Laparoscopic Sleeve Gastrectomy (LSG) is becoming more popular as a primary option for the surgical management of morbid obesity. Although some early sleeves performed over large-sized bougies have resulted in poor long-term weight loss maintenance, recent research has demonstrated that more restrictive sleeve gastrectomies can maintain nearly 60% excess weight loss. While the choice of a LSG as a primary procedure remains controversial, its utilization will likely increase, therefore resulting in the possibility of more patients presenting with “failed sleeves” over time. Learning the appropriate workup and management of these patients is important, and familiarity with the surgical options is essential.
This video shows a case of a morbidly obese 42 year-old male with an initial BMI of 48.7 kg/m2 who underwent a sleeve gastrectomy over a 60F bougie in February 2003. After initially losing almost 40% excess weight loss (EWL) in the first year, he regained most of his weight and plateued at only 15% excess weight loss. This weight has been stable for the past 2 years. After a thorough workup that included an Upper GI swallow that showed a dilated fundus, we reviewed the surgical options with the patient. He refused any malabsorptive procedure or gastric bypass, and ultimately the decision was made to proceed with laparoscopic adjustable gastric banding (LGB). If the insertion of an adjustable band were not technically feasible, the patient was willing to undergo a secondary sleeve. The case proceeded successfully and he began adjustments at six weeks. At six months post surgery, the patient has already achieved a total of 42% EWL from his original weight – equivalent to an additional 50 pounds lost and a BMI of 37 kg/m2.
In certain situations after a failed sleeve gastrectomy, the insertion of an adjustable gastric band into its normal anatomic position proximal to any staple line may be feasible and is a safe option for a second stage procedure. By reintroducing adequate restriction, weight loss can continue, and since there is no second staple line or anastomosis, patients can receive sufficient restriction with minimal risk.
Session: Podium Presentation
Program Number: V022