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Outcome following resectional gastric bypass for failed bariatric surgery
THE GARY P. WRATTEN SURGICAL SYMPOSIUM Outcome Following Resectional Gastric Bypass for Failed Bariatric Surgery THOMAS K. CURRY, MD, PRESTON L. CARTER, MD, FACS, DAVID M. WATTS, MD, FACS, AND CLIFFORD PORTER, MD, FACS Purpose: An increasing number of patients who have failed a primary bariatric procedure are presenting for revisional surgery. There are few studies examining the outcome following any revisional surgery, and none examining resectional gastric bypass (RGB) in this role. We examine the indications, outcome, and patient satisfaction following conversion of a prior bariatric procedure to the RGB. Methods: From May 1992 to May 1998, 38 patients underwent RGB as a conversion from prior bariatric operations. Weight loss, indications, and complications were reviewed. A patient survey was used to examine patient satisfaction. Results: Mean body mass index decreased from 46 to 33 kg/m2 following revision to RGB. Median weight loss after revision to RGB was 34 kg. From the time of the initial bariatric procedure to post-RGB, mean body mass index decreased from 52 to 33 kg/m2. Patients with pre-RGB Visick scores of 3 or 4 improved following RGB. Ninety-five percent of respondents were satisfied with the RGB, and 85% thought it improved their lives. Constant nausea and vomiting and failure of weight control were the most common indications for revision. Conclusions: Resectional gastric bypass is a safe and effective revisional procedure for patients who have had failed or complicated bariatric surgery. (Curr Surg 1999;56:432– 434.)
The Roux-en-Y GB has been demonstrated to be more effective than VBG for long-term weight loss in randomized studies.3 Both operations are associated with a number of complications, such as outlet stenosis, reflux, and staple line dehiscence and marginal ulceration.4 –7 To avoid these complications, we perform a variation of the GB with resection of the distal bypassed stomach. This is called the resectional gastric bypass (RGB). Results in patients undergoing primary and revisional RGB are presented elsewhere.8 With the increase in popularity of bariatric surgery, there has been an increase in failed or complicated operations. Few studies examine the objective outcome and the quality of life following revision of a primary bariatric surgery. In this study we examine the role of the RGB performed as a revision of a primary failed bariatric operation. PATIENTS AND METHODS From April 1992 to July 1998, 38 patients underwent RGB as a revision of a primary bariatric procedure. The operations were performed in a tertiary care military hospital by second- through fifth-year general surgery residents assisted by 1 of 3 general surgery staff (P.L.C., D.M.W., C.P.). Patient records were reviewed for demographics, indication for primary and revision operations, and weight loss following RGB. A survey was mailed to all patients to examine their quality of life. Telephone follow-up was attempted for patients who did not return surveys, using their last known phone number, a hospital central database, and the Defense Eligibility Enrollment Reporting System database.
INTRODUCTION RESULTS Morbid obesity is a common health problem in the United States, leading to life-shortening conditions such as diabetes mellitus, hypertension, and cardiac and pulmonary problems.1 Surgical therapy is recognized as an effective longterm treatment of morbid obesity, with improvement in comorbid conditions.2 The most common surgical therapies are the verticalbanded gastroplasty (VBG) and the gastric bypass (GB).
432
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Thirty-six female and 2 male patients underwent RGB as a revision of a prior bariatric procedure. Nineteen female and 2 male patients responded to either the mailed survey or to telephone contact. Weight and body mass index (BMI) prebariatric procedure, pre-RGB, and post-RGB are summarized in Table 1. The 21 respondents had undergone a total of 27 procedures prior to RGB (Table 2). There was a median of 84 months between the patients’ first bariatric
Published 2000 by Elsevier Science Inc.
0149-7944/99/$20.00 PII S0149-7944(99)00160-9
Table 1 Bariatric procedures prior to resectional gastric bypass Vertical-banded gastroplasty Biliopancreatic diversions Jejunoileal bypass Revision or reversal of prior procedure Nondivided gastric bypass Adjustable silastic ring
15 4 3 3 1 1
procedures and their conversion to RGB. Mean follow-up post-RGB is 33 months. Only 1 patient has undergone an additional bariatric procedure following RGB. Indications for conversion to RGB are listed in Table 3. Postoperative complications in the 38 patients include 1 patient who experienced a leak from the enteroenterostomy requiring reoperation and a lengthy hospital stay prior to discharge. There were no gastric pouch leaks, iatrogenic splenic or hepatic injuries, or deaths in this series. Of patients available for follow-up, 15 of 16 female patients lost weight following revision to RGB. The remaining patient, who failed adjustable silastic VBG and then failed conversion to BPD, has subsequently failed RGB. The mean prebariatric surgery weight, excess body weight, and BMI were 142 kg, 82 kg, and 54 kg/m2, respectively. Median weight and BMI prior to RGB were 124 kg and 46 kg/m2. No patient had a BMI less than 38%. Current weight and BMI are 90 kg and 33 kg/m2. Patients lost a mean of 20% of their excess body weight after their initial procedure. This increased to 63% following revision to RGB. The most common indications for revision in this group were constant nausea or vomiting, followed by regain of or failure to lose weight. All but 4 of these patients had undergone VBG. Two others had weight regain following reversal of a malabsorptive procedure. The remaining patient had documented disruption of a staple line following conventional nondivided GB with regain of weight. Both male patients in our series were revised primarily for failure to lose weight or maintain weight loss following VBG. One patient had outlet stenosis, was limited to a liquid diet, and was in constant pain. Despite his limitations, he was able to regain almost all his original weight. Mean prebariatric weight, excess body weight, and BMI were 140 kg, 72 kg, and 48 kg/m2. Pre-RGB weight and BMI were 137 kg and 47 kg/m2. These patients lost less than 8% of excess body weight following their initial procedure. This increased to 36% and 92% following RGB. Post-RGB weight and BMI are 95 kg and 33 kg/m2.
Table 2 Median weights and body mass index (BMI) Female
Male
140 58 108 41 89 33
140 48 137 48 95 32
Prebariatric weight (kg) Prebariatric BMI (kg/m2) Pre-RGB weight Pre-RGB BMI Post-RGB weight Post-RGB BMI RGB ⫽ resectional gastric bypass. CURRENT SURGERY
•
Table 3 Indication for revision to resectional gastric bypass Constant nausea or emesis Regain of weight Outlet stenosis Malnourishment Failure to lose weight Constant pain Diarrhea Could not swallow Anemia Excessive weight loss
9 8 7 7 6 6 5 5 3 1
Five female patients gained an average of 12 kg following conversion to RGB. Three were converted from malabsorbing procedures (2 biliopancreatic diversions and 1 jejunoileal bypass) and 2 from VBG. Mean prebariatric weight, excess body weight, and BMI were 134 kg, 74 kg, and 50 kg/m2, respectively. Pre-RGB weight and BMI were 74 kg and 28 kg/m2. Body mass index increased to 32 kg/m2 postrevision. All patients converted from malabsorbing procedures complained of constant diarrhea and a need for daily electrolyte supplementation. The 2 patients with prior VBGs complained of constant emesis, pain, and inability to consistently eat solids. All patients had a Visick score9 of 4, which improved to 1.2 following RGB. All patients report complete resolution of the symptoms that prompted revision. Ninety-five percent (20/21) of respondents were satisfied or very satisfied with the outcome following their revision. Ninety percent (19/21) think revision improved their lives. All patients are satisfied with the kinds of food they can eat, and 95% are satisfied with the volume they can eat. Only 10% feel limited by their diet in any way. No patient feels he or she has lost too much weight. All but one patient expresses desire to lose more weight. Ninety-five percent of patients would recommend RGB to another obese person considering surgical weight control. DISCUSSION The patient who experiences failure of a bariatric procedure presents unique challenges for the general surgeon. The etiology of failure is multifactorial, with technical failure, infection, and patient factors all playing a role. The GB requires revision in 5% to 29% of patients.5–7,10 Fobi reports need for revision in one third of patients undergoing VBG.11 Little consensus exists on the proper approach, the correct revisional procedure, or whether revisional surgery is effective or warranted. The University of Kentucky series had a high incidence of complications and poor weight loss in patients undergoing revision of the conventional GB.10 Those involved with other series report substantially fewer complications. The Mayo Clinic series of 61 patients undergoing revisional surgery had acceptable morbidity and mortality. In the Mayo Clinic doctors’ experience, conversion to a conventional GB produced more effective weight loss than VBG.11 At our institution, the standard operation for primary and revisional bariatric surgery is the RGB.8 By resecting the distal stomach, we avoid the complications of staple line disruption, gastrogastric fistula, and acid problems in the distal stomach that have prompted revision in other series.5–7 As with other revisional procedures, RGB in the revisional
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patient is technically more complicated by the often dense adhesions to adjacent structures, especially in the VBG patient. The resection of the distal stomach, including old staple lines and prosthetic material, ensures optimal perfusion and exposure of the anastomic site. Revisional RGB can convert a weight-loss failure into a success. Male and female patients who either failed to lose weight or regained weight lost a mean of 29 kg following revision to RGB, with a decrease in mean BMI from 47 to 34 kg/m2. After revision to RGB, the percent of excess body weight lost increased from 20% to 63%. This is similar to other reported series.11 Patients with debilitating complications or malnutrition following bariatric procedures often improve following conversion to RGB. Five patients in our series were revised for intolerable symptoms not responsive to conservative management. Three of these patients had undergone malabsorbing procedures; 2 had near-complete gastric obstruction following VBG. All patients report resolution of their symptoms. Of the 18 patients who underwent revision for failure of weight loss, 7 complained of frequent nausea or emesis following their initial procedure. All 7 report improvement or resolution after RGB. Three complained of frequent epigastric pain, which was relieved following revision. The 2 patients revised from malabsorbing procedures reported resolution of their diarrhea. Patient satisfaction with the RGB is good. While 95% of the patients expressed a desire to lose more weight, an equal percentage would recommend this operation to another person. Overall satisfaction with food type and volume intake is excellent, and very few express a sense of limitation with their diet. Our study has several limitations. It is not controlled, nor is our cohort compared to another group undergoing different approaches to the failed bariatric operation. Only 55% of our patients could be contacted for follow-up. This is a problem with any patient group in the military system, with frequent moves, increasingly difficult access to military care for retirees, and losses of eligibility due to termination of military service. Data on lifestyle limitation were gathered retrospectively, sometimes years after the fact.
434
CONCLUSIONS The RGB is safe as a revision of a prior bariatric operation. When performed for a failure of weight loss, it can produce weight loss comparable to other primary bariatric procedures. Many patients suffering debilitating symptoms will improve following revision to RGB. THOMAS K. CURRY, MD* PRESTON L. CARTER, MD, FACS† DAVID M. WATTS, MD, FACS† CLIFFORD PORTER, MD, FACS† *Department of General Surgery Weed Army Community Hospital Fort Irwin, California †Madigan Army Medical Center Tacoma, Washington REFERENCES 1. Drenic EJ, Bale GS, Seltzer F, Johnson DG. Excess mortality and causes of death in morbidly obese men. JAMA 1980;243:443– 445. 2. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult onset diabetes mellitus. Ann Surg 1995;222:339 –352. 3. Sugarman HJ, Starkey JV, Birkenhauer R. A randomized prospective trial of gastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus non-sweets eaters. Ann Surg 1987;205:613– 624. 4. MacLean LD, Rhode BM, Forse RA. Late results of vertical banded gastroplasty for morbid and super obesity. Surgery 1990;107:20 – 27. 5. MacLean LD, Rhode BM, Nohr C, Katz S, McLean AP. Stomal ulcer after gastric bypass. J Am Coll Surg 1997;185:1–7. 6. Sugarman HJ, Kellum JM Jr, De Maria EJ, Reines HD. Conversion of failed or complicated vertical banded gastroplasty of gastric bypass in morbid obesity. Am J Surg 1996;171:263–269. 7. Jordan JH, Hocking MP, Rout WR, Woodward ER. Marginal ulcer following gastric bypass for morbid obesity. Am Surg 1991;57:286 – 288. 8. Curry TK, Carter PL, Porter CA, Watts DM. Resectional gastric bypass is a new alternative in morbid obesity. Am J Surg 1998;175: 367–370. 9. Visick AH. A study of the failures after gastrectomy: Hunterian lecture. Ann R Coll Surg 1948;3:266 –284. 10. Schwartz RW, Strodel WE, Simpson WS, Griffen WO Jr. Gastric bypass revision: lessons learned from 920 cases. Surgery 1988;104: 806 – 812. 11. Fobi MAL, Lee H, Holness R, Cabinda D. Gastric bypass operation for obesity. World J Surg 1998;22:925–935.
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Volume 56 / Numbers 7/8 • September/October 1999
The Roux-en-Y GB has been demonstrated to be more effective than VBG for long-term weight loss in randomized studies.3 Both operations are associated with a number of complications, such as outlet stenosis, reflux, and staple line dehiscence and marginal ulceration.4 –7 To avoid these complications, we perform a variation of the GB with resection of the distal bypassed stomach. This is called the resectional gastric bypass (RGB). Results in patients undergoing primary and revisional RGB are presented elsewhere.8 With the increase in popularity of bariatric surgery, there has been an increase in failed or complicated operations. Few studies examine the objective outcome and the quality of life following revision of a primary bariatric surgery. In this study we examine the role of the RGB performed as a revision of a primary failed bariatric operation. PATIENTS AND METHODS From April 1992 to July 1998, 38 patients underwent RGB as a revision of a primary bariatric procedure. The operations were performed in a tertiary care military hospital by second- through fifth-year general surgery residents assisted by 1 of 3 general surgery staff (P.L.C., D.M.W., C.P.). Patient records were reviewed for demographics, indication for primary and revision operations, and weight loss following RGB. A survey was mailed to all patients to examine their quality of life. Telephone follow-up was attempted for patients who did not return surveys, using their last known phone number, a hospital central database, and the Defense Eligibility Enrollment Reporting System database.
INTRODUCTION RESULTS Morbid obesity is a common health problem in the United States, leading to life-shortening conditions such as diabetes mellitus, hypertension, and cardiac and pulmonary problems.1 Surgical therapy is recognized as an effective longterm treatment of morbid obesity, with improvement in comorbid conditions.2 The most common surgical therapies are the verticalbanded gastroplasty (VBG) and the gastric bypass (GB).
432
CURRENT SURGERY
•
Thirty-six female and 2 male patients underwent RGB as a revision of a prior bariatric procedure. Nineteen female and 2 male patients responded to either the mailed survey or to telephone contact. Weight and body mass index (BMI) prebariatric procedure, pre-RGB, and post-RGB are summarized in Table 1. The 21 respondents had undergone a total of 27 procedures prior to RGB (Table 2). There was a median of 84 months between the patients’ first bariatric
Published 2000 by Elsevier Science Inc.
0149-7944/99/$20.00 PII S0149-7944(99)00160-9
Table 1 Bariatric procedures prior to resectional gastric bypass Vertical-banded gastroplasty Biliopancreatic diversions Jejunoileal bypass Revision or reversal of prior procedure Nondivided gastric bypass Adjustable silastic ring
15 4 3 3 1 1
procedures and their conversion to RGB. Mean follow-up post-RGB is 33 months. Only 1 patient has undergone an additional bariatric procedure following RGB. Indications for conversion to RGB are listed in Table 3. Postoperative complications in the 38 patients include 1 patient who experienced a leak from the enteroenterostomy requiring reoperation and a lengthy hospital stay prior to discharge. There were no gastric pouch leaks, iatrogenic splenic or hepatic injuries, or deaths in this series. Of patients available for follow-up, 15 of 16 female patients lost weight following revision to RGB. The remaining patient, who failed adjustable silastic VBG and then failed conversion to BPD, has subsequently failed RGB. The mean prebariatric surgery weight, excess body weight, and BMI were 142 kg, 82 kg, and 54 kg/m2, respectively. Median weight and BMI prior to RGB were 124 kg and 46 kg/m2. No patient had a BMI less than 38%. Current weight and BMI are 90 kg and 33 kg/m2. Patients lost a mean of 20% of their excess body weight after their initial procedure. This increased to 63% following revision to RGB. The most common indications for revision in this group were constant nausea or vomiting, followed by regain of or failure to lose weight. All but 4 of these patients had undergone VBG. Two others had weight regain following reversal of a malabsorptive procedure. The remaining patient had documented disruption of a staple line following conventional nondivided GB with regain of weight. Both male patients in our series were revised primarily for failure to lose weight or maintain weight loss following VBG. One patient had outlet stenosis, was limited to a liquid diet, and was in constant pain. Despite his limitations, he was able to regain almost all his original weight. Mean prebariatric weight, excess body weight, and BMI were 140 kg, 72 kg, and 48 kg/m2. Pre-RGB weight and BMI were 137 kg and 47 kg/m2. These patients lost less than 8% of excess body weight following their initial procedure. This increased to 36% and 92% following RGB. Post-RGB weight and BMI are 95 kg and 33 kg/m2.
Table 2 Median weights and body mass index (BMI) Female
Male
140 58 108 41 89 33
140 48 137 48 95 32
Prebariatric weight (kg) Prebariatric BMI (kg/m2) Pre-RGB weight Pre-RGB BMI Post-RGB weight Post-RGB BMI RGB ⫽ resectional gastric bypass. CURRENT SURGERY
•
Table 3 Indication for revision to resectional gastric bypass Constant nausea or emesis Regain of weight Outlet stenosis Malnourishment Failure to lose weight Constant pain Diarrhea Could not swallow Anemia Excessive weight loss
9 8 7 7 6 6 5 5 3 1
Five female patients gained an average of 12 kg following conversion to RGB. Three were converted from malabsorbing procedures (2 biliopancreatic diversions and 1 jejunoileal bypass) and 2 from VBG. Mean prebariatric weight, excess body weight, and BMI were 134 kg, 74 kg, and 50 kg/m2, respectively. Pre-RGB weight and BMI were 74 kg and 28 kg/m2. Body mass index increased to 32 kg/m2 postrevision. All patients converted from malabsorbing procedures complained of constant diarrhea and a need for daily electrolyte supplementation. The 2 patients with prior VBGs complained of constant emesis, pain, and inability to consistently eat solids. All patients had a Visick score9 of 4, which improved to 1.2 following RGB. All patients report complete resolution of the symptoms that prompted revision. Ninety-five percent (20/21) of respondents were satisfied or very satisfied with the outcome following their revision. Ninety percent (19/21) think revision improved their lives. All patients are satisfied with the kinds of food they can eat, and 95% are satisfied with the volume they can eat. Only 10% feel limited by their diet in any way. No patient feels he or she has lost too much weight. All but one patient expresses desire to lose more weight. Ninety-five percent of patients would recommend RGB to another obese person considering surgical weight control. DISCUSSION The patient who experiences failure of a bariatric procedure presents unique challenges for the general surgeon. The etiology of failure is multifactorial, with technical failure, infection, and patient factors all playing a role. The GB requires revision in 5% to 29% of patients.5–7,10 Fobi reports need for revision in one third of patients undergoing VBG.11 Little consensus exists on the proper approach, the correct revisional procedure, or whether revisional surgery is effective or warranted. The University of Kentucky series had a high incidence of complications and poor weight loss in patients undergoing revision of the conventional GB.10 Those involved with other series report substantially fewer complications. The Mayo Clinic series of 61 patients undergoing revisional surgery had acceptable morbidity and mortality. In the Mayo Clinic doctors’ experience, conversion to a conventional GB produced more effective weight loss than VBG.11 At our institution, the standard operation for primary and revisional bariatric surgery is the RGB.8 By resecting the distal stomach, we avoid the complications of staple line disruption, gastrogastric fistula, and acid problems in the distal stomach that have prompted revision in other series.5–7 As with other revisional procedures, RGB in the revisional
Volume 56 / Numbers 7/8 • September/October 1999
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patient is technically more complicated by the often dense adhesions to adjacent structures, especially in the VBG patient. The resection of the distal stomach, including old staple lines and prosthetic material, ensures optimal perfusion and exposure of the anastomic site. Revisional RGB can convert a weight-loss failure into a success. Male and female patients who either failed to lose weight or regained weight lost a mean of 29 kg following revision to RGB, with a decrease in mean BMI from 47 to 34 kg/m2. After revision to RGB, the percent of excess body weight lost increased from 20% to 63%. This is similar to other reported series.11 Patients with debilitating complications or malnutrition following bariatric procedures often improve following conversion to RGB. Five patients in our series were revised for intolerable symptoms not responsive to conservative management. Three of these patients had undergone malabsorbing procedures; 2 had near-complete gastric obstruction following VBG. All patients report resolution of their symptoms. Of the 18 patients who underwent revision for failure of weight loss, 7 complained of frequent nausea or emesis following their initial procedure. All 7 report improvement or resolution after RGB. Three complained of frequent epigastric pain, which was relieved following revision. The 2 patients revised from malabsorbing procedures reported resolution of their diarrhea. Patient satisfaction with the RGB is good. While 95% of the patients expressed a desire to lose more weight, an equal percentage would recommend this operation to another person. Overall satisfaction with food type and volume intake is excellent, and very few express a sense of limitation with their diet. Our study has several limitations. It is not controlled, nor is our cohort compared to another group undergoing different approaches to the failed bariatric operation. Only 55% of our patients could be contacted for follow-up. This is a problem with any patient group in the military system, with frequent moves, increasingly difficult access to military care for retirees, and losses of eligibility due to termination of military service. Data on lifestyle limitation were gathered retrospectively, sometimes years after the fact.
434
CONCLUSIONS The RGB is safe as a revision of a prior bariatric operation. When performed for a failure of weight loss, it can produce weight loss comparable to other primary bariatric procedures. Many patients suffering debilitating symptoms will improve following revision to RGB. THOMAS K. CURRY, MD* PRESTON L. CARTER, MD, FACS† DAVID M. WATTS, MD, FACS† CLIFFORD PORTER, MD, FACS† *Department of General Surgery Weed Army Community Hospital Fort Irwin, California †Madigan Army Medical Center Tacoma, Washington REFERENCES 1. Drenic EJ, Bale GS, Seltzer F, Johnson DG. Excess mortality and causes of death in morbidly obese men. JAMA 1980;243:443– 445. 2. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult onset diabetes mellitus. Ann Surg 1995;222:339 –352. 3. Sugarman HJ, Starkey JV, Birkenhauer R. A randomized prospective trial of gastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus non-sweets eaters. Ann Surg 1987;205:613– 624. 4. MacLean LD, Rhode BM, Forse RA. Late results of vertical banded gastroplasty for morbid and super obesity. Surgery 1990;107:20 – 27. 5. MacLean LD, Rhode BM, Nohr C, Katz S, McLean AP. Stomal ulcer after gastric bypass. J Am Coll Surg 1997;185:1–7. 6. Sugarman HJ, Kellum JM Jr, De Maria EJ, Reines HD. Conversion of failed or complicated vertical banded gastroplasty of gastric bypass in morbid obesity. Am J Surg 1996;171:263–269. 7. Jordan JH, Hocking MP, Rout WR, Woodward ER. Marginal ulcer following gastric bypass for morbid obesity. Am Surg 1991;57:286 – 288. 8. Curry TK, Carter PL, Porter CA, Watts DM. Resectional gastric bypass is a new alternative in morbid obesity. Am J Surg 1998;175: 367–370. 9. Visick AH. A study of the failures after gastrectomy: Hunterian lecture. Ann R Coll Surg 1948;3:266 –284. 10. Schwartz RW, Strodel WE, Simpson WS, Griffen WO Jr. Gastric bypass revision: lessons learned from 920 cases. Surgery 1988;104: 806 – 812. 11. Fobi MAL, Lee H, Holness R, Cabinda D. Gastric bypass operation for obesity. World J Surg 1998;22:925–935.
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Volume 56 / Numbers 7/8 • September/October 1999