Louise Yeung, MD1, Brandice Durkan, MD1, Allison Barrett, MD2, Scott Cunneen, MD, FACS1, Edward Phillips, MD, FACS1, Miguel Burch, MD, FACS1. 1Cedars-Sinai Medical Center, 2Long Island Jewish Medical Center
Introduction: Laparoscopic adjustable gastric banding (LABG) is a restrictive weight-loss procedure that is increasingly requiring revisional surgery for complications or failures. Removal of the band and conversion to either laparoscopic sleeve gastrectomy (LSG) or laparoscopic roux-en-y gastric bypass (LRYGB) is feasible as a single-stage procedure, but insufficient data exists regarding safety and the most effective revisional procedure. This study compares the safety and efficacy of single-stage revision from LAGB to either LRYGB or LSG at six and twelve months postoperatively.
Methods: Retrospective analysis was performed on patients who underwent single-stage revision between 2009 and 2014 at a single academic medical center. Patients were followed at six and twelve months postoperatively and reassessed for weight loss and complications.
Results: 32 patients underwent laparoscopic single-stage revision from LAGB to LRYGB, and 72 from LAGB to LSG. The most common indication for surgery was insufficient weight loss in 71%. Band complications due to GERD/esophagitis occurred in 12%, band slip in 14%, and port-related problems in 3%. Preoperative BMI was 41.41 in the LRYGB group and 39.63 in the LSG group (p=0.27). Median length of stay for LRYGB was 3 days versus 2 days for LSG (p=0.14). Three patients with LRYGB required reoperation within 30 days, two for leak at the gastrojejunostomy and one for bleeding. Two patients with LSG required reoperation within 30 days (p=0.15), for sleeve leak and for incarcerated incisional hernia. One patient in the LRYGB and 7 patients in the LSG group returned to the ER (p=0.24) and one patient in the LRYGB group and three patients in the LSG group required readmission (p=0.80) within 30 days of operation. Ten delayed complications were seen in the LSG group, with three developing a stricture (two requiring stenting) at two months postoperatively, two with a port-site hernia, one patient developing prolonged nausea two months postoperatively, one patient hospitalized for pancreatitis and one patient developing acute angle glaucoma after restarting medical weight loss supplements after revision. At six months postoperatively, percent excess weight loss (%EWL) was 49.98 for LRYGB and 30.60 for LSG (p=0.08). At twelve months, %EWL was 51.52 for LRYGB and 27.76 for LSG (p=0.26). When results were stratified for patients who underwent revision primarily due to insufficient weight loss, the %EWL at 12 months was 52.17 for LRYGB and 49.47 for LSG (p=0.75). There was no difference in the medication reduction at 12 months for diabetes and hypertension between LRYGB (67% reduced, 33% off medications for diabetes; 64% reduced, 27% off medications for hypertension) and LSG (75% reduced, 50% off medications for diabetes; 38% reduced, 12.5% off medications for hypertension; p>0.25).
Conclusion: Revision from LAGB to either LRYGB or LSG is feasible as a single stage operation. There was no difference between the cohorts in readmission or reoperation at 30 days, or complications within 12 months. Weight loss at six and twelve months postoperatively is equivalent for both procedures, in particular for patients with failure of weight loss as their main indication for revision.