B R Veenstra, MD, S Lynch, MD, M Buchanan, J A Stauffer, MD, H J Asbun, MD, C D Smith, MD, S P Bowers, MD. Mayo Clinic of Florida
For credentialing purposes, revisional bariatric operations are considered to be conversion of one bariatric operation to another, presumably for weight loss failure. It is our experience at a low volume bariatric, but high volume foregut center, that this does not represent the full spectrum of remedial foregut operations involving bariatric surgery.
METHODS AND PROCEDURES:
We identified from our Foregut Registry 93 patients who underwent 96 elective, major remedial foregut operations involving bariatric surgery between May of 2008 and September of 2014. We identified three groups: prior bariatric operation and bariatric re-operation (B-B, n=66), prior bariatric operation and non-bariatric foregut re-operation (B-NB, n=19), and prior non-bariatric foregut operation and bariatric re-operation (NB-B, n=11). A surgical history including Roux en y Gastric Bypass (RYGB, n=37), Vertical Banded Gastroplasty (VBG, n=20), Adjustable Gastric Band (LAGB, n=19), Sleeve Gastrectomy (SG, n=6), and Horizontal Gastroplasty (n=3) represent prior bariatric operations, while a history of Nissen (n=9) or Toupet fundoplication (n=2) represent prior non-bariatric foregut operations. Bariatric re-operations included RYGB (n=44), revision of RYGB (n=22), and SG (n=11). Non-bariatric foregut re-operations included completion gastrectomy with esophagojejunostomy (n=6), gastrogastrostomy (n=5), remnant gastrectomy (n=4), thoracoabdominal esophagogastrectomy (n=2), gastric seromyotomy (n=1) and Heller myotomy (n=1).
There was no 6 month mortality and no patient required unplanned or emergent re-operation. Post-operative leak occurred in three patients. Post-operative (within 6 months) interventions (n=13) were required after 11 operations: diagnostic EGD (n=4), endoscopic dilation (n=2), endoscopic injection of fibrin glue to fistula tract (n=2), endoscopic placement of stent (n=2), CT guided drain placement (n=2), and placement of gastrostomy tube (n=1). The requirement for post-operative intervention was the same in the B-B and NB-B groups (both 9%), with a trend towards higher post-operative intervention in the B-NB group (21%, p=0.22, Fisher’s Exact Test). Of the 96 total operations, 45 were “conversion” operations, with only 19 solely for failed weight loss.
Our study demonstrates that less than half of remedial bariatric operations at our institution were conversion operations, with only a small percentage done solely for failed weight loss (19%). There is a significant overlap between remedial foregut and remedial bariatric surgery. Bariatric patients requiring a non-bariatric foregut re-operation may signify a population of patients requiring a higher complexity of care. As such, credentialing for revisional bariatric surgery should reflect this.