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Laparoscopic sleeve gastrectomy after failed gastric banding: is it really effective? Six years of follow-up
Surgery for Obesity and Related Diseases ] (2017) 00–00
Paired editorial
Laparoscopic sleeve gastrectomy after failed gastric banding: is it really effective? Six years of follow-up In this issue of Surgery for Obesity and Related Diseases, Carandina et al. [1] from University Hospital in France publish their study comparing outcomes and long-term follow-up of patients receiving primary sleeve gastrectomy (SG) with those undergoing conversion to SG after failed laparoscopic adjustable gastric band (LAGB). Follow-up was at 3-month intervals for first 2 years, 6-month intervals for year 3, and annually to year 6. This is a highly relevant and timely comparison, as the paradigm shift away from LAGB has now positioned SG as the most commonly performed bariatric procedure in the United States exceeding 50% compared to only 6% for LAGB. The initial wave of enthusiasm for LAGB has largely diminished due to band complication profiles (migration, slippage, pouch dilation) and high late weight-loss failures. As such, the bariatric surgical community can also expect to see increasing numbers of LAGB recipients requiring conversion to a more sustainable bariatric intervention in the future. The authors focus on outcomes after conversion to SG based on the indication for band removal: either failed weight loss or band related complications. The aim of the study was to determine whether conversion to SG after failed LAGB is safe and effective compared with primary SG. All patients underwent a 2-staged standard surgical approach performed by 2 surgeons. Of 701 patients undergoing SG, 100 (14.3%) were converted from LAGB and overall morbidity was comparable between the groups. Regardless of indication, a higher weight loss failure (excess weight loss o50%) was observed at each follow-up period in the conversion group compared with the primary sleeve group. Furthermore, patients undergoing conversion for failed weight loss demonstrated less weight loss compared with patients converted for band-related complications. This is similar to what other centers have reported and raises the question of which revisional procedure will provide the most durable weight loss with the least number of early and late complications.
Regarding safety, Carandina et al. demonstrate that a 2-stage SG after failed LAGB can be done with morbidity comparable to primary SG [1]. This was also demonstrated in one of the largest series of 300 patients by Noel et al. [2]. Although many authors perform 2-stage procedures to reduce perioperative leak rate, this practice has been increasingly challenged with single stage procedures offering comparable morbidity and outcomes at reduced cost [3]. Finally, this paper raises questions as to whether it is appropriate to convert one failed restrictive procedure for another, especially when patients undergo revision for failed weight loss [1]. In this regard, a malabsorptive procedure such as Roux-en-Y gastric bypass may be a more durable option. Technically, conversion from band to either SG or Roux-en-Y gastric bypass is feasible. Both have low rates of complications and good short-term results related to weight loss. Only a randomized trial or large retrospective study with long-term follow-up will determine whether one procedure outperforms the other. Andrea Pakula, M.D., M.P.H., F.A.C.S. Department of Surgery, Kern Medical Bakersfield, California
References [1] Carandina S, Genser L, Bossi M, Polliand C, Tabbara M, Barrat C. Laparoscopic sleeve gastrectomy after failed gastric banding: is it really effective? Six years of follow-up. Surg Obes Relat Dis 2017. pii: S1550-7289(17)30069-2. [2] Noel P, Schneck A, 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;10(6):1116–22. [3] Aarts E, Koehestanie P, Dogan K, Berends F, Janssen I. Revisional surgery after failed gastric banding: results of one-stage conversion to RYGB in 195 patients. Surg Obes Relat Dis 2014;10(6):1077–83.
http://dx.doi.org/10.1016/j.soard.2017.03.010 1550-7289/r 2017 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Paired editorial
Laparoscopic sleeve gastrectomy after failed gastric banding: is it really effective? Six years of follow-up In this issue of Surgery for Obesity and Related Diseases, Carandina et al. [1] from University Hospital in France publish their study comparing outcomes and long-term follow-up of patients receiving primary sleeve gastrectomy (SG) with those undergoing conversion to SG after failed laparoscopic adjustable gastric band (LAGB). Follow-up was at 3-month intervals for first 2 years, 6-month intervals for year 3, and annually to year 6. This is a highly relevant and timely comparison, as the paradigm shift away from LAGB has now positioned SG as the most commonly performed bariatric procedure in the United States exceeding 50% compared to only 6% for LAGB. The initial wave of enthusiasm for LAGB has largely diminished due to band complication profiles (migration, slippage, pouch dilation) and high late weight-loss failures. As such, the bariatric surgical community can also expect to see increasing numbers of LAGB recipients requiring conversion to a more sustainable bariatric intervention in the future. The authors focus on outcomes after conversion to SG based on the indication for band removal: either failed weight loss or band related complications. The aim of the study was to determine whether conversion to SG after failed LAGB is safe and effective compared with primary SG. All patients underwent a 2-staged standard surgical approach performed by 2 surgeons. Of 701 patients undergoing SG, 100 (14.3%) were converted from LAGB and overall morbidity was comparable between the groups. Regardless of indication, a higher weight loss failure (excess weight loss o50%) was observed at each follow-up period in the conversion group compared with the primary sleeve group. Furthermore, patients undergoing conversion for failed weight loss demonstrated less weight loss compared with patients converted for band-related complications. This is similar to what other centers have reported and raises the question of which revisional procedure will provide the most durable weight loss with the least number of early and late complications.
Regarding safety, Carandina et al. demonstrate that a 2-stage SG after failed LAGB can be done with morbidity comparable to primary SG [1]. This was also demonstrated in one of the largest series of 300 patients by Noel et al. [2]. Although many authors perform 2-stage procedures to reduce perioperative leak rate, this practice has been increasingly challenged with single stage procedures offering comparable morbidity and outcomes at reduced cost [3]. Finally, this paper raises questions as to whether it is appropriate to convert one failed restrictive procedure for another, especially when patients undergo revision for failed weight loss [1]. In this regard, a malabsorptive procedure such as Roux-en-Y gastric bypass may be a more durable option. Technically, conversion from band to either SG or Roux-en-Y gastric bypass is feasible. Both have low rates of complications and good short-term results related to weight loss. Only a randomized trial or large retrospective study with long-term follow-up will determine whether one procedure outperforms the other. Andrea Pakula, M.D., M.P.H., F.A.C.S. Department of Surgery, Kern Medical Bakersfield, California
References [1] Carandina S, Genser L, Bossi M, Polliand C, Tabbara M, Barrat C. Laparoscopic sleeve gastrectomy after failed gastric banding: is it really effective? Six years of follow-up. Surg Obes Relat Dis 2017. pii: S1550-7289(17)30069-2. [2] Noel P, Schneck A, 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;10(6):1116–22. [3] Aarts E, Koehestanie P, Dogan K, Berends F, Janssen I. Revisional surgery after failed gastric banding: results of one-stage conversion to RYGB in 195 patients. Surg Obes Relat Dis 2014;10(6):1077–83.
http://dx.doi.org/10.1016/j.soard.2017.03.010 1550-7289/r 2017 American Society for Metabolic and Bariatric Surgery. All rights reserved.