BMI> 35 with age < 70 years) were paired with 172 primary gastric bypass patients. The revisional bariatric group had preoperative BMI 48+/-9, age 52+/-9 years, 93% female, 44% laparoscopic, 30% diabetic, 60% hypertensive. Primary bypass patients had preoperative BMI 49+/-8, age 52+/-9 years, 93% female, 97% laparoscopic, 49% diabetic, 67% hypertensive. Compared to primary bypass patients, revisional patients had significantly higher estimated blood loss (463.7 vs 113.3mL), longer operative time (272.5 vs. 175.5 min), greater risk for postoperative ICU stay (N=24, 14% vs. N=2, 1%), and longer length of stay (5.6 vs. 2.5 days). There were significantly more intraoperative liver (N=13, 8% vs. N=1, 1%) and spleen (N=18, 10% vs. N=0) injuries, as well as more enterotomies (N=9, 5% vs. N=0) in the revisional group compared to the primary group. There were also significantly more postoperative complications (N=94, 55% vs. N=48, 28%), and more readmissions (N=27, 16% vs. N=12, 7%) and reoperations (N=16, 9% vs. N=3, 2%) within 30 days of surgery.  Mean percentage weight loss at 1 year was 27% for revisional patients and 37% for primary bariatric patients. The 30-day mortality rate in the revision group was 3.5% (N=6) while the primary group had no mortalities.

CONCLUSION: Even in experienced hands, complex revisional bariatric surgery is associated with more perioperative morbidity and mortality than primary bypass surgery. There is also less percentage weight loss at 1 year than primary bariatric surgery.