Remedial Foregut Operations Involving Bariatric Surgery

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

INTRODUCTION:

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).

RESULTS:

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.

CONCLUSIONS:

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.