OBES SURG (2013) 23:1899–1914 DOI 10.1007/s11695-013-1058-0
REVIEW ARTICLE
Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy as Revisional Procedure after Adjustable Gastric Band—a Systematic Review Usha K. Coblijn & Caroline J. Verveld & Bart A. van Wagensveld & Sjoerd M. Lagarde
Published online: 28 August 2013 # Springer Science+Business Media New York 2013
Abstract The adjustable gastric band (L)AGB gained popularity as a weight loss procedure. However, long-term results are disappointing; many patients need revision to laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG). The purpose of this study was to assess morbidity, mortality, and results of these two revisional procedures. Fifteen LRYGB studies with a total of 588 patients and eight LSG studies with 286 patients were included. The reason for revision was insufficient weight loss or weight regain in 62.2 and 63.9 % in LRYGB and LSG patients. Short-term complications occurred in 8.5 and 15.7 % and long-term complications in 8.9 and 2.5 %. Reoperation was performed in 6.5 and 3.5 %. Revision to LRYGB or LSG after (L)AGB is feasible and relatively safe. Complication rate is higher than in primary procedures.
Keywords Bariatric surgery . Conversion . Insufficient weightlosslaparoscopic adjustablegastric band . Laparoscopic Roux-en-Y gastric bypass . Laparoscopic sleeve gastrectomy . LRYGB . LSG . Malabsorption . Restrictive . Revision . Weight regain
Usha K. Coblijn and Caroline J. Verveld participated equally in the establishment of this article. U. K. Coblijn (*) : C. J. Verveld : B. A. van Wagensveld : S. M. Lagarde Department of Surgery, Obesity Center Amsterdam, Sint Lucas Andreas Hospital, Jan Tooropstraat 164, 1061 Amsterdam, The Netherlands e-mail:
[email protected] U. K. Coblijn e-mail:
[email protected]
Introduction Obesity is a rising concern all over the world. In the USA alone, the prevalence is around 30 % in the adult population [1]. The World Health Organization (WHO) predicts that worldwide, in 2025, there will be 300 million obese people [2]. Obesity is associated with a wide array of comorbidities such as the development of metabolic syndrome, obstructive sleep apnea, cardiovascular disease, and early osteoarthritis [3]. In contrast to bariatric surgery, nonsurgical treatment is ineffective for sustainable weight loss and reduction of associated comorbidities [4]. Bariatric surgery is based on reducing gastric volume (restrictive surgery) or reducing the absorption capacity of the intestines (malabsorptive surgery) or a combination of both. Over the last decades, laparoscopic adjustable gastric band (L)AGB gained popularity because of its relatively low complexity and adjustability in combination with low perioperative morbidity (1–5 %) and mortality rate (0–0.05 %). (L)AGB has good results in the first postoperative period [5–7]. Furthermore, the procedure is considered reversible; after removing the band, the stomach regains its normal anatomy [8]. Worldwide, the (L)AGB represents approximately 42 % of all bariatric procedures and is the most common bariatric procedure performed in many countries [4, 5, 9–11]. Despite good results in the first postoperative period, the procedure has several limitations. Band-related complications such as esophageal dilatation, food intolerance, gastric necrosis, band slippage, band dilation, and pouch dilation are reported in 15–58 % of all patients [8, 12–16]. Furthermore, a growing number have inadequate weight loss or weight regain after successful initial weight loss. Inadequate weight loss and weight regain is reason for a reoperation in 27–100 % of the patients [17, 18] [19]. There are different surgical options to treat late complications or inadequate weight loss. Removal of the band, without
1900
further intervention, is associated with high weight regain [20]. Although (L)AGB repositioning or replacement is technically possible, studies show mixed results (concerning feasibility and long-term weight loss especially when compared to revision into Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (LSG) [11, 21–24]. Although band placement does not create a permanent anatomic alteration, it does not leave the stomach region undamaged. Erosion, scar tissue, pouch dilation, and adhesions make the area more complex and vulnerable during further interventions; this makes revisional surgery technically demanding [17, 19, 20]. Laparoscopic Roux-en-Y gastric bypass (LRYGB) and LSG are more and more frequently performed as a rescue operation after failed (L)AGB. However, it is unclear which operation should be performed and when. Safety, effectiveness, and timing of revision are subjects of debate. In recent years, many groups have published their (small) series. The purpose of this systematic review was to assess the morbidity, mortality, and long-term results of revisional surgery to LRYGB or gastric sleeve after gastric banding.
Materials and Methods Literature Search The Cochrane Database of systematic reviews, the Cochrane central register of controlled trials, and MEDLINE databases were searched by using the keywords (conversion OR revision OR revisional OR revisionary) AND (gastric band OR gastric banding OR bariatric surgery OR gastric bypass OR sleeve) in order to identify studies published up to February 2012. Free-text words instead of MeSH terms were used to avoid missing recent articles that had not been given a MeSH label yet. Three investigators (CJV, UKC, and SML) independently performed the literature search. Electronic links to related articles and references of selected articles were hand searched as well. References were snowballed. A hand search of relevant journals and conference proceedings was not performed. The search was not restricted to any language; however, this systematic review only took studies published in English into account. Study Selection and Data Extraction Of the potentially eligible publications, studies were included if they reported (based on a clear definition) on revision from (L)AGB into LRYGB or LSG. Studies were excluded if they reported on less than 10 patients or presented results of revisions to other bariatric procedures. Studies were also excluded if they presented results from revisions of primary RYGB, performed rebanding, if revisional procedure was (primarily) open, or if primary procedure was different than (L)AGB. The
OBES SURG (2013) 23:1899–1914
same investigators independently searched the list of abstracts according to the search results and selected articles for closer reading. Subsequently, two investigators (CVJ and UKC) extracted the following data, if reported, from the original articles using a preformatted sheet. Variables were operation technique, conversion and reoperation rate, mortality, number and type of early and late morbidity, indication for revision and follow-up in terms of weight loss. Data were retrieved from the articles only. No attempt was made to collect missing data by contacting the authors. Each of the selected studies was critically appraised by two investigators (CJVand UKC) using a modified form as proposed by the Dutch Cochrane Collaboration. Duration of the data collection; study design (randomisation, prospective, or retrospective consecutive data collection); comparability of study groups; adequate follow-up; commercial interest and description of statistical analysis; and different technique (learning curve) and different kind of treatment were assessed. In case of retrospective analysis of data from a prospective consecutive collected database, the study was qualified as being prospective. Final inclusion was done after consensus was reached. Discrepancies in judgment, if any, were resolved by discussion between the investigators (CJV, UKC, and SML) in a consensus meeting. Primary outcome measurement is safety of revision from (L)AGB into RYGB or LSG. Items scored included: one- or two-step revisions, number of reoperations and complications (anastomotic leakage, staple line leakage, wound infection, bleeding, perforation, and intra-abdominal abscess), conversions and duration of hospital stay Secondary outcome measurements were reason for revisional surgery in the first place and weight loss (in percentage excessive weight loss (EWL)).
Results Included Studies Nine hundred fifteen publications were identified. Seven hundred seventy-eight contained the search terms in a different context and were therefore deemed irrelevant. In total, 137 abstracts were selected for closer reading. One hundred eleven articles were excluded based on the abstract. Of the remaining articles, two were not written in English and were therefore discarded. Twenty-four articles remained. With snowballing, one extra article was identified. These 25 articles were scrutinized and mined for data. Three articles had different primary procedures (e.g., vertical banded gastroplasty and sleeve gastrectomy), but more than 10 revisions of (L)AGB into RYGB were reported and for that reason the articles were included. In two articles, all data from different primary procedure were combined and for that reason, the articles were excluded (Fig. 1, flowchart). Finally, a total of 15 articles about revision into LRYGB and 8 articles
OBES SURG (2013) 23:1899–1914 Fig. 1 Flowchart of a systematic review about the complications and safety of conversion from laparoscopic gastric band to RYGB or sleeve gastrectomy
1901 Search PubMed en Cochrane Library N = 915 articles
Articles excluded based on words in different context N = 778
Abstracts selection: N = 137
Exclusion abstracts 115 : - Case report < 10 cases - Article not written in English - Words in different context - Incomparable results - Duodenal switch, mini gastric bypass new band - Laparotomic surgery - VBG and RYGB as primary procedure
Suitable articles: N = 22
Snowballing references: 1
Articles reviewed n = 23
Diff. primary procedures N=3
Revision from (L)AGB N= 12
Revision to LRGYB N = 15
Revision to Sleeve N =8
about revision into LSG were used in this review. Table 1 (supplemental) contains the included studies and rates their level of quality.
Performing a meta-analysis or a pooled analysis on this type of studies is not reliable.
Data synthesis
Patients
No randomized clinical trials were found. For this reason, our data collection merely exists on observational studies.
All patients included in this review met the International Federation for the Surgery of Obesity criteria for morbid
1902
OBES SURG (2013) 23:1899–1914
Table 1 Quality rate of included articles Publication
Description of study
Follow-up median±SD (range) Quality points
Total
1 2 3 4 5 6 7 8 9 10 Abu-Gazala and Keidara [32] Ardestani et al.a [11] Hamza et al.b [26] Hii et al. [8] Khoursheed et al.b [28] Langer et al. [19] Mognol et al [20] Moore et al. [17] Muller et al.c [21] van Nieuwenhove [18], 2 step van Nieuwenhove et al. [18], 1 step Robert et al. [27] Spivak et al. [35] Topart et al.d [33]
Prospective consecutive series Prospective consecutive series Retrospective consecutive studies Prospective consecutive series Retrospective consecutive series Prospective consecutibe series Prospective consecutive series Prospective consecutive series Prospective consecutive series Retrospective consecutive series Retrospective consecutive series Prospective consecutive series Prospective consecutive series Retrospective consecutive series
14.6±9.7 44.4±9.4 12.9±7.9 36 15.83(1–48) 12 7.3 (3–18) 18 36 (24–60) 9 (3–21) 10 (4–23) 22 (3–72) 15.7 (12–26) 12
1 1 1 1 1 1 1 1 1 1 1 1 1 1
0 1 0 1 0 1 0 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 0 0 1 1 1
0 0 0 0 0 1 1 0 0 1 1 0 0 0
0 0 1 0 0 0 1 1 1 1 1 1 0 1
1 1 1 0 1 1 1 1 0 0 0 1 1 1
1 0 1 1 1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 0 1 1 1 1 1
1 1 0 1 0 1 1 0 1 0 0 1 1 0
1 1 1 1 1 1 1 1 1 1 1 1 1 1
7 7 7 7 6 9 9 8 7 7 7 9 8 8
van Wageningene [34] Weber et al.c [22] Acholonu et al. [36] Berende et al. [29] Dapri et al. [40] Foletto et al. [30] Goitein et al. [37] Himpens et al. [31] Iannelli et al. [38] Jacobs et al. [39] Quality rate Definition of study objectives Statistical method described Possible bias in inclusion/exclusion Different types of treatment besides the evaluated one Different technique in patients from same series (learning curve) Differences in population of compared groups Measures of outcome Eventual commercial interest related to techniques and/or certain devices Prospective data collection More than 10 patients Maximum points 10
Prospective consecutive series. Prospective consecutive series Prospective consecutive series Prospective consecutive series Prospective consecutive series Prospective consecutive series Prospective Retrospective Prospective Prospective Points: 1 Clear Yes Not present Not present
12±12 12 6 (2–24) 13.8 (2–46) 18.6±14.8 ( 1–59) 20 (3–36) 17 (1–39) 32.6±14.8 13.4 (1–36) 26 (5–40) Points: 0 Unclear/no No Present/unclear Present/unclear
1 1 1 1 1 1 1 1 1 1
1 1 0 1 0 1 0 0 0 0
1 1 1 1 1 1 1 0 1 0
0 0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 1 0 1 1
1 0 1 1 1 1 1 1 1 1
1 1 1 0 1 0 1 1 1 1
1 1 1 1 1 1 1 0 1 1
1 1 1 1 1 1 1 1 1 1
8 6 6 6 6 6 7 4 7 6
No
Yes/not defined
No
Yes/not defined
Defined Devices not cited
Had to be calculated Devices cited
Yes Yes
No No
a
Revision to multiple procedures (e.g., gastric sleeve, RYGB, biliopancreatic diversion)
b
Multiple primary procedures
c
Comparing LRYGB and rebanding
d
Comparing primary and secondary RYGB
e
Comparing open and laparoscopic revisions
obesity before the first bariatric procedure. Most of them still did at the time of revision [25].
Five hundred eighty-eight patients underwent revision of (L)AGB into LRYGB. The number of patients in each study
46.6 39.2 (19–65) 43.6±11.4 (25–66) 49.9±11.9
46 40 41 32 286
Goitein et al. [37] Himpens et al. [31] Iannelli et al. [38] Jacobs et al. [39] Total
a
3/12 – 10/17 20/37
39.3 (20–56) 43.8 (31–62) 42.5±9.9 42.7±8.8 46±9.5 (28–60)
85 33 58 26 32 588 15 28 27 57 12/34 17/23 7/34 7/25 76/182
5/18
Eight two-step revisions, data could not be seperately extracted
40 (20–60) 47.2±12.4 (25–66) 42 (19–63) 45.5 44.5
13/72 3/30 5/53 11/15 9/23
44±12
23
10/8 2/17 2/9 12/70 – 1/24 22/58 3/23 – 4/10
43.7±13.2 42.3±12.3 46.5±8.6 49 (18–66) 36.95±8.97 (21–53) 43±11 41±10.14 (21–68) 46 – 40±11
18 19 11 82 36 25 70 26 30 14
Sex (M/F)
Abu-Gazala and Keidar [32] Ardestani et al. [11] Hamza et al. [26] Hii et al. [8] Khoursheed et al. [28] Langer et al. [19] Mognol et al [20] Moore et al. [17] Muller et al. [21] van Nieuwenhove et al. [18], 2 steps van Nieuwenhove et al. [18], 1 step Robert et al. [27] Spivak et al. [35] Topart et al. [33]a van Wageningen [34] Weber et al. [22] Total Acholonu et al. [36] Berende et al. [29] Dapri et al. [40] Foletto et al. [30]
Age
N
Author
Table 2 Patient demographics and revision procedure
– 60.2±30.1 (22–132) – 67
– 46±8.0 (35–64) 53.1 (35.9–63) 45.2 (36.2–59.1)
20 2 – 0 53
17 0 8 1 0 88 2 13 0 16
– 28.2 (11–46; SD, 11. 3) 46.1±17.4 50.4±24 42 (17–73) 34.7 (16–60) – 51.2±30.1 (22–132) 90.48±57.6
42.9 (27–72) 42.8 (33.1–50; SD, 4.4) 43.2±7.0 43.8±9.5 42.0±6.7 (30.7–59.3)
0
– 1 2 18 2 0 23 2 – 14
Two-step revision
90 (40–144)
– 27.6 (11–48) 29.7±14.3 46 (9–168) – 53 (17–118) 42±18 (7–74) 29 – 80 (28–120)
Months since first operation
– 45.3 (35–77) 45±8.1 (35–64) 51.2±11.1 (39–85)
47.2 (33–67) 45.8 (39.9–53; SD, 3.4) 46.3±7.2 49.7±9.3 47.8±7.6
41.4±6.7
41.6±5.3 – 42.8±6.7 43 (31–70) 45.15±7.95 47.6±7.7 (34–70) 44.9±10.8 (26.9–81) 40 41.9 43.8±5.8
– 44.1±5.7 – 47(32–73) – 51.0±8.1 – 45 47.1 45.0±6.7 41.9±6.1
BMI at revision
BMI before first band
26 38 – 32 192
68 33 50 25 32 452 13 15 27 41
23
– 18 9 64 34 25 47 24 – 0
One-step revision
43.1 (33–57) 43.5±8.1 (25.3–61) 49.9 (35.9–63) 42.69
38.66 30.6 (23–61) 39±9.6 (24–61) 45.7±10.8 (36–77)
BMI at conversion
OBES SURG (2013) 23:1899–1914 1903
OBES SURG (2013) 23:1899–1914
1 1/388=0.8 % 2 2/191=1.0 % 3 3/388=0.8 % 1 1/191=0.5 % 39 39/388=10.1 % 4 4/191=2.1 % 2 2/424=0.5 % 0 0 14 14/424=3.3 % 3 3/191=1.6 % 388 388/588 191 191/286 Gastric bypass Total Gastric sleeve Total
Insufficient weight Food intolerance/ Pouch dilation loss/weight regain vomiting
Thirteen studies on LRYGB and eight on LSG reported perioperative and long-term mortality rate. The perioperative mortality rate was zero in the LRYGB studies. Hii et al. describes one patient who died 60 days postoperatively (unrelated to surgery; Table 6) [8]. The LSG group tells about three deaths. Foletto et al. is the only study which describes mortality [30]. Three patients died during the perioperative period. One patient died of multi-organ failure because of septic shock. The second patient, suffering from chronic obstructive pulmonary disease, died after 6 months of sepsis
N
Mortality and Morbidity
Author
Primary Outcomes
Table 3 Reason for revision into RYGB or gastric sleeve
In the gastric bypass group, 88 patients (16.3 %) were operated upon in two steps, compared to 53 patients (21.6 %) who underwent sleeve gastrectomy. The reason for two-step revision was referral from another institution after band removal, pouch dilation, or poor tissue quality at band removal as judged by the individual surgeon [20, 26, 32]. Only three articles mentioned the interval between band removal and second stage LRYGB. This interval ranged from 2 to 102 months [18, 37]. Table 5 is added as supplement for details about operation technique.
Band erosion
One- or Two-Step Revision
65 65/388=16.8 % 2 2/191=1.0 %
Indications for revisional surgery are displayed in Table 3 and supplemental Table 4. Some patients had more than one reason for revisional surgery. Five of the 15 studies did not mention the reason for revision [21, 22, 28, 32–34]. Main reason for revisional surgery in the LRYGB as well as the LSG groups was insufficient weight loss or weight regain in 62.6 and 63.9 % [8, 11, 17–20, 26, 27, 30, 35–39].
23 23/388=5.9 % 18 18/191=9.4 %
Indication for Revisional Surgery
243 243/388=62.6 % 122 122/191=63.9 %
Necrosis of the Reflux oesophagitis/ Intra-abdominal Duodenal fistula Band slippage stomach oesophageale dysmotility abscess
varied between 11 and 85 (Table 2) [26, 27]. Only two (0.003 %) patients underwent revision as emergency operation [17, 28]. All other operations were in an elective setting. In two studies (66 patients), male/female ratio was not mentioned. Of the remaining 522 patients, 83 % was female (Table 2). Age and weight are normally distributed in most studies. The mean age was reported in 14 studies. It varied between 37 and 49 years (range, 18–68; Table 2) [8, 20, 28]. A total of 8 studies, including 286 patients, reported revision into LSG. All operations were elective. In one study (12 patients), the male/female ratio was not mentioned. Of the remaining 258 patients, 70.5 % was female. Age and weight are normally distributed in most research groups. The mean age was reported in all studies and varied between the 39 and 50 (range, 19–66; Table 2) [29–31].
24 24/388=6.2 % 28 28/191=14.7 %
1904
–
– 16 7 42 – 10
18
19 11 82 36 25
70 26 30 37 85 33 58 26 32 388/588
15
28 27
57 46 40 41 32 191/286
Abu-Gazala and Keidar [32] Ardestani et al. [11] Hamza et al. [26] Hii et al. [8] Khoursheed et al. [28] Langer et al. [19]
Mognol et al [20] Moore et al. [17] Muller et al. [21] van Nieuwenhove [18] Robert et al. [27] Spivak et al. [35] Topart et al. [33] van Wageningen [34] Weber et al. [22] Total
Acholonu et al. [36]
Berende et al. [29] Dapri et al. [40]
Foletto et al. [30] Goitein et al. [37] Himpens et al. [31] Iannelli et al. [38] Jacobs et al. [39] Total
Sometimes, there are more than one reason for revision
4 13 – 0 1 18/191=9.4 %
– –
– – 27 23 – 41 21 122/191= 63.9 %
0
1 9 – 0 3 10 – – – 23/388=5.9 %
17+34 7 – 37 48 25 – – – 243/388= 62.6 % 10
0 0 0 – 0
Food intolerance/ vomiting
Insufficient weight loss/ weight regain
N
Author
Table 4 Reason for revisional surgery
1 0 – 0 1 2/191= 1.0 %
– –
15 0 – 0 2 21 – – – 65/388= 16.8 % 0
0 1 11 – 15
–
Pouch dilation
2 0 – 0 1 3/191= 1.6 %
– –
3 0 – 0 1 0 – – – 14/424= 3.3 % 0
1 1 7 1 0
–
Band erosion
0 0 – 0 0 0
– –
0
0 1 – 0 0 0 – – – 2/424=0.5 %
0 0 0 1 0
–
Necrosis of the stomach
0 0 – 0 0 4/191=2.1 %
– –
4
0 4 – 0 24 0 – – – 39/388=10.1 %
0 1 10 – 0
–
Reflux esophagitis/ esophageal dysmotility
0 0 – 0 1 1/191=0.5 %
– –
0
0 1 – 0 0 0 – – – 3/388=0.8 %
0 1 1 – 0
–
Intra-abdominal abscess
–
0 0 – 0 0 0 – – – 1/388= 0.3 %
1 0 0 – 0
–
(Total) obstruction
17 0 – 0 5 28/191= 14.7 %
– –
0 5 – 0 2 4 – – – 24/388= 6.2 % 6
2 0 11 – 0
–
Band slippage
0 0 – 0 1 2/191= 1.0 %
– –
1
Duodenal fistula
OBES SURG (2013) 23:1899–1914 1905
150
75–25 Antecolic
Antecolic Above
Below – –
Circular 25
Single
– 50
–
Conversion Rate
–
No
Inamed
Stapled
–
150 Antecolic
Antecolic Below
Below Stapled
Stapled
Single
Single Circular
Linear
–
– –
Inamed No
No
100–150
150
Antecolic
Antecolic
–
Stapled Single
No
Linear
–
30
– Yes
Yes
–
Single
Hand sewn
–
150
– –
Antecolic Above or below
– –
Circular
–
–
Single
–
25 No
–
–
–
Stapled
100–150
100 Antecolic
Antecolic Below
Above or below Stapled
Stapled and hand-sewn Single
Single
Linear
Circular
25–30
– –
– No
Circular and linear – –
Yes
100–150
– – – Stapled
75–150
–
–
–
Antecolic
Below
– Hand-sewn
Stapled and hand-sewn Sometimes
Single No
20–30 Yes
–
–
30
–
Weber et al. [22]
van Wageningen [34]
Topart et al. [33]
Spivak et al. [35]
van Nieuwenhove [18]
Robert et al. [27]
Muller et al.c [21]
Moore et al. [17]
Khoursheed et al. [28]
Langer et al. [19]
Hii et al. [8]
Hamza et al. [26]
Mognol et al [20]
150 Antecolic
Antecolic
Above or below
–
Stapled and hand-sewn
Stapled Linear -
Double layered Linear 25
Inamed
–
after an uneventful discharge at home. The third patient died of pulmonary embolism 24 months after revisional LSG. The amount of complications varied according to the study cited. Considering LRYGB, the short- and long-term complication rate varied between 3.0 and 29.3 % [8, 35]. Altogether, a total of 45 perioperative complications occurred (8.5 %) and ranged from minor complications as wound infection to major complications as bleeding and perforation (Table 6). The most common short-term complication was wound infection (3.5 %). Anastomotic leakage and bleeding (bleedings combined with splenic injuries) appeared in 0.9 and 1.8 % of the operations, respectively. Three patients needed reoperation for anastomotic leakage, accountable for 7.3 % of reoperations. Bleeding was responsible for 17.1 % of reoperations [8, 17–20, 22, 26–28, 32–35]. A total of 35 (12.2 %) perioperative complications occurred in the patients who underwent LSG. Most were minor but staple line leakage had an incidence of 5.6 %, thereby being the most frequent complication. Almost all complications could be handled conservatively [30, 31, 36–40]. Three patients needed reoperation because of staple line leakage, accounting for 30 % of reoperations [29, 31, 36–38]. Long-term complications are those who occur later than 30 days postoperative. Details are displayed in supplemental Table 7. Ten of the 15 articles that comprised RYGB revision scored long-term complications. In a total of 478 patients, 42 (8.9 %) complications were seen; some patients developed more than one. Stenosis at the gastrojejunostomy was by far the most common complication at 6.5 %. Marginal ulceration followed at 1.0 % [8, 18–22, 27, 33–35]. Only three studies about LSG mentioned long-term complications. Just one occurred; this was an internal herniation which required reoperation [31]. Median length of stay was reported in 13 studies and varied from 1 to 39 days with a mean of 5.3. This included patients with and without complications. Readmission was not mentioned in all studies [27, 35].
All articles mentioned the rate of conversion to open surgery. Conversion to open surgery was performed in 14 (2.4 %) LRYGB patients; and in 5 (1.7 %) LSG patients, most common reason was (expected) adhesions and large incisional herniations [30, 37]. Reoperation
Ardestani et al. [11]
Abu-Gazala and Keidara [32]
-
–
–
Route of the Roux limb Pouch creation above or below scar tissue GJ technique GJ technique Stapler Pouch size (ml) Type band Capsule resection Article
Table 5 Operative techniques
100
OBES SURG (2013) 23:1899–1914 Size alimentary limb (cm)
1906
The mean incidence of reoperation was respectively 6.5 and 3.5 % [29, 31, 38]. Besides already mentioned bleeding and staple line leakage, intestinal obstruction, stenosis, and internal herniations were reasons also for reoperation (Table 8 and 9) [8, 17, 18, 20, 22, 26–28, 33–35]. In only two studies, none
0 0 1 0 0 1 0
Acholonu et al. [36] Berende et al. [29] Dapri et al. [40] Foletto et al. [30] Goitein et al. [37] Himpens et al. [31] Iannelli et al. [38]
0 0 0 0 0 2 0
Fever
0 0 0 3 (>30 dagen) 0 0 0
3 2 3 2 4 37 6.5 %
1
1 2 1 1 2 2 1 0 10 3.5 % 0 – 1 10 4 0 4 1 2 0
Reoperations
5.5 3 (2–38) 3.2±1.4 (2–8) – 3 (1–100) 4.2±1.2 (2–77) 7.9 (5–71)
Hospital stay, days
166 (110–360) 105 (85–175) 128±25.9 194±45 215±62.7 (135–380) 167 167
150±39
195±59 – 165±75.8 132 (70–236) 145±35 (120–240) 219±52 (135–375) 240±40 (210–280) 160 (140–195) – 116±31
120 99 (54–221) 120.6±32.4 (65–195) 120 (90–180) 118 (70–250) 95.6±30.4 (35–195) 117 (90–165) –
Operating time, min.
Death
2 0 1 (2 open) 4 0 14/588=2.4 %
85 33 58 26 32 588 569=100 %
Subphrenich hematoma
0
23
Author
0 0 0 3 2 0 0 0 5 1.7 % 0 0 0 3 1 0 3 0 0 0
15 28 27 57 46 40 41 32 286 100 % 18 19 11 82 36 25 70 26 30 14
Acholonu et al. [36] Berende et al. [29] Dapri et al. [40] Foletto et al. [30] Goitein et al. [37] Himpens et al. [31] Iannelli et al. [38] Jacobs et al. [39] Total Total percentage Abu-Gazala and Keidar [32] Ardestani et al. [11] Hamza et al. [26] Hii et al. [8] Khoursheed et al. [28] Langer et al. [19]† Mognol et al [20] Moore et al. [17] Muller et al. [21] van Nieuwenhove et al. [18], 2 steps van Nieuwenhove et al. [18], 1 step Robert et al. [27] Spivak et al. [35] Topart et al. [33] van Wageningen [34] Weber et al. [22] Total Total percentage
Conversions
N
Author
Table 6 Operative characteristics and short-term complications
Anastomotic leakage
0 0 3 0 2 19 3.3 %
0
0 0 0 0 0 0 0 0 0 0% 0 – 0 11 0 0 3 0 – 0
2 0 0 1 1 4 0.7 %
0
0 0 0 0 0 0 3 0 3 1.0 % 0 – 0 0 0 0 0 0 – 0
1 5 0 3 2 3 1 1 16 5.6 %
Staple line leak
Herniation port site
Intra-abdominal abscess
Bleeding/spleen laceration
Wound infection
Perforation of stomach
1 0 0 1 0 1 1 0 4 1.4 %
Acute gastric outlet obstruction (ileus)
Pneumonia
0 4 0 3 1 0 0 0 8 2.8 %
Bleeding
OBES SURG (2013) 23:1899–1914 1907
0 2 0.7 %
Jacobs et al. [39] Total Total percentage Abu-Gazala and Keidar [32] Ardestani et al. [11] Hamza et al. [26] Hii et al. [8] Khoursheed et al. [28]
Langer et al. [19]† Mognol et al [20] Moore et al. [17] Muller et al. [21] van Nieuwenhove et al. [18], 2 steps van Nieuwenhove et al. [18], 1 step Robert et al. [27] Spivak et al. [35] Topart et al. [33] van Wageningen [34] Weber et al. [22] Total Total percentage
Subphrenich hematoma
Author
Table 6 (continued)
0 0 0 – 0 0 0 0 0 0 0 0 0
0 1 0 0 0 0 4 0.7 %
0 3 1.0 % 0 – 0 0 0
Death
0 3 0 – 0
0 2 0.7 % 0 – 0 0 0
Fever
5.2 (3–35) 2.8 (1–10) 7.7±2.8 7.9±5.6 8.9±4.9(4–24) 5.3 5.3
3 (3–8)
5 (4–20) 7.2 3 – 3 (2–7)
1.5 (1–3) 4.1 4.1 3.9±1.5 – 2.0±1.3 4.5 (3–39) 3.36 ±1.2 (3–10)
Hospital stay, days
0 0 0 2 1 5 0.9 %
0
0 0 1 – 0
0 – 0 1 0
Anastomotic leakage
0 1 0 2 0 10 1.8 %
0
0 3 0 – 0
1 – 1 1 1
Bleeding/spleen laceration
0 0 0 0 0 2 0.4 %
0
1 0 0 – 0
0 – 0 0 1
Herniation port site
0 0 0 0 0 1 0.2 %
0
0 1 0 – 0
0 – 0 0 0
Pneumonia
0 0 0 1 0 1 0.2 %
0
0 0 0 – 0
0 – 0 0 0
Perforation of stomach
1908 OBES SURG (2013) 23:1899–1914
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Table 7 Long-term complications Author
Abu-Gazala and Keidar [32] Ardestani et al. [11] Hamza et al. [26] Hii et al. [8] Khoursheed et al. [28] Langer et al. [19] Mognol et al [20] Moore et al. [17] Muller et al. [21] van Nieuwenhove [18] Robert et al. [27] Spivak et al. [35] Topart et al. [33] van Wageningen [34] Weber et al. [22] Total Total percentage Acholonu et al. [36] Berende et al. [29] Dapri et al. [40] Foletto et al. [30] Goitein et al. [37] Himpens et al. [31] Iannelli et al. [38] Jacobs et al. [39] Total Total percentage
Total of patients
Gastro-gastric fistulae
Stenosis at the gastro-jejunostomy/ small bowel obstruction
Marginal ulcer
Port-site hernia
Internal hernia
82
– – – 0
– – – 22
– – – 2
– – – 0
– – – 0
– 1 0 – 0 0 0 0 0 0 0 1 0.2 % – – – – –
– 1 3 – 1 3 1 0 0 1 2 31 6.4 % – – – – –
– 0 3 – 0 0 0 0 0 0 0 5 1.0 % – – – – –
– 1 0 – 0 0 2 0 1 0 0 4 0.8 % – – – – –
– 0 0 – 0 0 0 1 0 0 0 1 0.2 % – – – – –
– – – – 1 (2× PC)
0 – – 0 0%
0 – – 0 0%
0 – – 0 0%
0 – – 0 0%
1 – – 1 2.5 %/1.2 %
0 – – 1 2.5 %/1.2 %
25 70 30 37 85 55 58 26 32 478 100 %
46 40
40/86 100 %
Chronic anemia
PC packed cells
of the patients who underwent LRYGB required reoperation [19, 32]. Secondary Outcomes Follow-Up and Weight Loss The BMI at revision varied from 40 to 47.6 in the LRYGB group and from 30.6 to 49.9 in the LSG group [17, 19, 29, 38]. The amount of months between the first operation and revision varied between 28 and 90 months (Table 2 and 10) [11, 18, 30]. The mean follow-up after revision to LRYGB was reported in all studies and the mean varied between 7.3 and 44.4 months [11, 20]. The results were reported in BMI at follow-up by four studies [21, 22, 27, 35], in EWL at follow-up by four studies [11, 17, 19, 33], and by seven studies in both [8, 18, 20, 26, 28, 32, 34]. The BMI at follow-up varied between 30.7
and 37.4 [34, 35]. Comparing the first BMI with the BMI at follow-up, the difference was 12.7 points in two studies [18, 20]. The time difference of follow-up was 8 months; 10 months follow-up by van Nieuwenhove and 18 months by Mognol. The smallest descent in BMI appeared in Muller et al., a decrease of 6 points, with the longest follow-up of 36 months. Of the studies where EWL were reported, Moore had the least with only 23 % in 18 months of follow-up. Hii reported EWL of 74 % in 36 months (Table 10).
Discussion This systematic review shows that laparoscopic gastric bypass and laparoscopic gastric sleeve as revisional procedures after gastric banding are relatively safe with a small amount of complications and a very low mortality rate.
N
57 46 40 41 32 286 100 %
Foletto et al. [30] Goitein et al. [37] Himpens et al. [31] Iannelli et al. [38] Jacobs et al. [39] Total Total percentage
1 2 2 1 0 10 3.5 %
82 10 36 4 25 0 70 4 26 1 30 2 14 0 23 1 85 3 33 2 58 3 26 2 32 4 569 37 100 % 6.5 % 15 1 28 2 27 1
0 – 1
1 0 0 0 0 1 0.3 %
0 1 0 0 0 0 0 0 1 0 0 0 0 2 0.4 % 0 0 0
0 – 0 0 0 0 0 0 0 0 0 0 0 0 2 1 3 0.5 %
0 – 0
0 0 0 0 0 2 0.7 %
1 2 0 1 0 0 0 1 0 1 0 0 0 7 1.2 % 0 2 0
0 – 1
0 0 0 0 0 0 0%
3 0 0 0 0 0 0 0 0 0 1 0 0 4 0.7 % 0 0 0
0 – 0
0 0 1 1 0 2 0.7 %
6 1 0 0 1 2 0 0 1 1 1 0 2 15 2.6 % 0 0 0
0 – 0
0 0 0 0 0 0 0%
0 0 0 0 0 0 0 0 0 0 0 0 1 1 0.2 % 0 0 0
0 – 0
0 0 0 0 0 0 0%
0 0 0 0 0 0 0 0 0 0 1 0 0 1 0.2 % 0 0 0
0 – 0
0 0 0 0 0 0 0%
0 0 0 0 0 0 0 0 1 0 0 0 0 1 0.2 % 0 0 0
0 – 0
0 0 0 3 0 0 0 0 0 0 0 0 0 3 0.5 %
0 – 0
Number of Perforation Anastomotic Bleeding Wound Small bowel obstruction/ Intra-abdominal Atelectasis Fistulae Fever reoperations leakage infection stenosis/hiatial hernia abscess
Hii et al. [8] Khoursheed et al. [28] Langer et al. [19] Mognol et al [20] Moore et al. [17] Muller et al. [21] van Nieuwenhove [18] van Nieuwenhove [18] Robert et al. [27] Spivak et al. [35] Topart et al. [33] van Wageningen [34] Weber et al. [22] Total Total percentage Acholonu et al. [36] Berende et al. [29] Dapri et al. [40]
Abu-Gazala and Keidar [32] 18 Ardestani et al. [11] 19 Hamza et al. [26] 11
Author
Table 8 Reasons for reoperation
1
–
0 0 1 0 0 2 0.7 %
0 0 1
Staple Subphrenic line leak hematoma
1910 OBES SURG (2013) 23:1899–1914
0 0% 3 0.5 % 2 0.7 % 0 0% 0 0% 1 0.2 % 0 0% 1 0.2 % 0 0% 1 0.2 % 2 0.7 % 15 2.6 % 0 0% 4 0.7 % 2 0.7 % 7 1.2 % 3 1.0 % 3 0.5 % 1 0.3 % 2 0.4 % 286 100 % 569/588 100 % Sleeve Total percentage LRYGB Total percentage
10 3.5 % 37 6.5 %
Staple line leak/ anastomotic leakage Perforation Number of reoperations N Author
Table 9 Reasons for reoperations difference Sleeve and LRYGB
Bleeding
Wound infection
Small bowel obstruction/ stenosis/hiatial hernia
Intra-abdominal abscess
Atelectasis
Fistulae
Subphrenich hematoma
Fever
OBES SURG (2013) 23:1899–1914
1911
The (L)AGB used to be one of the most performed weight loss operations, but long-term results are disappointing. LRYGB and LSG have a better outcome in long-term weight loss and reducing comorbidities [4, 41, 42]. The main reason for revision is insufficient weight loss or weight regain after (L)AGB, but also a wide array of complaints may lead to revision. For this reason, more and more bands are reversed into LRYGB or LSG [8, 20, 33, 40]. In potential, the revisional operation is more difficult than primary LRYGB or LSG due to adhesions around the (L)AGB and often the area around the stomach has been damaged and scarred. In recent years, many study groups have published their results of conversion surgery; however, the numbers of performed procedures remain small. The present review shows that laparoscopic revisions can be performed safely in around 98 %. The need for conversion was low. However, some operations were primary open because of expected adhesions in the first place. Open procedures were excluded from this review. This can lead to a potential bias about the difficulty of the revision procedure [33]. Nevertheless, results seem similar if compared with primary LRYGB (conversions rates, 0–23 %) [4, 43]. It should be realized that there is always a potential bias in reporting mortality and morbidity since studies with disappointing results might not be published (publication bias). However, mortality was not different between the procedures (one patient died). All studies have a relatively good outcome in morbidity and mortality [43]. In LSG, a staple line leakage percentage of 5.6 % was found, which is higher than reported in primary surgery (0.35–2.40 %) [30, 44]. Remarkably, LRYGB after gastric banding showed a leakage rate of 0.9 %. After primary LRYGB, this number is reported between 0.4 and 5.0 % [45–48] and can thus been seen as equal. It is difficult to draw definite conclusions, although the higher leakage rate after LSG may indicate that perhaps the tissue of the stomach (e.g., scar tissue) after banding needs time to recover. Literature concerning one- or two-step revisions is scarce and conclusions cannot be drawn. Future studies should focus on doing a staged approach which may decrease the leak and overall complication rate. Despite the fact that the rate of (the feared) anastomotic leakage is comparable in revisional and primary LRYGB, the percentage of reoperations after revisional surgery seems higher. The amount of reoperations after revisional surgery was 6.5 %. This is relatively high compared with reoperation rates reported in the literature after primary LRYGB (3.2 %) [43]. The reasons for reoperation were diverse (e.g., small bowel obstruction, stenosis, or hiatal hernia). This extreme variety in reported complications raises questions about the way the complications were collected and scored. However, a reoperation rate of almost 7 % is high and patients should be informed preoperatively accordingly. It is unclear if a staged
Number of patients
18 19 11 82
36 25 70 26 30 14 23 85 33 58 26 32
588 15 28 27 57 46 40
41 32 286
Author
Abu-Gazala and Keidar [32] Ardestani et al. [11] Hamza et al. [26] Hii et al. [8]
Khoursheed et al. [28] Langer et al. [19] Mognol et al [20] Moore et al. [17] Muller et al. [21] van Nieuwenhove [18] van Nieuwenhove [18] Robert et al. [27] Spivak et al. [35] Topart et al. [33] van Wageningen [34] Weber et al. [22]
Total Acholonu et al. [36] Berende et al. [29] Dapri et al. [40] Foletto et al. [30] Goitein et al. [37] Himpens et al. [31]
Iannelli et al. [38] Jacobs et al. [39] Total
Table 10 BMI and excessive weight loss
53.1 (35.9–63) 42.69
– 39.8 45.7±10.8 (36–77) 43.1 (33–57) 43.5±8.1 (25.3–61)
45.15 ±7.95 47.6±7.7 (37–70) 44.9±10.8 40 41.9 43.8±5.8 41.4±6.7 42.9 42.8 (33.1–50.0, SD 4.4) 43.2±7.0 43.8±9.5 42.0±6.7 (30.7–59.3)
41.6±5.3 – 43.9±7.4 43 (31–70)
BMI at revision
35.23±6.70 (22.94–51.85) – 32.2±6.3 – 35.2 35.3±7.55 28.7±10.8 34.8 (22–50) 30.7 (22–39 SD 5.3) – 37.4 ± 8.6 31.8
31.8±5.1 – 34.3±8.1 33 (27–54)
BMI at follow-up
42.7 (4–76) 60 (13.5–120)
64.2 (46.5–80.1) – 16.7 48 31
41.19±20.22 (0.00–89.66) 56.9±15.0 70.2±21 23.0 – 35.4±13.2 26.5±5.5 – – 66.1±26.8 51.9±23.9 –
52±44.3 53.7±21.9 62.1±24.0 74 (16–85)
Excessive weight loss at follow-up (EWL %)
13.4 (1–36) 26
6 – 20 (3–36) 36 32.6±14.8 (3–83)
12
15.83±13.43 (1–48) 12 18 18 36 9 (3–31) 10 (4–23) 22 (3–72) 15.7 (12–26) 12 12
14.6±9.7 24 12.9±7.9 36
Time of follow-up at weight measurement (months)
42.7 33.3 (23–50)
– 32.5 34.6±8.7 (21–50.4) 39.0±8.5 – 36.2±8.7 (25–54)
BMI at follow-up/lost weight at follow-up
1912 OBES SURG (2013) 23:1899–1914
OBES SURG (2013) 23:1899–1914
procedure would decrease these numbers and future studies should focus on this. Furthermore, centralizing such surgery in large centers may further decrease reoperation rates. Although in most studies the pouch was created below the scar tissue, in some studies it was created above the scar tissue according to the surgeon’s preference and local situation. No studies compared the position of the pouch. Based on the results of this review, the assumption can be made that perioperative decision making, based on the surgeon’s expertise is save. Numbers are too small to define a reliable conclusion about stapled or hand sewn anastomosis and its influence on occurrence of complications. From primary gastric bypass surgery, it is known that hand-sewn anastomosis with absorbable material may reduce the risk of late-onset complications such as the development of marginal ulceration [49, 50]. Mean hospital stay of revision gastric bypass was 5.3 days which is comparable with primary LRYGB between 2 and 7 days [4, 15, 51–54]. The mean hospital stay of the revisional LSG is 1 day less (4.1 days) than that of revisional LRYGB. Revisional surgery after restrictive procedures is effective. All articles that reported on RYGB mentioned weight loss (some in percentage of BMI others as EWL). Eleven reported weight loss after revision in EWL. The mean ranged from 23 to 74 % [8, 17] of the EWL (range, 0–89 %) [28]. To interpret the results of revisional surgery, the time of follow-up and the initial BMI is important for good interpretation. Standardized report systems should be made from variables as BMI and EWL at a standard follow-up time. Although LGS has no malabsorptive component, the effects are promising also compared to primary gastric band [55–57]. In this review, the EWL and BMI after revisional LSG are almost comparable to those after revisional RYGB. A randomized controlled trial may answer the question about the different types of revisional surgery and its successes. Another important issue to pay attention to is that possibly there is a difference (and thus a difference in weight loss after revision) between those patients whose indication for revision was weight regain or inadequate weight loss compared with those whose indication for revision was due to a complication of the band-like erosion or band slippage. This would give a better idea of what the expected weight loss would be after a revision. The current review has its weaknesses. All studies included are cohort studies, both retrospective and prospective consecutive series. This is the best evidence available at the moment. Additional work needs to be done to unravel the indications and options for revision. This review only comprises the revision from (L)AGB to LRYGB and LSG. More options of revisional surgery are possible such as minigastric bypass, biliopancreatic diversion, and duodenal switch. It remains unclear if there are differences between those procedures. Revisions are becoming increasingly common and numbers will dramatically increase. There are no clear data to identify the risk of revision, what the best procedures will
1913
be, how patients should be screened, and how the follow-up should be performed. Randomized controlled trials would be favored to answer some of these questions in the near future, but since this can be difficult to realize, prospective cohort studies with a large number of patients could be valuable as well.
Conclusion The present review shows that laparoscopic surgical revision of a gastric band into gastric bypass or gastric sleeve is relatively save, although reoperation rate is higher. Both have good outcomes. RYGB seems to have better long-term results regarding at weight loss. However, the articles published about gastric sleeve as a revision procedure lacks reliable information about the long-term complications and benefits. The decision to perform revision and type of procedure should be based on individual patient characteristics.
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