Revision of Primary Sleeve Gastrectomy to Roux-en-Y Gastric Bypass, Indications and Outcomes from a High Volume Center

Robert A Casillas, MD, Jorge Zelada Getty, MD, Scott S Um, MD, Benjamin B Kim, MD. Kaiser Permanente West Los Angeles.

Background
Since reports as early as 2005, the laparoscopic sleeve gastrectomy (SG) has gained increased acceptance as a primary weight loss operation. As with any bariatric procedure, insufficient weight loss and long term complications have been reported. We analyzed primary SG warranting revision to Roux-en-Y gastric bypass (RYGB). Our experience appears to be one of the largest in the literature.
Methods
A retrospective review of a prospectively collected data base identified all SG performed as primary weight loss operation from 2/2009 to 8/2013. All patients that underwent revision from SG to RYGB were included in our study.
Results
There were 2446 patients that underwent laparoscopic SG within the study period and 28 (1.1%) underwent revision to RYGB. The mean time to revision was 23 months (range 2-60) and the mean follow up after RYGB was 7 months (range 1-28). Indications for revision included severe reflux (n= 12), inadequate weight loss (n=5), both reflux symptoms and lack of weight loss (n= 4), stricture (n= 4), persistent leak (n=1) and both diabetes and severe reflux (n= 2). Acid reflux symptoms resolved in 100% of patients and hiatal hernias were identified and repaired in 13 patients (46.4%) at the time of RYGB. Percentage of excess weight loss (%EWL) at 3, 6 and 12 months was 33.3%, 49% and 56.7%. Diabetes improvement was noted in 75% of patients with a decrease in HgbA1c. One patient with a gastrocutaneous fistula required further endoscopic procedures. Dysphagia resolved in all patients with strictures. Overall complication rate was 7.1% with one patient requiring postoperative transfusion and one patient requiring EGD with dilatation for stricture. There were no leaks, no conversions to open procedure, and mortality was 0 %.
Conclusion
Revision of SG to RYGB was rare in our series but does appear to be a safe and effective means of treating complications associated with SG. Acid reflux was the most common cause for revision, with a high incidence of associated hiatal hernia. Our data suggests that careful evaluation for hiatal hernia at the time of SG is warranted to help prevent future reflux symptoms.  With longer follow up, revisions for observed weight gain may present at a higher frequency.

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