Sleeve Gastrectomy Failure: Just When We Thought We Had the Perfect Operation

Just wanted to share of those who are thinking bad thoughts about the band, whenever that PERFECT weight loss surgery exist, I will be on board.... until  then...it's me and my quirky band

http://bariatrictimes.com/2010/07/22/sleeve-gastrectomy-fail ure-just-when-we-thought-we-had-the-perfect-operation/

Sleeve Gastrectomy Failure: Just When We Thought We Had the Perfect Operation

July 2010

by Amir Mehran, MD, FACS, FASMBS, and Alaa Koleilat

Dr. Mehran and Ms. Koleilat are from the University of California, Los Angeles Department of Surgery, Los Angeles, California.

Bariatric Times. 2010;7(7):16–17

Abstract
Sleeve gastrectomy is gaining popularity among the bariatric surgery community. Whereas short-term studies have demonstrated the safety and efficacy of sleeve gastrectomy, its long-term outcomes and durability are unknown. A paucity of such studies exists, with a few recent reports and presentations pointing to failure rates as high as 30 percent. Similar to other bariatric surgery procedures, sleeve gastrectomy failure is likely to be multifactorial and related to a combination of technical, physiological, and psychological parameters, such as gradual sleeve dilation, hormonal adaption, and recurrence of improper eating behaviors, respectively. Our goal is to provide an updated summary of the current bariatric literature in regard to sleeve gastrectomy failure.

Introduction
Unable to decide between multiple bariatric surgery options, patients often ask one of our least favorite questions, “What if it were your own family member? What would you recommend to him or her?" to which I usually reply, “Sleeve gastrectomy even though I honestly do not know its long-term outcomes."

Initially utilized as a risk-reduction staging strategy for the biliopancreatic diversion/duodenal switch (BPD/DS), many surgeons have now adopted sleeve gastrectomy (SG) as a stand-alone operation. Whereas short-term studies have demonstrated the safety and efficacy of SG, its long-term outcomes and durability are unknown.[1–3] Its mechanism of action as well as the technical nuances of the surgery, such as bougie size calibration and proximity to pylorus, remain controversial topics.[4] Equally debated are the causes for failure, the most appropriate revisional surgery should it become necessary, as well as the exact definition of the term failure.[5] A plethora of literature furthermore exists on factors behind inadequate weight loss or weight regain following various bariatric surgery procedures where both physiologic and psychological aspects are extensively discussed. The latter, however, remains beyond the scope of our discussion.[6]

The exact failure rate of sleeve gastrectomy is unknown. Using the Spanish National Registry for bariatric surgery, Sanchez-Santos et al[7] reviewed 540 patients who had undergone SG either as a primary or staged procedure over a six-year period. The authors reported excellent overall outcomes; however, 15 percent of the subjects were considered failures based on weight recidivism in the first three years, with 3.3 percent of patients submitting to a second bariatric procedure. Younger age, lower body mass index (BMI), and thinner bougie size were attributed to improved sustainable outcomes. Similarly, Himpens, in an article by Deitel et al,[8] presented his early five-year results after sleeve gastrectomy at the First International Consensus Summit for Sleeve Gastrectomy in 2007. In 46 such patients, he reported a disappointing 37 and 23 percent inadequate weight loss and second procedure rates, respectively.

More recent unpublished presentations by Himpens indicate failure rates as high as 30 percent in five years.[9] Studying the Austrian experience with SG as a stand-alone operation, Felberbauer et al[10] reported a seven-percent failure rate at three years based on a cutoff of 25 percent excess weight loss (EWL). Applying the traditional 50-percent EWL criteria, the failure rate increased to 25 percent.[10]

A common motif in several articles has been the effect of the initial resected fundus volume and bougie size, as well as the role of gradual gastric remnant dilation in the failure of SG. Following 120 patients who underwent SG over five years, Weiner et al[11] reported a 13-percent failure rate, with a resected gastric volume of less than 500cc being a predictor for such failures. In a subsequent unpublished presentation of longer term follow-up data in patients who underwent a second procedure, the same group reported prepyloric dilation, fundal extension, and improper eating behavior as causes of sleeve failure in 54, 8, and 38 percent of cases.[9] Similarly, in 2009, Jossart[12] reported improved mid-term weight-loss outcomes in his subset of patients with a larger resected gastric volume versus those with less, albeit at the price of increased short-term complications.

In contrast, however, in five SG conversions to Roux-en-Y gastric bypass (RYGB), Langer et al[13] demonstrated that weight regain was not due to initial inadequate gastric fundus reduction. In a different study,[14] the same Austrian group could not correlate radiographic evidence of sleeve dilation with postoperative weight regain at one year after sleeve gastrectomy. Finally, a review of multiple other authors’ results have found initial sleeve size and weight loss percentages to be independent of each other.[1–3,4]

Adding pre-emptive additional restrictive adjuncts to a SG has also been proposed in a few animal studies. Banding of the gastric remnant at the time of SG in rats prevents postoperative gastric dilation. Use of polytetrafluorethylene (PTFE) mesh in a porcine model to reinforce the gastric sleeve, furthermore, demonstrated a reduction in weight regain compared to a control SG alone group.[15] In a human study, Alexander et al[16] utilized a strip of biologic mesh tissue to wrap around the SG approximately 6cm below the gastroesophageal junction to limit food intake volume and restrict downstream dilation. At two years, the weight loss results were found to be equal to a similar cohort of gastric bypass patients and no mesh-related complications were reported. The authors, however, did not use a nonmesh SG group as control. The results, therefore, may not be related to the me****self, especially since it was an absorbable type. In the absence of long-term studies on the outcomes and complications of foreign body use in SG, routine utilization should not be advocated.

If purely mechanical factors cannot account for weight recidivism after sleeve gastrectomy, could physiologic and hormonal factors play a role? The concept of SG as a metabolic and not a purely restrictive operation has been discussed extensively in the bariatric literature.[3,4] In one such recent review, Abu-Jaish and Rosenthal1 summarized some of these findings, such as markedly lower post-SG ghrelin levels, increased paracrine effects of incretins (GLP-1, GIP, PYY), and decreased insulin resistance.1 Most of the literature focus has been on ghrelin or appetite hormone. It has been postulated that SG failure is partly due to rising ghrelin levels, which may or may not be related to sleeve dilation. Bohdjalian et al[17] studied this hypothesis in a small subgroup of their SG patients who were followed for five years and had had ghrelin levels at various time intervals. The authors did report a small increase in ghrelin levels, especially in those who had regained weight, but the spike was very small in both groups and was found to be negligible. Small sample size, however, prevents drawing any firm conclusions. The current bariatric literature furthermore is devoid of any other studies examining long-term hormonal changes after SG.

Barring specific technical nuances, should a decision be made to convert a SG to another operation? Opinions vary as to the best option with the majority favoring DS and RYGB.[4,12] However, the bariatric surgery literature contains a variety of other salvage procedures as well including re-sleeve gastrectomy (RSG), adjustable and nonadjustable foreign bodies, and endoscopic attempts.

RSG has been proposed as a safe, simple second procedure with very good early results in two patients;[18] however, in both cases it was performed as part of conversion to DS. Himpens et al19 recently presented their RSG data at the 2010 ASMBS conference. Comparing past SG patients undergoing RSG versus DS, they found the former to be feasible, but less effective in terms of weight loss at two years and that it carries a higher risk of gastric fistula, which is very difficult to treat in SG. RSG, therefore, was discouraged as a salvage procedure for weight regain.

Multiple case studies exist about adjustable banding as a salvage procedure for failed RYGB. It has also been successfully attempted by Greenstein and Jacob20 in one patient whom they believed did not have adequate restriction after the initial SG performed three years prior. However, the initial SG was performed utilizing a 60Fr bougie. Enough gastric tissue, therefore, was available to allow gastric plication over the band, which may not be the case in most SG cases. At the latest Sleeve Gastrectomy Consensus Summit, adjustable bands were not considered as an acceptable salvage procedure by any of the attendees.[4]

As with any other revisional surgery, conversion of SG to another procedure carries a higher risk profile and should not be attempted without a thorough repeat preoperative psychological and dietary evaluation. In our practice, we reserve revisional surgery after SG only for those patients who have not been able to reach their desired weight loss or comorbidity resolution goals in spite of maintaining the necessary lifestyle and eating behavioral changes.

Conclusion
In summary, SG as a stand-alone operation is gaining popularity among both bariatric surgeons and patients. This enthusiasm, however, has to be balanced against a paucity of data in regards to potential long-term failure rates. Similar to other bariatric surgery procedures, SG failure is likely to be multifactorial and related to a combination of technical, physiological, and psychological parameters. When discussing SG, bariatric surgeons must review these unknowns with their patients to ensure they will make informed, long-term, surgical decisions based on all available information.

Thanks for sharing -- I think this study and others can be used to make the point that weight loss surgery of any variety is not a cure all for obesity. These surgeries are merely treatments to aid us in our battle with obesity.

Trixie

EXACTLY! Although the band is far from perfect, I have to give it CREDIT, when I work my band I will lose weight, Some people are seeking a crutch and think that ALL weight loss surgeries will automatically induce weight loss.

Just think I have a TON of RNY friends on another board, THEY HAVE TO HIT THE GYM HARDER THAN I DO, they are over 5 years post op like me, and they NO LONGER HAVE RESTRICTION, and no longer malabsorp food, so their tool NO LONGER HELPS PERIOD AT 5 YEARS.

My band IS STILL WORKING going on 6 years post op, my band helps me more maintaining weight, but if I want to further lose I have to HIT THE GYM or walk daily in order for the scale to move, I AM VERY HAPPY and content with my band, and I VERY HAPPY I did not get my stomach removed or RNY for life dependency on vitamins and risk long term illnesses of vitamin deficiencies and WITH LESS DANGEROUS COMPLICATION RISKS.

I Honestly don't consider port issues and tubing issues complications or band slippage complications those are mechanical issues that the manufacturer should help with and as far as band slippage is that IS TOTALLY PREVENTABLE.

I am still loving my band and REALLY appreciate it more now than when I first got banded since it still WORKS.

It is great you are happy with your band, but experience has shown that you are a rare person to have been banded this long. Everyone who was banded with me and lots of others I met have lost their band to slippage and erosion. I will tell you that when it happens, you will be devestated. It is like losing a best friend. Then you hope you have insurance or the money to have it removed. It cost the same to remove as to put it in. Personally it took them 6 hours to remove and clean up the mess it made. It was the worst surgery I have ever had. I am sleeved now, and if this was available when I was banded, I would have never had it done. So with that, please becareful and listen to the changes. If you have a problem, run, don't walk to the Doctor. Erosion is deadly!!

I am very sorry to hear your band eroded, this is all bandsters worst fear! Erosion is still unknown in what causes it, but many do take precautions to prevent weakening of the stomach tissues, but again no one knows.  I am blessed and lucky to have kept my band for this long, but it has NOT ALWAYS BEEN EASY! I've never kept my band extremely tight for long periods, I've been too tight several times throughout my journey but I always got unfilled.

I know several others who've had their bands for several years they no longer post here and several in real life,  so I am far from being rare, but I do feel blessed to have kept it this long complication free and I am very thankful and grateful for that, I had to keep up on my aftercare and of course anything unusual I am always in the doctors office, I had some issues a few years back that was resolved and I healed but all is well now. I try to give tips to the newbies on the board of things that have helped me but some are very nasty and bitter so I no longer help I guess If you try to warn newbies of the dangers of being too tight they don't want to hear it.

So I don't help anymore, there use to be a veteran that HELP ME Nancy she no longer post, her philosophy was, " just because you can doesn't mean you should" and always watch for your soft stops to stop eating, I never keep my band tight enough to slam shut or repeating vomiting, the only times I may vomit is if I attempt to overeat or eat too fast and those simple things have kept me my band this long. 

I wish you much success with your Sleeve!

thanks for sharing it just proves that NO weight loss surgery is perfect each and every one of them have complications or risks

 Interesting.  I can't say I'm glad to read that.  I keep hoping they find the "magic pill" that my mother promised me when I was just a teenager (and that was over 30 years ago)!  I think they may be on the right track regarding the impact that hormones can play in how our bodies respond to dietary changes.  Thanks for posting.

Tami

This article was very interesting. It shows that, more that ever, we must deal with the causes of our overeating in order to make what ever tool we choose keep on working for us. Another phrase that struck me is, " the exact definition of the term failure." We find this with band statistics, as well.

I truly wish there were a magic, perfect, cure. Until then we all have to work hard. I am intriqued by the experiments of using the mesh, but of course that will take much more study.

*LIKE*

Add me to the "rare" list.  I have had my band six years next month.  I have a 4 cc band with a 3 cc fill.  I am doing just fine and have kept my weight off.  What I find most beneficial about the band is the stoma can't enlarge.  The band keeps it from doing that.  No other surgery has this wonderful option.  And it can be adjusted.  It doesn't get any better than that in my opinion.  At least I know if I have problems it can be removed.  What do you do if you have issues and 3/4 of your stomach has been removed?  Like all the naysayers say, " that we bandsters will eventually have to have our bands removed."   I will welcome whatever new WLS device or option is available at that time.    In the mean time I will just  have to put  up with being the "skinny *****" that I am.  Thanks Naomi, I enjoyed seeing your wedding photos,  congrats and happiness to you.