Laparoscopic Revision Surgery of Failed Bariatric Procedures

September 5, 2018

Bariatric surgery has been shown to be a safe and effective long-term treatment for obesity. Over the past 25 years, there has been an increase in the number of primary bariatric operations in the United States. As a result of this trend, revisional bariatric procedures are expected to increase. The incidence of revisional bariatric surgery is between 3% and 60%, depending on the type of primary operation.

Over a decade follow-up, approximately 29-39% of patients who underwent a vertical banded gastroplasty (VBG) will require a revision. Revision rates for patients who had adjustable gastric banding (AGB) are up to 60%. Of the patients who underwent a gastric bypass (GBP), 3-13% will need revisional surgery.

The indications for revisional bariatric surgery are:

Inadequate weight loss
Weight regain
Complications

Inadequate weight loss or weight regain can occur after VBG, AGB or GBP due to a pouch or anastomotic (connection) dilation. The goals of revisional surgery for weight loss are to restore gastric restriction, add malabsorption or both. Due to adhesive disease (scar tissue) and altered anatomy, revisional procedures are expectedly more complex compared to primary bariatric procedures.

Outcomes of Laparoscopic Revision Surgery for Weight Loss

METHODS

Revision cases performed were identified and retrospectively analyzed. Patients were categorized into four groups:

Group 1 had an adjustable gastric band converted to gastric bypass as a single stage operation
Group 2 had a dilated gastric pouch after GBP and underwent a pouch reduction.
Group 3 had a GBP and underwent pouch reduction as well as elongation of the biliopancreatic limb (more malabsorption).
Group 4 had a VBG converted to GBP

All procedures were performed laparoscopically and the type of revision was determined by the above-outlined guidelines.

RESULTS

A total of 271 patients underwent revisional surgery during the study period and were categorized into four groups as described in (Table 1).

Table 1: Patient groups and demographics

Surgery	Conversion	Number of patients	Median age (years)	Sex (%) female)	BMI (kg/m2)
Group 1	AGB→GBP	67	38	76	40 +/- 2.8
Group 2	GBP pouch reduction	128	41	69	38 +/- 3.2
Group 3	GBP pouch reduction and elongation of BP limb	57	46	83	47 +/- 4.9
Group 4	VBG→GBP	19	67	100	46 +/- 5.3

AGB-adjustable gastric banding; GBP-gastric bypass;
VBG-vertical banded gastroplasty; BMI-body mass index, BP-biliopancreatic

.

The average body mass index (BMI) of the respective groups was 40+/-2.8, 38+/-3.2, 47+/-4.9, and 46 +/- 5.3.
The mean total body weight loss for groups 1-4 were 35.3% ± 2.2%, 22.9% ± 3.5%, 39.4% ± 2.1% and 33.2% ± 3.1%, respectively (Table 2).

Table 2: Weight losses after revisional bariatric surgery

Surgery	Mean total body weight loss (%)
Group 1	35.3 ±2.2
Group 2	22.9± 3.5 *
Group 3	39.4 ± 2.1
Group 4	33.2 ± 3.1

*Statistically significant (p <0.05) less weight loss compared to other groups

.

Patients in group 2 lost significantly less weight when compared to the other three groups. The follow up ranged from 3 to 12 years with a median of 4.2.

The perioperative outcomes are shown in (Table 3).

Table 3: Perioperative outcomes

Surgery	Duration of surgery (minutes)	LOS (days)
Group 1	185 ± 27	1.5 ±0.3
Group 2	75 ± 11	1.0 ± 0.0
Group 3	142 ± 18	2.0 ± 0.5
Group 4	205 ± 31	2.5 ± 0.3

LOS-length of stay

.

The average operative times were 185 ± 27, 75 ± 11, 142 ± 18 and 205 ± 31 minutes. The average hospital stays were 1.5 ± 0.3, 1.0, 2.0 ± 0.5 and 2.5 ± 0.25 days. Patients in group 2 had significantly shorter operative time and hospitalization compared to the other three groups. All cases were completed laparoscopically. Concomitant procedures were partial gastrectomy, cholecystectomy, liver biopsy, hiatal, ventral, and internal hernia repairs.

This study is a report of our experience with 271 patients who underwent revisional bariatric surgery for weight loss. This is the largest published series of revisional bariatric surgery. Patients who underwent restrictive revisions alone lost significantly less weight than those who underwent malabsorptive with or without additional restrictive procedures.

Revisional bariatric surgery is a complex and technically challenging surgery.

In our experience, the conversion of an adjustable gastric banding to a gastric bypass can be performed as a single stage without an increase in the risk of an anastomotic leak.

The main cause of failure in GBP is pouch dilation. In our series, GBP patients who underwent pouch reduction had the lowest total body weight loss of 22.9%. Another group of our patients underwent pouch reduction, in addition to the elongation of the biliopancreatic limb. The combination of this type of bariatric surgery revision has not been cited in the literature. In our series, this group of patients had the highest total body weight loss of 39.4%.

Patients who undergo VBG have the advantage of a restrictive procedure, but those who fail have demonstrated success by adding the malabsorptive component by a revision to a GBP. For our series of patients, there was a successful total body weight loss of 33.2%.

This series is the largest reported cohort of laparoscopic revisional procedures.

In conclusion, laparoscopic revisional bariatric surgery is technically demanding but is safe and effective when the causes of failure of primary procedure were identified, addressed and corrected by an experienced laparoscopic team. Revisional procedures involving the addition of malabsorption result in a greater weight loss than gastric restriction alone.

References

Frantzides, CT, Carlson, MA, and Schulte, WJ: Laparoscopic Gastric Stapling and Roux-en-Y Gastrojejunostomy for the Treatment of Morbid Obesity: an experimental model. J Laparoendosc Surg. 5(2) 97-100, 1995.
Madan AK, Frantzides, C.T., Pesce CR; The quality of information about laparoscopic bariatric surgery on the Internet; Surg. Endosc. 17(5): 685-687, 2003
Madan AK, Frantzides, C.T.; Triple-Stapling Technique for Jejunojejunostomy in Laparoscopic Gastric Bypass; Arch. Surg. 138-1029-1032, 2003
Frantzides, C.T., Carlson MA, Moore RE, Zografakis, JG, Madan AK, Puumala S, Keshavarzian A; Effect of Body Mass Index on Nonalcoholic Fatty Liver Disease in Patients Undergoing Minimally Invasive Bariatric Surgery: J. Soc. Laparoendosc. Surg. 8(7):849-855, 2004
Frantzides, C.T., Zeni TM, Mahr C, Denham, W, Meiselman M, Goldberg, MJ, Spiess S, Brand RE; Value of Preoperative Upper Endoscopy in Patients Undergoing Laparoscopic Gastric Bypass; Obesity Surgery; 16: 142-146, 2006.
Frantzides, C.T., Zeni, TM, Madan AK, Zografakis, JG, Moore RE, Laguna L; Laparoscopic Roux-en-Y Gastric Bypass Utilizing the Triple-Stapling Technique; J. Soc. Laparoendosc. Surg; 10: 176-179.
Loizides S., Zografakis J, Frantzides, C.T.; Recent Advances in the Surgical Management of Morbid Obesity. Hellenic Journal of Surgery. 6: 365-376, 2007.
Frantzides, C.T., Zografakis J; Laparoscopic Roux-en-Y Gastric Bypass; In Atlas of Minimally Invasive Surgery. Frantzides, Carlson (ed.) Elsevier 2008.
Frantzides, C.T., Carlson M, Shostrom K V, Roberts J, Stravropoulos G, Ayiomamitis G, Frantzides A.T.; A Survey of Dumping Symptomatology after Gastric Bypass with or without Lesser Omental Transection, Surg Obes Relat Dis. 21(2):186-193, 2011
Frantzides, C. T., Welle S., Frantzides, A.T., Is Routine Anticoagulation for Venous Thromboembolism Prevention Necessary Following Laparoscopic Gastric Bypass? J Soc. Laparoendosc. Surg .16: 33-37, 2012
Frantzides, C.T, Zografakis J, Bariatric Surgery; in Textbook of General Surgery; Ed; Sayek I, p1333, 2012
Frantzides, C.T., Zografakis J.G., Welle, S.N., Ruff, T. M. Revisional bariatric surgery. Video Atlas of Advanced Minimally Invasive Surgery, Frantzides, C.T., Carlson, M.A,.Eds, Sounders/Elsevier pp 71-78; 2013
Frantzides, C.T., Welle, S., Laparoscopic Conversion of Adjustable Gastric Band to Roux-en-Y Gastric Bypass.Video Atlas of Advanced Minimally Invasive Surgery. Sounders Elsevier 2013
Frantzides, C.T., Welle, S., Laparoscopic Removal of Eroded Adjustable Gastric Band and Conversion to Roux-en-Y Gastric Bypass with Partial Gastrectomy. Video Atlas of Advanced Minimally Invasive Surgery, Sounders Elsevier 2013
Frantzides, C.T., Welle, S., Laparoscopic Reduction of a Large Gastric Pouch. Video Atlas of Advanced Minimally Invasive Surgery, Sounders Elsevier 2013
Frantzides, C.T., Welle, S., Laparoscopic Revision of Gastrojejunostomy Due to Anastomotic Ulcer with Fistula to the Gastric Remnant. Video Atlas of Advanced Minimally Invasive Surgery, Sounders Elsevier 2013
Frantzides, C.T., Welle, S., Laparoscopic Revision of Jejunojejunostomy. Video Atlas of Advanced Minimally Invasive Surgery, Sounders Elsevier 2013
Frantzides, C.T., Welle, S., Laparoscopic Conversion of Failed Vertical Banded Gastroplasty to Roux-en-Y Gastric Bypass. Video Atlas of Advanced Minimally Invasive Surgery, Sounders Elsevier 2013
Frantzides, C.T., Welle, S., Laparoscopic Conversion of Mini-Loop Gastric Bypass to Roux-en-Y Gastric Bypass. Video Atlas of Advanced Minimally Invasive Surgery, Sounders Elsevier 2013
Frantzides, C.T., Ayiomamitis, G., Frantzides, T.A., Marcinkevicius, A., Manelis, T., Laparoscopic Revision of Failed Bariatric Procedures: a Series of 271 Cases. American College of Surgeons, Clinical Congress, Vol. 223, 2016
Frantzides, C.T., Luu, M., Obesity in Adults, British Medical Journal (BMJ), Epocrates, 2018

ABOUT THE AUTHOR

Dr. Frantzides is the Director of the Chicago Institute of Minimally Invasive Surgery; Director of the Laparoscopic and Bariatric Fellowship Program at St. Francis Hospital and professor of surgery at University of Illinois in Chicago. He operates at St. Francis Hospital, and Evanston Hospital in Evanston. He is recognized worldwide as an expert in the field of laparoscopic surgery and is a charter member of the United States Laparoscopic Founders Society. Dr. Frantzides is the author of the "Video Atlas of Advanced Minimally Invasive Surgery" book.

Laparoscopic Revision Surgery of Failed Bariatric Procedures