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Comment on: A retrospective comparison of early results of conversion of failed gastric banding to sleeve gastrectomy or gastric bypass
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W. R. J. Carr et al. / Surgery for Obesity and Related Diseases 11 (2015) 379–385
[3] Rogers AM. Improvement of esophageal dysmotility after conversion from gastric banding to gastric bypass. Surg Obes Relat Dis 2010;6: 681–3. [4] Van Gemert WG, van Wersch MM, Greve JW, Soeters PB. Revisional surgery after failed vertical banded gastroplasty: restoration of vertical banded gastroplasty or conversion to gastric bypass. Obes Surg 1998;8:21–8. [5] Alhamdani A, Wilson M, Jones T, et al. Laparoscopic adjustable gastric banding: a 10-year single-centre experience of 575 cases with weight loss following surgery. Obes Surg 2012;22:1029–38. [6] Müller MK, Attigah N, Wildi S, et al. High secondary failure rate of rebanding after failed gastric banding. Surg Endosc 2008;22:448–53. [7] Bueter M, Thalheimer A, Wierlemann A, Fein M. Reoperations after gastric banding: replacement or alternative procedures? Surg Endosc 2009;23:334–40. [8] Jennings NA, Boyle M, Mahawar K, Balupuri S, Small PK. Revisional laparoscopic Roux-en-Y gastric bypass following failed laparoscopic adjustable gastric banding. Obes Surg 2013;23:947–52. [9] Mognol P, Chosidow D, Marmuse J-P. Laparoscopic conversion of laparoscopic gastric banding to Roux-en-Y gastric bypass: a review of 70 patients. Obes Surg 2004;14:1349–53. [10] Ardestani A, Lautz DB, Tavakkolizadeh A. Band revision versus Roux-en-Y gastric bypass conversion as salvage operation after laparoscopic adjustable gastric banding. Surg Obes Relat Dis 2011;7: 33–7. [11] Calmes JM, Giusti V, Suter M. Reoperative laparoscopic Roux-en-Y gastric bypass: an experience with 49 cases. Obes Surg 2005;15: 316–22. [12] Lanthaler M, Mittermair R, Erne B, Weiss H, Aigner F, Nehoda H. Laparoscopic gastric re-banding versus laparoscopic gastric bypass as a rescue operation for patients with pouch dilatation. Obes Surg 2006;16:484–7. [13] Rosenthal RJ, Diaz AA, Arvidsson D, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of 412,000 cases. Surg Obes Relat Dis 2012;8:8–19. [14] Coblijn UK, Verveld CJ, van Wagensveld BA, Lagarde SM. Laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy as revisional procedure after adjustable gastric band—a systematic review. Obes Surg 2013;23:1899–914.
[15] Victorzon M, Tolonen P. Mean fourteen-year 100% follow-up of laparoscopic adjustable gastric banding for morbid obesity. Surg Obes Realt Dis 2013;9:753–7. [16] Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23:427–36. [17] Schouten R, Japink D, Meesters B, Nelemans PJ, Greve JWM. Systematic literature review of reoperations after gastric banding: is a stepwise approach justified? Surg Obes Relat Dis 2011;7:99–109. [18] Foletto M, Prevedello L, Bernante P, et al. Sleeve gastrectomy as revisional procedure for failed gastric banding or gastroplasty. Surg Obes Relat Dis 2010;6:146–51. [19] Berende CAS, de Zoete J-P, Smulders JF, Nienhuijs SW. Laparoscopic sleeve gastrectomy feasible for bariatric revision surgery. Obes Surg 2012;22:330–4. [20] Utech M, Shaheen H, Halter J, et al. Sleeve gastrectomy as a revision procedure for Failed Gastric Banding. Zentralbl Chir 2014;139: 79–82. [21] Yazbek T, Safa N, Denis R, Atlas H, Garneau PY. Laparoscopic sleeve gastrectomy (LSG)-a good bariatric option for failed laparoscopic adjustable gastric banding (LAGB): a review of 90 patients. Obes Surg 2013;23:300–5. [22] Acholonu E, McBean E, Court I, Bellorin O, Szomstein S, Rosenthal RJ. Safety and short-term outcomes of laparoscopic sleeve gastrectomy as a revisional approach for failed laparoscopic adjustable gastric banding in the treatment of morbid obesity. Obes Surg 2009;19:1612–6. [23] Peterli R, Borbély Y, Kern B, et al. Early results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. Ann Surg 2013;258:690–5. [24] Mahawar KK, Jennings N, Balupuri S, Small PK. Sleeve gastrectomy and gastro-oesophageal reflux disease: a complex relationship. Obes Surg 2013;23:987–91. [25] Khoursheed M, Al-Bader I, Mouzannar A, et al. Sleeve gastrectomy or gastric bypass as revisional bariatric procedures: retrospective evaluation of outcomes. Surg Endosc 2013;27:4277–83. [26] Jacobs M, Gomez E, Romero R, Jorge I, Fogel R, Celaya C. Failed restrictive surgery: is sleeve gastrectomy a good revisional procedure? Obes Surg 2011;21:157–60
Editorial comment
Comment on: A retrospective comparison of early results of conversion of failed gastric banding to sleeve gastrectomy or gastric bypass In this study, Carr et al. addressed the problem of band failure comparing the Roux-en-Y gastric bypass (RYGB) and the sleeve gastrectomy (SG) that are currently the 2 preferred surgical options for what has become a very common problem in bariatric surgery. Laparoscopic adjustable gastric band (LAGB) failure has certainly become a main concern, because a large number of morbidly obese patients have undergone this procedure. However, many patients are still offered the LAGB is spite of the high rate of long-term failure. The main reasons for its popularity are its simple and straightforward surgical technique and the very low rate of immediate postoperative complications and mortality [1].
The argument of reversibility has also been used in the past as one of the “benefits” of LAGB. However, it is now clear that band related scar tissue around the esophagogastric junction may complicate the reoperative surgery at a point that a 2 step approach is required in a significant proportion of patients. Interestingly, Carr et al. reported a significant difference in the need for 2 steps for LAGB to SG conversion compared with laparoscopic Roux-en-Y gastric bypass (LRYGB). The authors’ explanation for this difference was the increased number of patients presenting with emergency band complications and a dilated and/or inflamed pouch in the group of patients undergoing SG.
Conversion of LAGB to LSG or LRYGB Achieves Comparable Outcomes / Surgery for Obesity and Related Diseases 11 (2015) 379–385
However, this may also reflect the intention to avoid as much as possible the occurrence of a high leak, as the latter may be very difficult to manage. Indeed, the literature shows that conversion from band to SG increases the risk of this most feared complication [2]. We recently provided evidence that there is no difference between band conversion and primary SG when surgery is done in the hands of experienced bariatric surgeons [3]. We also found that the 2-step approach reduces the risk of a leak, when all the published series were compared for the one versus the 2-step approach [3]. Plausible explanations are the more favorable anatomic conditions, including the partial regression of band related scar tissue and the fact that the gastrogastric tunnel has already been dismantled. Both may impair the delicate process of tissue stapling and be responsible for increased risk of leak and/or the persistence of part of the gastric fundus as in the case of concomitant band removal and conversion. In the case of RYGB, the main technical point is where to staple the stomach, below or above the band scar. My preference is to shape a long narrow pouch that has a reduced tendency to dilate over time and empties slower than a short and large pouch according to the La Place’s and Poiseuille's laws [4,5]. Most authors advocate the division of the stomach above the band, as the dissection is easier to do and falls above the band related scar tissue. However, such a short pouch may be source of tension on the gastrojejunostomy and result in a leak. Furthermore, the adhesions around the stomach generated by the band fix the former to the surrounding tissues preventing the pouch to accommodate the downward pull of the Roux-en-Y (RY) loop. Consequently, the tension may increase the risk of ischemic complications. The policy of dividing the stomach below the band scar advocated by Carr et al. most probably accounts for their low rate of leak. Band erosion is a major risk factor for staple line or anastomotic leak when converting a band to another procedure. My personal preference is splitting the procedure into 2 steps, waiting as long as possible before the second step, and doing a RYGB. Indeed, any leak, anastomotic or staple line related, is easier to manage in the setting of a RYGB. Such a leak may easily become a nightmare in the case of a SG. In any case patients should be fully informed about the risk of serious postoperative complications. The other main point concerns the risk of gastroesophageal reflux disease (GERD) that may be aggravated by the SG, whereas, the RYGB is an anti-reflux procedure. The latter avoids reflux because of the Roux-en-Y anatomy, the exclusion of the fundus, and the small size of the gastric pouch, but also because the Roux-en-Y anatomy mechanically pulls the stomach into the abdomen, reducing a hiatal hernia when present. For these reasons, clinical and endoscopic signs of GERD should be assessed and a hiatal hernia eliminated in all candidates for conversion to SG with both an esophagogastric endoscopy and
385
gastrointestinal radiographic series [6]. Soricelli et al. recently showed that if the hiatal hernia is systematically searched for during surgery and fixed when found, the rate of de novo GERD is significantly reduced [7]. This indicates that a misdiagnosed hiatal hernia may be responsible for the appearance of de novo GERD after SG. Indeed, Carr et al. reported 3 cases of de novo reflux (3/25; 12%) in the group of patients undergoing SG at the time of follow-up. On the other hand, in the presence of documented GERD, especially in the presence of esophagitis and/or hiatal hernia, the RYGB should be considered the procedure of choice. Although the excess weight loss was the same after both procedures in the study by Carr et al., these results only refer to a very limited follow-up with only half of the patients seen at 2 years. Weight loss in patients undergoing a second bariatric procedure for weight loss failure, representing half of the cases in the study by Carr et al., is difficult to predict and may be poorer than in primary procedures as patients are less compliant and more reluctant to change eating behaviors responsible for failure of the first procedure. This study further proves that SG can be achieved with comparable morbidity as RYGB after failed LAGB. De novo GERD after SG remains a concern as identifying which patients will develop this complication after surgery may be difficult. The loss of excess weight must be investigated in the long-term. Given the magnitude of the problem, the issue of what is the best procedure for failed bands should be addressed in a randomized trial. Antonio Iannelli, MD, Ph.D. Digestive Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France References [1] Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I. Trends in mortality in bariatric surgery: A systematic review and meta-analysis. Surgery 2007;142:621–35. [2] Rebibo L, Mensah E, Verhaeghe P, et al. Simultaneous gastric band removal and sleeve gastrectomy: a comparison with front-line sleeve gastrectomy. Obes Surg 2012;22:1420–6. [3] Noel P, Schneck AS, Nedelcu M, et al. Laparoscopic sleeve gastrectomy as a revisional procedure for failed gastric banding: lessons from 300 consecutive cases. Surg Obes Relat Dis 2014. pii: S1550-7289(14) 00123. [4] Capella RF, Iannace VA, Capella JF. An analysis of gastric pouch anatomy in bariatric surgery. Obes Surg 2008;18:782–90. [5] Iannelli A, Kassir R, Schneck AS, Gugenheim J. The long and narrow pouch for Roux-en-Y gastric bypass. Obes Surg. In press. [6] Heacock L, Parikh M, Jain R, Balthazar E, Hindman N. Improving the diagnostic accuracy of hiatal hernia in patients undergoing bariatric surgery. Obes Surg 2012;22:1730–3. [7] Soricelli E, Iossa A, Casella G, Abbatini F, Calì B, Basso N. Sleeve gastrectomy and crural repair in obese patients with gastroesophageal reflux disease and/or hiatal hernia. Surg Obes Relat Dis 2013;9: 356–61.
W. R. J. Carr et al. / Surgery for Obesity and Related Diseases 11 (2015) 379–385
[3] Rogers AM. Improvement of esophageal dysmotility after conversion from gastric banding to gastric bypass. Surg Obes Relat Dis 2010;6: 681–3. [4] Van Gemert WG, van Wersch MM, Greve JW, Soeters PB. Revisional surgery after failed vertical banded gastroplasty: restoration of vertical banded gastroplasty or conversion to gastric bypass. Obes Surg 1998;8:21–8. [5] Alhamdani A, Wilson M, Jones T, et al. Laparoscopic adjustable gastric banding: a 10-year single-centre experience of 575 cases with weight loss following surgery. Obes Surg 2012;22:1029–38. [6] Müller MK, Attigah N, Wildi S, et al. High secondary failure rate of rebanding after failed gastric banding. Surg Endosc 2008;22:448–53. [7] Bueter M, Thalheimer A, Wierlemann A, Fein M. Reoperations after gastric banding: replacement or alternative procedures? Surg Endosc 2009;23:334–40. [8] Jennings NA, Boyle M, Mahawar K, Balupuri S, Small PK. Revisional laparoscopic Roux-en-Y gastric bypass following failed laparoscopic adjustable gastric banding. Obes Surg 2013;23:947–52. [9] Mognol P, Chosidow D, Marmuse J-P. Laparoscopic conversion of laparoscopic gastric banding to Roux-en-Y gastric bypass: a review of 70 patients. Obes Surg 2004;14:1349–53. [10] Ardestani A, Lautz DB, Tavakkolizadeh A. Band revision versus Roux-en-Y gastric bypass conversion as salvage operation after laparoscopic adjustable gastric banding. Surg Obes Relat Dis 2011;7: 33–7. [11] Calmes JM, Giusti V, Suter M. Reoperative laparoscopic Roux-en-Y gastric bypass: an experience with 49 cases. Obes Surg 2005;15: 316–22. [12] Lanthaler M, Mittermair R, Erne B, Weiss H, Aigner F, Nehoda H. Laparoscopic gastric re-banding versus laparoscopic gastric bypass as a rescue operation for patients with pouch dilatation. Obes Surg 2006;16:484–7. [13] Rosenthal RJ, Diaz AA, Arvidsson D, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of 412,000 cases. Surg Obes Relat Dis 2012;8:8–19. [14] Coblijn UK, Verveld CJ, van Wagensveld BA, Lagarde SM. Laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy as revisional procedure after adjustable gastric band—a systematic review. Obes Surg 2013;23:1899–914.
[15] Victorzon M, Tolonen P. Mean fourteen-year 100% follow-up of laparoscopic adjustable gastric banding for morbid obesity. Surg Obes Realt Dis 2013;9:753–7. [16] Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23:427–36. [17] Schouten R, Japink D, Meesters B, Nelemans PJ, Greve JWM. Systematic literature review of reoperations after gastric banding: is a stepwise approach justified? Surg Obes Relat Dis 2011;7:99–109. [18] Foletto M, Prevedello L, Bernante P, et al. Sleeve gastrectomy as revisional procedure for failed gastric banding or gastroplasty. Surg Obes Relat Dis 2010;6:146–51. [19] Berende CAS, de Zoete J-P, Smulders JF, Nienhuijs SW. Laparoscopic sleeve gastrectomy feasible for bariatric revision surgery. Obes Surg 2012;22:330–4. [20] Utech M, Shaheen H, Halter J, et al. Sleeve gastrectomy as a revision procedure for Failed Gastric Banding. Zentralbl Chir 2014;139: 79–82. [21] Yazbek T, Safa N, Denis R, Atlas H, Garneau PY. Laparoscopic sleeve gastrectomy (LSG)-a good bariatric option for failed laparoscopic adjustable gastric banding (LAGB): a review of 90 patients. Obes Surg 2013;23:300–5. [22] Acholonu E, McBean E, Court I, Bellorin O, Szomstein S, Rosenthal RJ. Safety and short-term outcomes of laparoscopic sleeve gastrectomy as a revisional approach for failed laparoscopic adjustable gastric banding in the treatment of morbid obesity. Obes Surg 2009;19:1612–6. [23] Peterli R, Borbély Y, Kern B, et al. Early results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. Ann Surg 2013;258:690–5. [24] Mahawar KK, Jennings N, Balupuri S, Small PK. Sleeve gastrectomy and gastro-oesophageal reflux disease: a complex relationship. Obes Surg 2013;23:987–91. [25] Khoursheed M, Al-Bader I, Mouzannar A, et al. Sleeve gastrectomy or gastric bypass as revisional bariatric procedures: retrospective evaluation of outcomes. Surg Endosc 2013;27:4277–83. [26] Jacobs M, Gomez E, Romero R, Jorge I, Fogel R, Celaya C. Failed restrictive surgery: is sleeve gastrectomy a good revisional procedure? Obes Surg 2011;21:157–60
Editorial comment
Comment on: A retrospective comparison of early results of conversion of failed gastric banding to sleeve gastrectomy or gastric bypass In this study, Carr et al. addressed the problem of band failure comparing the Roux-en-Y gastric bypass (RYGB) and the sleeve gastrectomy (SG) that are currently the 2 preferred surgical options for what has become a very common problem in bariatric surgery. Laparoscopic adjustable gastric band (LAGB) failure has certainly become a main concern, because a large number of morbidly obese patients have undergone this procedure. However, many patients are still offered the LAGB is spite of the high rate of long-term failure. The main reasons for its popularity are its simple and straightforward surgical technique and the very low rate of immediate postoperative complications and mortality [1].
The argument of reversibility has also been used in the past as one of the “benefits” of LAGB. However, it is now clear that band related scar tissue around the esophagogastric junction may complicate the reoperative surgery at a point that a 2 step approach is required in a significant proportion of patients. Interestingly, Carr et al. reported a significant difference in the need for 2 steps for LAGB to SG conversion compared with laparoscopic Roux-en-Y gastric bypass (LRYGB). The authors’ explanation for this difference was the increased number of patients presenting with emergency band complications and a dilated and/or inflamed pouch in the group of patients undergoing SG.
Conversion of LAGB to LSG or LRYGB Achieves Comparable Outcomes / Surgery for Obesity and Related Diseases 11 (2015) 379–385
However, this may also reflect the intention to avoid as much as possible the occurrence of a high leak, as the latter may be very difficult to manage. Indeed, the literature shows that conversion from band to SG increases the risk of this most feared complication [2]. We recently provided evidence that there is no difference between band conversion and primary SG when surgery is done in the hands of experienced bariatric surgeons [3]. We also found that the 2-step approach reduces the risk of a leak, when all the published series were compared for the one versus the 2-step approach [3]. Plausible explanations are the more favorable anatomic conditions, including the partial regression of band related scar tissue and the fact that the gastrogastric tunnel has already been dismantled. Both may impair the delicate process of tissue stapling and be responsible for increased risk of leak and/or the persistence of part of the gastric fundus as in the case of concomitant band removal and conversion. In the case of RYGB, the main technical point is where to staple the stomach, below or above the band scar. My preference is to shape a long narrow pouch that has a reduced tendency to dilate over time and empties slower than a short and large pouch according to the La Place’s and Poiseuille's laws [4,5]. Most authors advocate the division of the stomach above the band, as the dissection is easier to do and falls above the band related scar tissue. However, such a short pouch may be source of tension on the gastrojejunostomy and result in a leak. Furthermore, the adhesions around the stomach generated by the band fix the former to the surrounding tissues preventing the pouch to accommodate the downward pull of the Roux-en-Y (RY) loop. Consequently, the tension may increase the risk of ischemic complications. The policy of dividing the stomach below the band scar advocated by Carr et al. most probably accounts for their low rate of leak. Band erosion is a major risk factor for staple line or anastomotic leak when converting a band to another procedure. My personal preference is splitting the procedure into 2 steps, waiting as long as possible before the second step, and doing a RYGB. Indeed, any leak, anastomotic or staple line related, is easier to manage in the setting of a RYGB. Such a leak may easily become a nightmare in the case of a SG. In any case patients should be fully informed about the risk of serious postoperative complications. The other main point concerns the risk of gastroesophageal reflux disease (GERD) that may be aggravated by the SG, whereas, the RYGB is an anti-reflux procedure. The latter avoids reflux because of the Roux-en-Y anatomy, the exclusion of the fundus, and the small size of the gastric pouch, but also because the Roux-en-Y anatomy mechanically pulls the stomach into the abdomen, reducing a hiatal hernia when present. For these reasons, clinical and endoscopic signs of GERD should be assessed and a hiatal hernia eliminated in all candidates for conversion to SG with both an esophagogastric endoscopy and
385
gastrointestinal radiographic series [6]. Soricelli et al. recently showed that if the hiatal hernia is systematically searched for during surgery and fixed when found, the rate of de novo GERD is significantly reduced [7]. This indicates that a misdiagnosed hiatal hernia may be responsible for the appearance of de novo GERD after SG. Indeed, Carr et al. reported 3 cases of de novo reflux (3/25; 12%) in the group of patients undergoing SG at the time of follow-up. On the other hand, in the presence of documented GERD, especially in the presence of esophagitis and/or hiatal hernia, the RYGB should be considered the procedure of choice. Although the excess weight loss was the same after both procedures in the study by Carr et al., these results only refer to a very limited follow-up with only half of the patients seen at 2 years. Weight loss in patients undergoing a second bariatric procedure for weight loss failure, representing half of the cases in the study by Carr et al., is difficult to predict and may be poorer than in primary procedures as patients are less compliant and more reluctant to change eating behaviors responsible for failure of the first procedure. This study further proves that SG can be achieved with comparable morbidity as RYGB after failed LAGB. De novo GERD after SG remains a concern as identifying which patients will develop this complication after surgery may be difficult. The loss of excess weight must be investigated in the long-term. Given the magnitude of the problem, the issue of what is the best procedure for failed bands should be addressed in a randomized trial. Antonio Iannelli, MD, Ph.D. Digestive Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France References [1] Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I. Trends in mortality in bariatric surgery: A systematic review and meta-analysis. Surgery 2007;142:621–35. [2] Rebibo L, Mensah E, Verhaeghe P, et al. Simultaneous gastric band removal and sleeve gastrectomy: a comparison with front-line sleeve gastrectomy. Obes Surg 2012;22:1420–6. [3] Noel P, Schneck AS, Nedelcu M, et al. Laparoscopic sleeve gastrectomy as a revisional procedure for failed gastric banding: lessons from 300 consecutive cases. Surg Obes Relat Dis 2014. pii: S1550-7289(14) 00123. [4] Capella RF, Iannace VA, Capella JF. An analysis of gastric pouch anatomy in bariatric surgery. Obes Surg 2008;18:782–90. [5] Iannelli A, Kassir R, Schneck AS, Gugenheim J. The long and narrow pouch for Roux-en-Y gastric bypass. Obes Surg. In press. [6] Heacock L, Parikh M, Jain R, Balthazar E, Hindman N. Improving the diagnostic accuracy of hiatal hernia in patients undergoing bariatric surgery. Obes Surg 2012;22:1730–3. [7] Soricelli E, Iossa A, Casella G, Abbatini F, Calì B, Basso N. Sleeve gastrectomy and crural repair in obese patients with gastroesophageal reflux disease and/or hiatal hernia. Surg Obes Relat Dis 2013;9: 356–61.