Bariatric Surgery: Revisions

First submitted by:
Shawn Tsuda
(see History tab for revisions)
Category

Banding Failed Bypasses

Roux en Y gastric bypass (RYGB) is the most frequently performed operation for the treatment of morbid obesity and is being performed in increasing numbers. Failure to achieve 50% of excess weight loss or a BMI of <35 is reported to occur in about 15% of patients.
Therefore, there are going to be plenty of patients who have, or are going to have, a “failed” gastric bypass.

Revisional procedures following RYGB have focused on resizing of the pouch, the stoma and the limb lengths. However, the perfect size for a pouch or a stoma has never been determined. Revisional operations have a significantly increased risk of leaks and perioperative
complications compared to primary operations.1 Endoluminal approaches at pouch and stoma resizing are being attempted, and will be discussed later by Dr. Chris Thompson. This talk will not be an in depth review of revisional bariatric surgery, but will specifically focus on the results from banding a failed gastric bypass

Risks and Benefits of using an adjustable gastric band for a failed bypass.

Banding a failed gastric bypass has several theoretical benefits over other revisional procedures. First of all, though dissection and exposure remain a technical challenge, banding a failed gastric bypass avoids the further dangers of pouch or stoma revision since there are no new staple lines or anastomoses. Therefore, there are fewer theoretical problems of leaks, stenoses, bleeding etc. As there is no resection, there is less probability of making the pouch ischemic by damaging it’s blood supply. As opposed to revisions in which limb lengths are altered, banding a failed bypass is a restrictive operation and so has no malabsorptive sequelae. Also, the adjustable nature of the band allows one to titrate the size postoperatively to maximize weight loss for that individual. Another important benefit of banding a failed bypass is that the external reinforcement may help to prevent recurrent pouch or stoma dilation.

Risks associated with this technique include any of the risks associated with the band including port or tubing failure, erosion, slippage, dysphagia, intolerance, and longer term failure or need for explantatation. Infection of the band may be a greater risk due to the inherent
challenges of dissection in this reoperative field. Furthermore, if the stoma size or pouch size was not the reason the patient failed after the bypass, then this mechanically restrictive procedure might not be of further benefit.

Techniques:

Placing an adjustable gastric band on a failed gastric bypass was first published by Kyzer et al in 2001.2 They describe placing an adjustable gastric bands in 12 patients who had undergone previous gastric bypasses. They describe an open technique with the band placed around the proximal stomach pouch after blunt finger dissection, and fixed with two 2-0 Prolene sutures at the anterior lesser and greater curvatures. Initially they used calibration balloons, then stopped as they felt that these balloons caused trauma and mucosal edema.

Marc Bessler and his colleagues at Columbia initially reported on 8 patients in Obesity Surgery in 2005.3 The first three were done open, the last 6 laparoscopically. A pars flaccida technique was used. 10 cm LapBands® were placed. Intraoperative endoscopy confirmed that
the band was around the pouch and not the esophagus. Plicating sutures were placed anteriorly. George Fielding and his group described their experience with 11 patients in 2008.4

Mostly LapBand VG® bands were placed, laparoscopically with one conversion. A pars flaccida technique was used.

Dugal Heath and colleagues describe a technique in which the adjustable gastric band is placed more distally around the lower gastric pouch.5 A perigastric dissection was used and the band placed 1 cm above the gastrojejeunal anastomosis. The band was placed distally since they “were aware that a number of patients having restrictive devices inserted had experienced degrees of vomiting or discomfort such that the device had to be removed.” They also comment that they tried a more proximal location, but adhesions prevented them from pursuing further in that position. The ultimate distal position was similar to where one might put a band in a banded.

RYGB

Fixed bands of various materials have also been described. The concept is similar to the banded gastric bypass as advocated for by Fobi where a 6 or 6.5 cm fixed silastic band “not more than 2 cm above the gastrojejunostomy.”6

Outcomes:

Results following the placement of an adjustable gastric band for a failed gastric bypass have been limited to the cases and small series described above.

Marc Bessler and his colleagues at Columbia recently published in January 2010 the “intermediate results” on 22 patients who they had treated from 2002 to 2007. 7 They report three major complications: one partial SBO related to the band tubing, one band slip and one port infection requiring reoperation and explantation.

Fielding’s group which reported on 11 patients, had only one complication — a flipped port.4 They report 100% follow-up with a mean follow-up time of 13 months (2-32 months) with a mean %EWL after LAGB for failed RYGB of 20.8 ± 16.9%

Conclusion:

Adjustable gastric banding seems to be a reasonable approach for patients with failed gastric bypass operations, and has many theoretical benefits over other revisional procedures being performed. Small series by experienced groups report low complication rates, which compared to the results from other revisional operations, are quite promising. Whether similar results can be replicated in other surgeons’ hands is not clear, as few others have published results.

Intermediate term follow-up, though limited by small numbers and limited % of patients followed, suggests a reasonable %EWL.

More data is needed.

Failed Biliopancreatic Diversion or Duodenal Switch

The Laparoscopic Duodenal Switch (LDS) is a superior operation which preserves the antro-pyloric pump, leaves the vagal innervations undisturbed and the sleeve gastrectomy itself minimizes the ulcerogenicity of the duodenal switch by reducing the parietal cell mass. A recent comparison of BPD and DS, after 10 years of follow-up, clearly demonstrates the superiority of the DS in most aspects, including better weight loss by an additional 25% and lesser revisions (18.5% versus 2.7%). Analysis of serum vitamins and minerals points to a better maintenance of calcium and iron metabolism, lesser anemia’s by the presence of a short proximal duodenum in the DS.

But, BPD with or without DS, are complex and technically more difficult to perform laparoscopic ally than a sleeve gastrectomy alone, or Roux-en-Y gastric bypass, probably due to a tedious dissection of the proximal duodenum, with nearby gastro duodenal artery, hepatic artery and common bile duct, but also due to thinner bowel wall in both the duodenum and ileum which renders this anastomosis (in DS) probably more risky to leaks. Several studies have been published, mostly retrospective, with one ongoing prospective randomized study from Norway and Sweden, comparing laparoscopic gastric bypass and BPD/DS. Sixty patients with a BMI between 50 and 60 were randomized to a laparoscopic Roux-en-Y gastric bypass (RYGB) versus laparoscopic DS. Both groups were comparable; the mean operative time was twice as long in LDS compared to RYGB (206 vs. 91 minutes, p < 0.001). However, the mean BMI at 1 year was dramatically lower after LDS (32.5) vs. RYGB (38.5), with a greater %EWL (75 vs. 55%, p< 0.001). Weight loss after DS is superior to gastric bypass in super-obese patients. This has enormous consequences in USA, where half of the patients operated have a BMI more than 50 kg/m2, and will undoubtedly lead to a higher failure rate long-term (for gastric bypass).

A recent collected series of 467 patients, showed a mean age of 39 years, with female patients present in 63.5 %. The preoperative BMI was 47.3 as a mean value. Most studies report a high percentage of associated co morbidities, like arterial hypertension, diabetes mellitus, degenerative joint disease or sleep apnea. The conversion rate varies widely and is averaged at 7.6 %.

Revisions

The operation is used increasingly to convert a failed laparoscopic banding, due to an anastomosis being performed away from the scar tissue. It can also salvage weight regain following sleeve gastrectomy, without having to revise the stomach itself, and work in a new territory.

Concerning these operations themselves, revisions are lower (<5%) than what is seen with gastric bypass (10-20%) or gastric banding (up to 50%), and therefore literature on the subject is scarce. For BPD, Scopinaro mentioned that with an “ad hoc stomach” of 200 to 500ml gastric capacity, a 200 cm alimentary limb, and a 50 cm common channel, leads to a revision rate of 1.7%. Those were mostly due for protein malnutrition, and the correction is a common limb elongation at the expense of the biliopancreatic limb, or complete restoration. Laparoscopically, this is a transection with an endoGIA and an anastomosis done more proximal on the biliopancreatic limb (usually 100cm), increasing both the common limb and the alimentary limb. This will result in a higher absorption of fat, proteins and sugars. Prior to the “ad hoc stomach” period, a high rate of revisions were performed due to a too small stomach that led to an unacceptable high rate of protein malnutrition, simulating a very distal gastric bypass. If inadequate weight loss is seen after BPD, a partial gastrectomy can be done (sleeve style, preventing a reanastomosis). Complete reversal is reserved for an incompliant patient, with severe multiple nutritional deficiencies (emphasizing the importance of patient selection). In those cases, a Billroth I type anastomosis can be done between the
stomach and duodenum, with complete restoration of bowel continuity.

Revisions of duodenal switches operations are less prevalent than with BPD, as published by Marceau in the 10 year comparison between the 2 procedures. In a cohort of 701 patients with DS, followed over 10 years, 33 patients needed revisions for protein malnutrition (20), diarrhea (9), metabolic abnormalities (5), abdominal pain (3), liver disease (3), emesis (2), and gastrointestinal  hemorrhage (1). Most revisions were performed by a side to side enteroenterostomy 100 cm proximal to the original anastomosis. There was no mortality and follow-up demonstrated after 39 months following the revision, a median weight gain of 9 kg. The revision has been performed by myself a few times, laparoscopicaly, it is easy, after proper identification of each limb, after proper measurements with a 50 cm umbilical tape, one laparoscopic anastomosis is done, with very little risks and a smaller postoperative period (hospital stay 2 days).

Complete reversal is rare and can be performed in several ways; the ileum can be interposed by being disconnected from the common limb and reanastomosed to the second duodenum, making this a SGIT (Sleeve gastrectomy with an ileal interposition). The most complex one is restoration of all anastomosis with bowel limbs in their original positions. A simpler one is to do a side to side jejuno-ileostomy below the duodenoileal anastomosis. For inadequate weight loss following the DS, a re-sleeve has been performed repetitively with great success; no stenosis should be created to prevent protein malnutrition. Limbs should be re-measured to assure that proper lengths were
used at the primary procedure.

Conclusion:

Increasingly, the laparoscopic duodenal switch has become easier to perform technically, and is applied more and more too super obese patient, and it is often performed in two stages in high risk patients. Future studies with larger number of patients should be able to demonstrate the effectiveness of this procedure, similarly to its open counterpart, in reducing weight and resumption of co morbidities like
hyperlipidemia, sleep apnea, hypertension and diabetes mellitus. The use of a laparoscopic approach to perform this procedure minimizes local and systemic complications in these high risk patients. Revisions are lower than other procedures (<5%), and are easier to perform laparoscopically.