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Optimizing Peri-operative Care in Bariatric Surgery Patients

Coblijn, U.K.

2018

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CHAPTER 10Laparoscopic 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 in: Obes Surg. 2013 Nov;23(11):1899-914

CHAPTER 10Laparoscopic 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 in: Obes Surg. 2013 Nov;23(11):1899-914

172

Revisional bariatric surgery, systematic review

Abstract

The adjustable gastric band (LAGB) gained popularity as a weight loss procedure. However,

long term results are disappointing, many patients need revision to laparoscopic Roux-en-Y

gastric bypass (LRGYB) or sleeve gastrectomy (LSG). The purpose of this study was to

assess morbidity, mortality and results of these two revisional procedures. 15 LRYGB studies

with a total of 588 patients and 8 LSG studies with 286 patients were included. 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 percent; long term complications

in 8.9 and 2.5 percent. Reoperation was performed in 6.5 and 3.5 percent. Revision to LRYGB

or LSG after LAGB is feasible and relatively safe. Complication rate is higher than in primary

procedures.

172


Abstract

The adjustable gastric band (LAGB) gained popularity as a weight loss procedure. However,

long term results are disappointing, many patients need revision to laparoscopic Roux-en-Y

gastric bypass (LRGYB) or sleeve gastrectomy (LSG). The purpose of this study was to

assess morbidity, mortality and results of these two revisional procedures. 15 LRYGB studies

with a total of 588 patients and 8 LSG studies with 286 patients were included. 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 percent; long term complications

in 8.9 and 2.5 percent. Reoperation was performed in 6.5 and 3.5 percent. Revision to LRYGB

or LSG after LAGB is feasible and relatively safe. Complication rate is higher than in primary

procedures.

173


Introduction

Obesity is a rising concern all over the world. In the United States alone, the prevalence is around

30% in the adult population (1). The World Health Organisation (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 apnoea,

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, LAGB gained popularity because of

its relatively low complexity and adjustability in combination with low perioperative morbidity

(1-5%) and mortality rate (0-0.05%). LAGB 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 LAGB 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 post-operative period, the procedure has several limitations.

Band related complications such as oesophageal dilatation, food intolerance, gastric necrosis,

band slippage, band- 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 to 100 percent

of the patients (17-19).

There are different surgical options to treat late complications or inadequate weight loss.

Removal of the band, without further intervention is associated with high weight regain (20).

Although LAGB repositioning or replacement is technically possible, studies show mixed results

(concerning feasibility and long-term weight loss especially when compared to revision into

RYGB or 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). LRYGB and LSG are more and more frequently performed as a

10

173


Introduction

Obesity is a rising concern all over the world. In the United States alone, the prevalence is around

30% in the adult population (1). The World Health Organisation (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 apnoea,

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, LAGB gained popularity because of

its relatively low complexity and adjustability in combination with low perioperative morbidity

(1-5%) and mortality rate (0-0.05%). LAGB 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 LAGB 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 post-operative period, the procedure has several limitations.

Band related complications such as oesophageal dilatation, food intolerance, gastric necrosis,

band slippage, band- 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 to 100 percent

of the patients (17-19).

There are different surgical options to treat late complications or inadequate weight loss.

Removal of the band, without further intervention is associated with high weight regain (20).

Although LAGB repositioning or replacement is technically possible, studies show mixed results

(concerning feasibility and long-term weight loss especially when compared to revision into

RYGB or 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). LRYGB and LSG are more and more frequently performed as a

10

174


rescue operation after failed LAGB. However, it is unclear which operation should be performed

and when. Safety, effectiveness and timing of revision are subject 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, SML) independently performed the literature

search. Electronic links to related articles and references of selected articles were hand-searched

as well. References were eyeballed. A hand search of relevant journals and conference proceed-

ings 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 the revisional procedure was (primarily) open or if the primary procedure was different than

(L)AGB. The same investigators independently searched the list of abstracts according to the

search results and selected articles for closer reading. Subsequently, two investigators (CVJ,

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.

174


rescue operation after failed LAGB. However, it is unclear which operation should be performed

and when. Safety, effectiveness and timing of revision are subject 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, SML) independently performed the literature

search. Electronic links to related articles and references of selected articles were hand-searched

as well. References were eyeballed. A hand search of relevant journals and conference proceed-

ings 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 the revisional procedure was (primarily) open or if the primary procedure was different than

(L)AGB. The same investigators independently searched the list of abstracts according to the

search results and selected articles for closer reading. Subsequently, two investigators (CVJ,

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.

175


Each of the selected studies was critically appraised by two investigators (CJV, UKC), using a

modified form as proposed by the Dutch Cochrane Collaboration. Assessed was duration of

the data collection; study design (randomisation, prospective or retrospective consecutive data

collection); comparability of study groups; adequate follow up; commercial interest, description

of statistical analysis; different technique (learning curve) and different kind of treatment. 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, 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, complications (anastomotic

leakage; staple line leakage; wound infection; bleeding; perforation; 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 EWL).

Results

Included studies

915 publications were identified. 778 contained the search terms in a different context and

were therefore deemed irrelevant. In total, 137 abstracts were selected for closer reading.

111 articles were excluded based on the abstract. Of the remaining articles two were not

written in English and were therefore discarded. 24 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, sleeve gastrectomy), but more than 10 revi-

sions of LAGB 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

excluded (Figure 1: Flowchart). Finally, a total of 15 articles about revision into LRYGB and

eight articles about revision into LSG were used in this review. Table 1 (supplemental)

contains the included studies and rates their level of quality.

10

175


Each of the selected studies was critically appraised by two investigators (CJV, UKC), using a

modified form as proposed by the Dutch Cochrane Collaboration. Assessed was duration of

the data collection; study design (randomisation, prospective or retrospective consecutive data

collection); comparability of study groups; adequate follow up; commercial interest, description

of statistical analysis; different technique (learning curve) and different kind of treatment. 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, 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, complications (anastomotic

leakage; staple line leakage; wound infection; bleeding; perforation; 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 EWL).

Results

Included studies

915 publications were identified. 778 contained the search terms in a different context and

were therefore deemed irrelevant. In total, 137 abstracts were selected for closer reading.

111 articles were excluded based on the abstract. Of the remaining articles two were not

written in English and were therefore discarded. 24 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, sleeve gastrectomy), but more than 10 revi-

sions of LAGB 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

excluded (Figure 1: Flowchart). Finally, a total of 15 articles about revision into LRYGB and

eight articles about revision into LSG were used in this review. Table 1 (supplemental)

contains the included studies and rates their level of quality.

10

176


Data synthesis

No randomized clinical trials were found. For this reason, our data collection merely exists

of observational studies. Performing a meta-analysis or a pooled analysis on this type of

studies is not reliable.

Figure 1: Flowchart of a systematic review about the complications and safety of conversion from laparoscopic

gastric band to RYGB or Sleeve Gastrectomy

176


Data synthesis

No randomized clinical trials were found. For this reason, our data collection merely exists

of observational studies. Performing a meta-analysis or a pooled analysis on this type of

studies is not reliable.

Figure 1: Flowchart of a systematic review about the complications and safety of conversion from laparoscopic

gastric band to RYGB or Sleeve Gastrectomy

177


Patients

All patients included in this review met the IFSO criteria for morbid obesity before the first

bariatric procedure. Most of them still did at the time of revision (25).

588 patients underwent revision of (L)AGB into LRYGB. The number of patients in each study

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 fourteen studies. It varied between 37 and 49 years (range 18-68) Table 2 (8;20;28).

A total of eight 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 normal 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).

Indication for revisional surgery

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 fifteen 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

percent (8;11;17-20;26;27;30;35-39).

One or two step revision:

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. 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 2-102

months (18;37). Table 5 is added as supplement for details about operation technique.

10

177


Patients

All patients included in this review met the IFSO criteria for morbid obesity before the first

bariatric procedure. Most of them still did at the time of revision (25).

588 patients underwent revision of (L)AGB into LRYGB. The number of patients in each study

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 fourteen studies. It varied between 37 and 49 years (range 18-68) Table 2 (8;20;28).

A total of eight 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 normal 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).

Indication for revisional surgery

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 fifteen 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

percent (8;11;17-20;26;27;30;35-39).

One or two step revision:

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. 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 2-102

months (18;37). Table 5 is added as supplement for details about operation technique.

10

178


Table 2: Patient demographics and revision procedure

Author N AgeSex (M/F)

BMI before 1st band BMI at revision

Months since first operation

Two steps revision

One steprevision

Abu-Gazala, 18 43.7 ± 13.2 10/8 - 41.6±5.3 - - -Ardestani, 19 42.3 ± 12.3 2/17 44.1 ± 5.7 - 27.6 (11-48) 1 18Hamza 11 46.5 ± 8.6 2/9 - 42.8 ± 6.7 29.7 ±14.3 2 9Hii 82 49 (18-66) 12/70 47(32-73) 43 (31-70) 46 (9-168) 18 64Khoursheed 36 36.95 ±8.97

(21-53)- - 45.15 ±7.95 - 2 34

Langer 2008 25 43±11 1/24 51.0±8.1 47.6±7.7 (34-70) 53 (17-118) 0 25Mognol, 70 41± 10.14

(21-68)22/58 - 44.9±10.8

(26.9-81)42 ± 18(7 – 74)

23 47

Moore, 26 46 3/23 45 40 29 2 24Muller 30 - - 47.1 41.9 - - -Nieuwenhove, 2 step

14 40 ± 11 4/10 45.0 ± 6.7 43.8 ± 5.8 80 (28-120) 14 0

Nieuwenhove, 1 step

23 44 ± 12 5/18 41.9 ± 6.1 41.4 ± 6.7 90 (40-144) 0 23

Robert 85 39.3 (20-56)

13/72 47.2 (33-67)

42.9 (27-72) - 17 68

Spivak 33 43.8 (31-62)

3/30 45.8 (39.9-53, SD: 3.4)

42.8 (33.1-50, SD 4.4)

28.2 (11-46, SD 11. 3)

0 33

Topart* 58 42.5 ± 9.9 5/53 46.3 ±7.2 43.2 ±7.0 46.1 ±17.4 8 50Wageningen 26 42.7 ± 8.8 11/15 49.7 ± 9.3 43.8 ± 9.5 50.4 ± 24 1 25Weber 32 46 ± 9.5

(28-60)9/23 47.8 ± 7.6 42.0 ± 6.7 (

30.7-59.3)42 (17-73) 0 32

Total 588 88 452

* Eight two step revision, data were not extracted




Two steps revision

One step revision

Acholonu 15 46.6 3/12 - 38.66 34.7 (16-60) 2 13Berende 28 39.2

(19-65) -45.3(35-77)

30.6(23-61) - 13 15

Dapri 27 43.6 ± 11.4(25 - 66)

10/17 45 ± 8.1(35 – 64)

39 ± 9.6(24 - 61)

51.2 ± 30.1(22 – 132)

0 27

Foletto 57 49.9 ± 11.9 20/37 51.2 ±11.1 (39-85)

45.7 ±10.8 (36-77)

90.48 ± 57.6 16 41

Goitein 46 40 (20-60) 12/34 - 43.1 (33-57) - 20 26Himpens 40 47.2 ± 12.4

(25-66)17/23 46 ± 8.0

(35-64)43.5 ± 8.1 (25.3-61)

60.2 ±30.1 (22-132)

2 38

Ianelli 41 42 (19-63) 7/34 53.1 (35.9-63)

49.9 (35.9-63) - - -

Jacobs 32 45.5 7/25 45.2 (36.2-59.1)

42.69 67 0 32

Total 286 44.5 76/182 53 192

178


Table 2: Patient demographics and revision procedure




Two steps revision

One steprevision

Abu-Gazala, 18 43.7 ± 13.2 10/8 - 41.6±5.3 - - -Ardestani, 19 42.3 ± 12.3 2/17 44.1 ± 5.7 - 27.6 (11-48) 1 18Hamza 11 46.5 ± 8.6 2/9 - 42.8 ± 6.7 29.7 ±14.3 2 9Hii 82 49 (18-66) 12/70 47(32-73) 43 (31-70) 46 (9-168) 18 64Khoursheed 36 36.95 ±8.97

(21-53)- - 45.15 ±7.95 - 2 34

Langer 2008 25 43±11 1/24 51.0±8.1 47.6±7.7 (34-70) 53 (17-118) 0 25Mognol, 70 41± 10.14

(21-68)22/58 - 44.9±10.8

(26.9-81)42 ± 18(7 – 74)

23 47

Moore, 26 46 3/23 45 40 29 2 24Muller 30 - - 47.1 41.9 - - -Nieuwenhove, 2 step

14 40 ± 11 4/10 45.0 ± 6.7 43.8 ± 5.8 80 (28-120) 14 0

Nieuwenhove, 1 step

23 44 ± 12 5/18 41.9 ± 6.1 41.4 ± 6.7 90 (40-144) 0 23

Robert 85 39.3 (20-56)

13/72 47.2 (33-67)

42.9 (27-72) - 17 68

Spivak 33 43.8 (31-62)

3/30 45.8 (39.9-53, SD: 3.4)

42.8 (33.1-50, SD 4.4)

28.2 (11-46, SD 11. 3)

0 33

Topart* 58 42.5 ± 9.9 5/53 46.3 ±7.2 43.2 ±7.0 46.1 ±17.4 8 50Wageningen 26 42.7 ± 8.8 11/15 49.7 ± 9.3 43.8 ± 9.5 50.4 ± 24 1 25Weber 32 46 ± 9.5

(28-60)9/23 47.8 ± 7.6 42.0 ± 6.7 (

30.7-59.3)42 (17-73) 0 32

Total 588 88 452

* Eight two step revision, data were not extracted




Two steps revision

One step revision

Acholonu 15 46.6 3/12 - 38.66 34.7 (16-60) 2 13Berende 28 39.2

(19-65) -45.3(35-77)

30.6(23-61) - 13 15

Dapri 27 43.6 ± 11.4(25 - 66)

10/17 45 ± 8.1(35 – 64)

39 ± 9.6(24 - 61)

51.2 ± 30.1(22 – 132)

0 27

Foletto 57 49.9 ± 11.9 20/37 51.2 ±11.1 (39-85)

45.7 ±10.8 (36-77)

90.48 ± 57.6 16 41

Goitein 46 40 (20-60) 12/34 - 43.1 (33-57) - 20 26Himpens 40 47.2 ± 12.4

(25-66)17/23 46 ± 8.0

(35-64)43.5 ± 8.1 (25.3-61)

60.2 ±30.1 (22-132)

2 38

Ianelli 41 42 (19-63) 7/34 53.1 (35.9-63)

49.9 (35.9-63) - - -

Jacobs 32 45.5 7/25 45.2 (36.2-59.1)

42.69 67 0 32

Total 286 44.5 76/182 53 192

179


Tabl

e 3:

Rea

son

for r

evis

ion

into

RYG

B or

gas

tric

sle

eve

Aut

hor

N

Insu

ffici

ent

wei

ght l

oss/

wei

ght r

egai

n

Food

into

lera

nce/

vom

iting

Pouc

h

dila

tion

Band

eros

ion

Nec

rosi

s of

the

stom

ach

Reflu

x oe

soph

agiti

s/

oeso

phag

eale

dysm

otili

ty

Intr

a

-abd

omin

al

absc

ess

Duo

dena

l

fiste

l

Band

slip

page

Gas

tric

Bypa

ss38

824

323

6514

239

31

24

Tota

l38

8/58

824

3/38

8 =

62.6

%23

/388

= 5

.9%

65/3

88 =

16.

8%14

/424

= 3

.3%

2/42

4 =

0.5%

39/3

88 =

10.

1%3/

388

= 0.

8%1/

388

= 0.

8%24

/388

= 6

.2%

Gas

tric

Slee

ve19

112

218

23

04

12

28

Tota

l19

1/28

612

2/19

1 =

63.9

%18

/191

= 9

.4%

2/19

1 =

1.0%

3/19

1 =

1.6%

04/

191

= 2.

1%1/

191

= 0.

5%2/

191

= 1.

0%28

/191

= 1

4.7%

10

179


Tabl

e 3:

Rea

son

for r

evis

ion

into

RYG

B or

gas

tric

sle

eve

Aut

hor

N

Insu

ffici

ent

wei

ght l

oss/

wei

ght r

egai

n

Food

into

lera

nce/

vom

iting

Pouc

h

dila

tion

Band

eros

ion

Nec

rosi

s of

the

stom

ach

Reflu

x oe

soph

agiti

s/

oeso

phag

eale

dysm

otili

ty

Intr

a

-abd

omin

al

absc

ess

Duo

dena

l

fiste

l

Band

slip

page

Gas

tric

Bypa

ss38

824

323

6514

239

31

24

Tota

l38

8/58

824

3/38

8 =

62.6

%23

/388

= 5

.9%

65/3

88 =

16.

8%14

/424

= 3

.3%

2/42

4 =

0.5%

39/3

88 =

10.

1%3/

388

= 0.

8%1/

388

= 0.

8%24

/388

= 6

.2%

Gas

tric

Slee

ve19

112

218

23

04

12

28

Tota

l19

1/28

612

2/19

1 =

63.9

%18

/191

= 9

.4%

2/19

1 =

1.0%

3/19

1 =

1.6%

04/

191

= 2.

1%1/

191

= 0.

5%2/

191

= 1.

0%28

/191

= 1

4.7%

10

180


Primary outcomes

Mortality and morbidity

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 post-operatively (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 six months of sepsis after an uneventful discharge 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 percent (8;35). All

together 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 respectively

0.9% and 1.8% of the operations. Three patients needed reoperation for anastomotic

leakage, accountable for 7.3% of reoperations. Bleeding was responsible for 17.1 percent 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 conservative (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 then 30 days postoperative. Details are

displayed in supplemental Table 7. Ten of the fifteen 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 gastrojejunstomy was by far

the most common complication with 6.5%. Marginal ulceration followed by 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).

180


Primary outcomes

Mortality and morbidity

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 post-operatively (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 six months of sepsis after an uneventful discharge 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 percent (8;35). All

together 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 respectively

0.9% and 1.8% of the operations. Three patients needed reoperation for anastomotic

leakage, accountable for 7.3% of reoperations. Bleeding was responsible for 17.1 percent 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 conservative (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 then 30 days postoperative. Details are

displayed in supplemental Table 7. Ten of the fifteen 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 gastrojejunstomy was by far

the most common complication with 6.5%. Marginal ulceration followed by 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).

181


Median length of stay (LOS) was reported in 13 studies and varied from 1-39 days with a

mean of 5.3. This included patients with and without complications. Readmission was not

mentioned in all studies (27;35).

Conversion rate

All articles mentioned the rate of conversion to open surgery. Conversion to open surgery

was performed in 14 (2.4%) LRYGB patients; and in five (1.7%) LSG patients, most common

reason was (expected) adhesions and large incisional herniations (30;37).

Reoperation

The mean incidence of reoperation was respectively 6.5 and 3.5 percent (29;31;38). Besides

already mentioned bleeding and staple line leakage; intestinal obstruction, stenosis and

internal herniations were reasons for reoperation (Table 8+9) (8;17;18;20;22;26-28;33-35). In only two

studies none 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 number of months between the first operation and revision varied

between 28 and 90 months (Table 2 +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 4 studies (21;22;27;35), in Excessive Weight Loss (EWL) at follow up by four studies (11;17;19;33) and by 7 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 at van Nieuwenhove and

18 months of 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 a EWL of 74% in

36 months Table 10.

10

181


Median length of stay (LOS) was reported in 13 studies and varied from 1-39 days with a

mean of 5.3. This included patients with and without complications. Readmission was not

mentioned in all studies (27;35).

Conversion rate

All articles mentioned the rate of conversion to open surgery. Conversion to open surgery

was performed in 14 (2.4%) LRYGB patients; and in five (1.7%) LSG patients, most common

reason was (expected) adhesions and large incisional herniations (30;37).

Reoperation

The mean incidence of reoperation was respectively 6.5 and 3.5 percent (29;31;38). Besides

already mentioned bleeding and staple line leakage; intestinal obstruction, stenosis and

internal herniations were reasons for reoperation (Table 8+9) (8;17;18;20;22;26-28;33-35). In only two

studies none 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 number of months between the first operation and revision varied

between 28 and 90 months (Table 2 +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 4 studies (21;22;27;35), in Excessive Weight Loss (EWL) at follow up by four studies (11;17;19;33) and by 7 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 at van Nieuwenhove and

18 months of 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 a EWL of 74% in

36 months Table 10.

10

182


Tabl

e 6:

Ope

rativ

e ch

arac

teris

tics

and

shor

t ter

m c

ompl

icat

ions

RYG

B

Aut

hor

NC

onve

rsio

nsO

pera

ting

time,

min

.Re

oper

-at

ions

Wou

nd

infe

ctio

n

Intr

a-ab

dom

inal

ab

ces

Ana

s-to

mot

ic

leak

age

Blee

ding

/ sp

leen

la

cera

tion

Her

niat

ion

port

site

Pneu

-m

onie

Feve

rPe

rfor

atio

n of

sto

mac

hD

eath

Hos

pita

l st

ay, d

ays

Abu-

Gaz

ala

180

195

± 59

00

00

10

00

00

3.9

± 1.

5Ar

dest

ani,

2010

190

--

--

--

--

--

--

Ham

za11

016

5± 7

5.8

10

00

10

00

00

2.0

± 1.

3H

ii82

313

2

(70-

236)

1011

01

10

00

00

4.5

(3-3

9)

Khou

rshe

ed36

114

5 ±

35

(120

-240

)4

00

01

10

00

03.

36 ±

1.2

(3-1

0)La

nger

, 200

8†25

021

9 ±

52

(135

-375

)0

00

00

10

00

05

(4-2

0)

Mog

nol 2

004

703

240±

40

(210

-280

)4

30

03

01

30

07.

2

Moo

re 2

008

260

160

(1

40-1

95)

10

01

00

00

00

3

Mul

ler

300

-2

--

--

--

--

--

Nie

uwen

hove

, va

n 2

step

140

116

± 31

00

00

00

00

00

3 (2

-7)

Nie

uwen

hove

, va

n 1

step

230

150

± 39

10

00

00

00

00

3 (3

-8)

Robe

rt85

216

6

(110

-360

)3

02

00

00

10

05.

2 (3

-35)

Spiv

ak33

010

5 (8

5-17

5)2

00

01

00

00

02.

8 (1

-10)

Topa

rt58

1 (2

ope

n)12

8. ±

25.

93

30

00

00

00

07.

7 ±

2.8

Wag

enin

gen

264

194

± 45

20

12

20

00

10

7.9

± 5.

6W

eber

320

215±

62.7

(1

35-3

80)

42

11

00

00

00

8.9±

4.9

(4-2

4)To

tal

588

14/5

88 =

2.4

%16

737

194

510

21

41

05.

3To

tal

perc

enta

ge56

9 =

100%

167

6.5%

3.3%

0.7%

0.9%

1.8%

0.4%

0.2%

0.7%

0.2%

05.

3

182


Tabl

e 6:

Ope

rativ

e ch

arac

teris

tics

and

shor

t ter

m c

ompl

icat

ions

RYG

B

Aut

hor

NC

onve

rsio

nsO

pera

ting

time,

min

.Re

oper

-at

ions

Wou

nd

infe

ctio

n

Intr

a-ab

dom

inal

ab

ces

Ana

s-to

mot

ic

leak

age

Blee

ding

/ sp

leen

la

cera

tion

Her

niat

ion

port

site

Pneu

-m

onie

Feve

rPe

rfor

atio

n of

sto

mac

hD

eath

Hos

pita

l st

ay, d

ays

Abu-

Gaz

ala

180

195

± 59

00

00

10

00

00

3.9

± 1.

5Ar

dest

ani,

2010

190

--

--

--

--

--

--

Ham

za11

016

5± 7

5.8

10

00

10

00

00

2.0

± 1.

3H

ii82

313

2

(70-

236)

1011

01

10

00

00

4.5

(3-3

9)

Khou

rshe

ed36

114

5 ±

35

(120

-240

)4

00

01

10

00

03.

36 ±

1.2

(3-1

0)La

nger

, 200

8†25

021

9 ±

52

(135

-375

)0

00

00

10

00

05

(4-2

0)

Mog

nol 2

004

703

240±

40

(210

-280

)4

30

03

01

30

07.

2

Moo

re 2

008

260

160

(1

40-1

95)

10

01

00

00

00

3

Mul

ler

300

-2

--

--

--

--

--

Nie

uwen

hove

, va

n 2

step

140

116

± 31

00

00

00

00

00

3 (2

-7)

Nie

uwen

hove

, va

n 1

step

230

150

± 39

10

00

00

00

00

3 (3

-8)

Robe

rt85

216

6

(110

-360

)3

02

00

00

10

05.

2 (3

-35)

Spiv

ak33

010

5 (8

5-17

5)2

00

01

00

00

02.

8 (1

-10)

Topa

rt58

1 (2

ope

n)12

8. ±

25.

93

30

00

00

00

07.

7 ±

2.8

Wag

enin

gen

264

194

± 45

20

12

20

00

10

7.9

± 5.

6W

eber

320

215±

62.7

(1

35-3

80)

42

11

00

00

00

8.9±

4.9

(4-2

4)To

tal

588

14/5

88 =

2.4

%16

737

194

510

21

41

05.

3To

tal

perc

enta

ge56

9 =

100%

167

6.5%

3.3%

0.7%

0.9%

1.8%

0.4%

0.2%

0.7%

0.2%

05.

3

183


Tabl

e 6:

Ope

rativ

e ch

arac

teris

tics

and

shor

t ter

m c

ompl

icat

ions

SG

Aut

hor

NC

onve

rsio

ns

Ope

ratin

g

time,

min

.

Reop

er-

atio

ns

Wou

nd

infe

ctio

n

Ado

mi-n

al

absc

ess

Stap

le

line

leak

Blee

ding

Acu

te g

astr

ic

outle

t obs

truc

tion

(ileu

s)

Subf

reni

c

hem

atom

afe

ver

Dea

th

Hos

pita

l

stay

, day

s

Acho

lonu

150

120

10

01

01

00

05.

5

Bere

nde

280

99 (5

4-22

1)2

00

54

00

00

3 (2

-38)

Dapr

i27

012

0.6

± 32

.4

(65

-195

)

10

00

00

10

03.

2 ±

1.4

(2 –

8)

Fole

tto

573

120

(90-

180)

10

03

31

00

3 (>

30

days

)-

Goi

tein

462

118

(70-

250)

20

02

10

00

03 (1

-100

)

Him

pens

400

95.6

±30

.4

(35-

195)

20

03

01

12

04.

2 ±1

.2

(2-7

7)

Iane

lli41

011

7 (9

0-16

5)1

03

10

10

00

7.9

(5-7

1)

Jaco

bs32

0-

00

01

00

00

01.

5

(1-3

)

Tota

l28

65

100

316

84

22

34.

1

Tota

l %10

0%1.

7%3.

5%0%

1.0%

5.6%

2.8%

1.4%

0.7%

0.7%

1.0%

4.1

10

183


Tabl

e 6:

Ope

rativ

e ch

arac

teris

tics

and

shor

t ter

m c

ompl

icat

ions

SG

Aut

hor

NC

onve

rsio

ns

Ope

ratin

g

time,

min

.

Reop

er-

atio

ns

Wou

nd

infe

ctio

n

Ado

mi-n

al

absc

ess

Stap

le

line

leak

Blee

ding

Acu

te g

astr

ic

outle

t obs

truc

tion

(ileu

s)

Subf

reni

c

hem

atom

afe

ver

Dea

th

Hos

pita

l

stay

, day

s

Acho

lonu

150

120

10

01

01

00

05.

5

Bere

nde

280

99 (5

4-22

1)2

00

54

00

00

3 (2

-38)

Dapr

i27

012

0.6

± 32

.4

(65

-195

)

10

00

00

10

03.

2 ±

1.4

(2 –

8)

Fole

tto

573

120

(90-

180)

10

03

31

00

3 (>

30

days

)-

Goi

tein

462

118

(70-

250)

20

02

10

00

03 (1

-100

)

Him

pens

400

95.6

±30

.4

(35-

195)

20

03

01

12

04.

2 ±1

.2

(2-7

7)

Iane

lli41

011

7 (9

0-16

5)1

03

10

10

00

7.9

(5-7

1)

Jaco

bs32

0-

00

01

00

00

01.

5

(1-3

)

Tota

l28

65

100

316

84

22

34.

1

Tota

l %10

0%1.

7%3.

5%0%

1.0%

5.6%

2.8%

1.4%

0.7%

0.7%

1.0%

4.1

10

184


Tabl

e 8:

Rea

sons

for r

e-op

erat

ions

RYG

B

Aut

hor

NN

umbe

r of

reop

erat

ions

Perf

orat

ion

Ana

stom

otic

leak

age

Blee

ding

Wou

nd

infe

ctio

n

Smal

l bow

el o

bstr

uctio

n/

Sten

osis

/ Hia

tial h

erni

a

Intr

a-ab

dom

inal

abce

ss

Ate

lect

asis

Fist

ulae

Feve

r

Abu-

Gaz

ala

180

00

00

00

00

0

Arde

stan

i19

--

--

--

--

--

Ham

za11

10

01

00

00

00

Hii

8210

00

13

60

00

0

Khou

rshe

ed36

41

02

01

00

00

Lang

er25

00

00

00

00

00

Mog

nol

704

00

10

00

00

3

Moo

re26

10

00

01

00

00

Mul

ler

302

00

00

20

00

0

Nie

uwen

hove

140

00

00

00

00

0

Nie

wen

hove

231

00

10

00

00

0

Robe

rt85

31

00

01

00

10

Spiv

ak33

20

01

01

00

00

Topa

rt58

30

00

11

01

00

Wag

enin

gen

262

02

00

00

00

0

Web

er32

40

10

02

10

00

Tota

l56

937

23

74

151

11

3

Tota

l

perc

enta

ge10

0%6.

5%0.

4%0.

5%1.

2%0.

7%2.

6%0.

2%0.

2%0.

2%0.

5%

184


Tabl

e 8:

Rea

sons

for r

e-op

erat

ions

RYG

B

Aut

hor

NN

umbe

r of

reop

erat

ions

Perf

orat

ion

Ana

stom

otic

leak

age

Blee

ding

Wou

nd

infe

ctio

n

Smal

l bow

el o

bstr

uctio

n/

Sten

osis

/ Hia

tial h

erni

a

Intr

a-ab

dom

inal

abce

ss

Ate

lect

asis

Fist

ulae

Feve

r

Abu-

Gaz

ala

180

00

00

00

00

0

Arde

stan

i19

--

--

--

--

--

Ham

za11

10

01

00

00

00

Hii

8210

00

13

60

00

0

Khou

rshe

ed36

41

02

01

00

00

Lang

er25

00

00

00

00

00

Mog

nol

704

00

10

00

00

3

Moo

re26

10

00

01

00

00

Mul

ler

302

00

00

20

00

0

Nie

uwen

hove

140

00

00

00

00

0

Nie

wen

hove

231

00

10

00

00

0

Robe

rt85

31

00

01

00

10

Spiv

ak33

20

01

01

00

00

Topa

rt58

30

00

11

01

00

Wag

enin

gen

262

02

00

00

00

0

Web

er32

40

10

02

10

00

Tota

l56

937

23

74

151

11

3

Tota

l

perc

enta

ge10

0%6.

5%0.

4%0.

5%1.

2%0.

7%2.

6%0.

2%0.

2%0.

2%0.

5%

185


Tabl

e 8:

Rea

sons

for r

eope

ratio

ns S

G

Aut

hor

NN

umbe

r of

reop

erat

ions

Perf

orat

ion

Stap

le

line

leak

Blee

ding

Wou

nd

infe

ctio

n

Smal

l bow

el o

bstr

uctio

n/

Sten

osis

/ Hia

tial h

erni

a

Intr

a-ab

dom

inal

abce

ss

Ate

lect

asis

Fist

ulae

Subf

reni

sch

hem

atoo

m

Acho

lonu

151

01

00

00

00

0

Bere

nde

282

00

20

00

00

0

Dap

ri27

10

00

00

00

01

Fole

tto

571

10

00

00

00

0

Goi

tein

462

02

00

00

00

0

Him

pens

402

00

00

10

00

1

Iann

elli

411

00

00

10

00

0

Jaco

bs32

00

00

00

00

00

Tota

l28

610

13

20

20

00

2

Tota

l

perc

enta

ge10

0%3.

5%0.

3%1.

0%0.

7%0%

0.7%

0%0%

0%0.

7%

Tabl

e 9:

Rea

sons

for r

eope

ratio

n RY

GB

vers

us S

G

Aut

hor

N

Num

ber o

f

reop

erat

ions

Perf

orat

ion

Stap

le li

ne le

ak/

anas

tom

otic

leak

age

Blee

ding

Wou

nd

infe

ctio

n

Smal

l bow

el

obst

ruct

ion/

Sten

osis

/

Hia

tial h

erni

a

Intr

a-

abdo

min

al

abce

ssA

tele

ctas

isFi

stul

ae

Subf

reni

sch

hem

atoo

mFe

ver

Slee

ve28

610

13

20

20

00

20

Tota

l

perc

enta

ge10

0%3.

5%0.

3%1.

0%0.

7%0%

0.7%

0%0%

0%0.

7%0%

LRYG

B56

9 /

588

372

37

415

11

10

3

Tota

l

perc

enta

ge10

0%6.

5%0.

4%0.

5%1.

2%0.

7%2.

6%0.

2%0.

2%0.

2%0%

0.5%

10

185


Tabl

e 8:

Rea

sons

for r

eope

ratio

ns S

G

Aut

hor

NN

umbe

r of

reop

erat

ions

Perf

orat

ion

Stap

le

line

leak

Blee

ding

Wou

nd

infe

ctio

n

Smal

l bow

el o

bstr

uctio

n/

Sten

osis

/ Hia

tial h

erni

a

Intr

a-ab

dom

inal

abce

ss

Ate

lect

asis

Fist

ulae

Subf

reni

sch

hem

atoo

m

Acho

lonu

151

01

00

00

00

0

Bere

nde

282

00

20

00

00

0

Dap

ri27

10

00

00

00

01

Fole

tto

571

10

00

00

00

0

Goi

tein

462

02

00

00

00

0

Him

pens

402

00

00

10

00

1

Iann

elli

411

00

00

10

00

0

Jaco

bs32

00

00

00

00

00

Tota

l28

610

13

20

20

00

2

Tota

l

perc

enta

ge10

0%3.

5%0.

3%1.

0%0.

7%0%

0.7%

0%0%

0%0.

7%

Tabl

e 9:

Rea

sons

for r

eope

ratio

n RY

GB

vers

us S

G

Aut

hor

N

Num

ber o

f

reop

erat

ions

Perf

orat

ion

Stap

le li

ne le

ak/

anas

tom

otic

leak

age

Blee

ding

Wou

nd

infe

ctio

n

Smal

l bow

el

obst

ruct

ion/

Sten

osis

/

Hia

tial h

erni

a

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a-

abdo

min

al

abce

ssA

tele

ctas

isFi

stul

ae

Subf

reni

sch

hem

atoo

mFe

ver

Slee

ve28

610

13

20

20

00

20

Tota

l

perc

enta

ge10

0%3.

5%0.

3%1.

0%0.

7%0%

0.7%

0%0%

0%0.

7%0%

LRYG

B56

9 /

588

372

37

415

11

10

3

Tota

l

perc

enta

ge10

0%6.

5%0.

4%0.

5%1.

2%0.

7%2.

6%0.

2%0.

2%0.

2%0%

0.5%

10

186


Table 10: BMI and excess weight loss in RYGB

AuthorNumber of patients BMI at revision

BMI at follow up

Excessive weight loss at follow up (EWL%)

Time of follow up at weight measure-ment (months)

Abu-Gazala 18 41.6 ± 5.3 31.8 ± 5.1 52 ± 44.3 14.6 ± 9.7

Ardestani 19 - - 53.7 ± 21.9 24

Hamza 11 43.9 ±7.4 34.3 ± 8.1 62.1 ± 24.0 12.9 ± 7.9

Hii 82 43 (31-70) 33 (27-54) 74 (16-85) 36

Khoursheed 36 45.15 ±7.9535.23 ± 6.70

(22.94-51.85)

41.19 ± 20.22

(0.00-89.66)

15-.83 ± 13.43

(1-48)

Langer 25 47.6 ± 7.7 (37-70) - 56.9 ± 15.0 12

Mognol 70 44.9 ± 10.8 32.2 ± 6.3 70.2 ± 21 18

Moore 26 40 - 23.0 18

Muller 30 41.9 35.2 - 36

Nieuwenhove 14 43.8 ± 5.8 35.3 ± 7.55 35.4 13.2 9 (3-31)

Nieuwenhove 23 41.4 ± 6.7 28.7 ±10.8 26.5 ±5.5 10 (4-23)

Robert 85 42.9 34.8 (22-50) - 22 (3-72)

Spivak 3342.8

(33.1-50.0, SD 4.4)

30.7

(22-39 SD 5.3)- 15.7 (12-26)

Topart 58 43.2 ± 7.0 - 66.1 ± 26.8 12

Wageningen 26 43.8 ± 9.5 37.4 ± 8.6 51.9 ± 23.9 12

Weber 3242.0 ± 6.7

(30.7-59.3)31.8 - 12

Total 588

Table 10: BMI and excess weight loss in SG


BMI at follow up / lost weight at follow up



Acholonu 15 - - 64.2 (46.5 – 80.1) 6

Berende 28 39,8 32,5 - -

Dapri 27 -34.6 ± 8.7

( 21 – 50.4)16.7 -

Foletto 5745.7 ± 10.8

(36-77)39.0 ± 8.5 - 20 (3-36)

Goitein 46 43.1 (33-57) - 48 36

Himpens 4043.5 ±8.1

(25.3-61)

36.2 ±8.7

(25-54)31 32.6 ±14.8 (3-83)

Iannelli 41 53.1 (35.9-63) 42.7 42.7 (4-76) 13.4 (1-36)

Jacobs 32 42.69 33.3 (23-50) 60 (13.5-120) 26

Total 286

186


Table 10: BMI and excess weight loss in RYGB


BMI at follow up



Abu-Gazala 18 41.6 ± 5.3 31.8 ± 5.1 52 ± 44.3 14.6 ± 9.7

Ardestani 19 - - 53.7 ± 21.9 24

Hamza 11 43.9 ±7.4 34.3 ± 8.1 62.1 ± 24.0 12.9 ± 7.9

Hii 82 43 (31-70) 33 (27-54) 74 (16-85) 36

Khoursheed 36 45.15 ±7.9535.23 ± 6.70

(22.94-51.85)

41.19 ± 20.22

(0.00-89.66)

15-.83 ± 13.43

(1-48)

Langer 25 47.6 ± 7.7 (37-70) - 56.9 ± 15.0 12

Mognol 70 44.9 ± 10.8 32.2 ± 6.3 70.2 ± 21 18

Moore 26 40 - 23.0 18

Muller 30 41.9 35.2 - 36

Nieuwenhove 14 43.8 ± 5.8 35.3 ± 7.55 35.4 13.2 9 (3-31)

Nieuwenhove 23 41.4 ± 6.7 28.7 ±10.8 26.5 ±5.5 10 (4-23)

Robert 85 42.9 34.8 (22-50) - 22 (3-72)

Spivak 3342.8

(33.1-50.0, SD 4.4)

30.7

(22-39 SD 5.3)- 15.7 (12-26)

Topart 58 43.2 ± 7.0 - 66.1 ± 26.8 12

Wageningen 26 43.8 ± 9.5 37.4 ± 8.6 51.9 ± 23.9 12

Weber 3242.0 ± 6.7

(30.7-59.3)31.8 - 12

Total 588

Table 10: BMI and excess weight loss in SG


BMI at follow up / lost weight at follow up



Acholonu 15 - - 64.2 (46.5 – 80.1) 6

Berende 28 39,8 32,5 - -

Dapri 27 -34.6 ± 8.7

( 21 – 50.4)16.7 -

Foletto 5745.7 ± 10.8

(36-77)39.0 ± 8.5 - 20 (3-36)

Goitein 46 43.1 (33-57) - 48 36

Himpens 4043.5 ±8.1

(25.3-61)

36.2 ±8.7

(25-54)31 32.6 ±14.8 (3-83)

Iannelli 41 53.1 (35.9-63) 42.7 42.7 (4-76) 13.4 (1-36)

Jacobs 32 42.69 33.3 (23-50) 60 (13.5-120) 26

Total 286

187


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.

The LAGB 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 a LAGB, but also a wide array of complaints may lead to revision. For

this reason, more and more bands are reversed into a 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 LAGB 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,

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 percent) (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 percent 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 percent. 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

10

187


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.

The LAGB 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 a LAGB, but also a wide array of complaints may lead to revision. For

this reason, more and more bands are reversed into a 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 LAGB 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,

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 percent) (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 percent 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 percent. 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

10

188


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 number of reoperations after revisional surgery was 6.5%. This is relatively high com-

pared with reoperation rates reported in literature after primary LRYGB (3.2%) (43). 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 seven percent is high and

patients should be informed preoperatively accordingly. It is unclear if a staged procedure

would decrease these numbers and future studies should focus on this. Furthermore,

centralizing such surgery in large centres 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 handsewn anastomosis with absorbable material

may reduce the risk of late onset complications such as the development of marginal

ulceration (53;54).

Mean hospital stay of revision gastric bypass was 5.3 days which is comparable with primary

LRYGB between the 2-7 days (4;15;49-52). The mean hospital stay of the revisional LSG is one

day less (4.1days) 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 excessive weight loss (EWL)).

Eleven reported weight-loss after revision in EWL. The mean ranged from 23-74 percent (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.

188


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 number of reoperations after revisional surgery was 6.5%. This is relatively high com-

pared with reoperation rates reported in literature after primary LRYGB (3.2%) (43). 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 seven percent is high and

patients should be informed preoperatively accordingly. It is unclear if a staged procedure

would decrease these numbers and future studies should focus on this. Furthermore,

centralizing such surgery in large centres 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 handsewn anastomosis with absorbable material

may reduce the risk of late onset complications such as the development of marginal

ulceration (53;54).

Mean hospital stay of revision gastric bypass was 5.3 days which is comparable with primary

LRYGB between the 2-7 days (4;15;49-52). The mean hospital stay of the revisional LSG is one

day less (4.1days) 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 excessive weight loss (EWL)).

Eleven reported weight-loss after revision in EWL. The mean ranged from 23-74 percent (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.

189


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 ret-

rospective and prospective consecutive series. This is the best evidence availabe at the

moment. Additional work needs to be done to unravel the indications and options for revi-

sion. This review only comprises the revision from LAGB to LRYGB and LSG. More options

of revisional surgery are possible such as mini gastric 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 be, how patients

should be screened and how the follow up should be performed. Randomized controlled

trials would be favoured 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 procedures 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.

10

189


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 ret-

rospective and prospective consecutive series. This is the best evidence availabe at the

moment. Additional work needs to be done to unravel the indications and options for revi-

sion. This review only comprises the revision from LAGB to LRYGB and LSG. More options

of revisional surgery are possible such as mini gastric 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 be, how patients

should be screened and how the follow up should be performed. Randomized controlled

trials would be favoured 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 procedures 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.

10

190


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years. Surg Endosc 2003 Mar;17(3):409-12.

16. Cherian PT, Goussous G, Ashori F, Sigurdsson A.

Band erosion after laparoscopic gastric banding:

a retrospective analysis of 865 patients over 5

years. Surg Endosc 2010 Aug;24(8):2031-8.

17. Moore R, Perugini R, Czerniach D, Gallagh-

er-Dorval K, Mason R, Kelly JJ. Early results of

conversion of laparoscopic adjustable gastric

band to Roux-en-Y gastric bypass. Surg Obes

Relat Dis 2009 Jul;5(4):439-43.

190


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191


18. Van Nieuwenhove Y, Ceelen W, Van RK, Van

de PD, Henckens T, Pattyn P. Conversion from

band to bypass in two steps reduces the risk

for anastomotic strictures. Obes Surg 2011

Apr;21(4):501-5.

19. Langer FB, Bohdjalian A, Shakeri-Manesch

S, Felberbauer FX, Ludvik B, Zacherl J, et al.

Inadequate weight loss vs secondary weight

regain: laparoscopic conversion from gastric

banding to Roux-en-Y gastric bypass. Obes Surg

2008 Nov;18(11):1381-6.

20. Mognol P, Chosidow D, Marmuse JP. Lapa-

roscopic conversion of laparoscopic gastric

banding to Roux-en-Y gastric bypass: a review of

70 patients. Obes Surg 2004 Nov;14(10):1349-53.

21. Muller MK, Attigah N, Wildi S, Hahnloser

D, Hauser R, Clavien PA, et al. High secondary

failure rate of rebanding after failed gastric

banding. Surg Endosc 2008 Feb;22(2):448-53.

22. Weber M, Muller MK, Michel JM, Belal R, Horber

F, Hauser R, et al. Laparoscopic Roux-en-Y

gastric bypass, but not rebanding, should be

proposed as rescue procedure for patients with

failed laparoscopic gastric banding. Ann Surg

2003 Dec;238(6):827-33.

23. Lanthaler M, Mittermair R, Erne B, Weiss H,

Aigner F, Nehoda H. Laparoscopic gastric

re-banding versus laparoscopic gastric bypass

as a rescue operation for patients with pouch

dilatation. Obes Surg 2006 Apr;16(4):484-7.

24. Niville E, Dams A, Van Der SK, Verhelst H. Results

of lap rebanding procedures after Lap-Band

removal for band erosion -- a mid-term

evaluation. Obes Surg 2005 May;15(5):630-3.

25. IFSO criteria for Bariatric Surgery. http://www

ifso com 2012 March 27

26. Hamza N, Darwish A, Ammori MB, Abbas MH,

Ammori BJ. Revision laparoscopic gastric

bypass: an effective approach following failure

of primary bariatric procedures. Obes Surg 2010

May;20(5):541-8.

27. Robert M, Poncet G, Boulez J, Mion F, Espalieu

P. Laparoscopic gastric bypass for failure of

adjustable gastric banding: a review of 85 cases.

Obes Surg 2011 Oct;21(10):1513-9.

28. Khoursheed MA, Al-Bader IA, Al-asfar FS,

Mohammad AI, Shukkur M, Dashti HM. Revision

of failed bariatric procedures to Roux-en-Y

gastric bypass (RYGB). Obes Surg 2011

Aug;21(8):1157-60.

29. Berende CA, de Zoete JP, Smulders JF, Nienhuijs

SW. Laparoscopic sleeve gastrectomy feasible

for bariatric revision surgery. Obes Surg 2012

Feb;22(2):330-4.

30. Foletto M, Prevedello L, Bernante P, Luca

B, Vettor R, Francini-Pesenti F, et al. Sleeve


gastric banding or gastroplasty. Surg Obes Relat

Dis 2010 Mar 4;6(2):146-51.

31. Himpens J, De SM, Dapri G. Laparoscopic con-

version of adjustable gastric banding to sleeve

gastrectomy: a feasibility study. Surg Laparosc

Endosc Percutan Tech 2010 Jun;20(3):162-5.

32. Abu-Gazala S, Keidar A. Conversion of failed

gastric banding into four different bariatric

procedures. Surg Obes Relat Dis 2011 Jun 30.

33. Topart P, Becouarn G, Ritz P. One-year weight

loss after primary or revisional Roux-en-Y gastric

bypass for failed adjustable gastric banding. Surg


34. van Wageningen B, Berends FJ, van RB, Janssen

IF. Revision of failed laparoscopic adjustable

gastric banding to Roux-en-Y gastric bypass.

Obes Surg 2006 Feb;16(2):137-41.

10

192


35. Spivak H, Beltran OR, Slavchev P, Wilson EB.

Laparoscopic revision from LAP-BAND to gastric

bypass. Surg Endosc 2007 Aug;21(8):1388-92.

36. Acholonu E, McBean E, Court I, Bellorin

O, Szomstein S, Rosenthal RJ. Safety and

short-term outcomes of laparoscopic sleeve

gastrectomy as a revisional approach for failed

laparoscopic adjustable gastric banding in the

treatment of morbid obesity. Obes Surg 2009

Dec;19(12):1612-6.

37. Goitein D, Feigin A, Segal-Lieberman G, Goitein

O, Papa MZ, Zippel D. Laparoscopic sleeve

gastrectomy as a revisional option after gastric

band failure. Surg Endosc 2011 Aug;25(8):2626-

30.

38. Iannelli A, Schneck AS, Ragot E, Liagre A,

Anduze Y, Msika S, et al. Laparoscopic sleeve


gastric banding and vertical banded gastroplasty.

Obes Surg 2009 Sep;19(9):1216-20.

39. Jacobs M, Gomez E, Romero R, Jorge I, Fogel

R, Celaya C. Failed restrictive surgery: is sleeve

gastrectomy a good revisional procedure? Obes

Surg 2011 Feb;21(2):157-60.

40. Dapri G, Cadiere GB, Himpens J. Feasibility

and technique of laparoscopic conversion of

adjustable gastric banding to sleeve gastrec-

tomy. Surg Obes Relat Dis 2009 Jan;5(1):72-6.

41. Birkmeyer NJ, Dimick JB, Share D, Hawasli A,

English WJ, Genaw J, et al. Hospital complication

rates with bariatric surgery in Michigan. JAMA

2010 Jul 28;304(4):435-42.

42. Brethauer SA, Hammel JP, Schauer PR.

Systematic review of sleeve gastrectomy as

staging and primary bariatric procedure. Surg


43. Flum DR, Belle SH, King WC, Wahed AS, Berk P,

Chapman W, et al. Perioperative safety in the

longitudinal assessment of bariatric surgery. N

Engl J Med 2009 Jul 30;361(5):445-54.

44. Aurora AR, Khaitan L, Saber AA. Sleeve

gastrectomy and the risk of leak: a systematic

analysis of 4,888 patients. Surg Endosc 2012

Jun;26(6):1509-15.

45. Leslie DB, Dorman RB, Anderson J, Serrot FJ,

Kellogg TA, Buchwald H, et al. Routine upper

gastrointestinal imaging is superior to clinical

signs for detecting gastrojejunal leak after

laparoscopic Roux-en-Y gastric bypass. J Am

Coll Surg 2012 Feb;214(2):208-13.

46. Lee WJ, Huang MT, Yu PJ, Wang W, Chen TC.

Laparoscopic vertical banded gastroplasty and

laparoscopic gastric bypass: a comparison. Obes

Surg 2004 May;14(5):626-34.

47. Al Harakeh AB. Complications of laparoscopic

Roux-en-Y gastric bypass. Surg Clin North Am

2011 Dec;91(6):1225-37, viii.

48. Ballesta C, Berindoague R, Cabrera M, Palau M,

Gonzales M. Management of anastomotic leaks

after laparoscopic Roux-en-Y gastric bypass.

Obes Surg 2008 Jun;18(6):623-30.

49. Lujan JA, Frutos MD, Hernandez Q, Cuenca JR,

Valero G, Parrilla P. Experience with the circular

stapler for the gastrojejunostomy in laparoscopic

gastric bypass (350 cases). Obes Surg 2005

Sep;15(8):1096-102.

50. Nguyen NT, Hinojosa M, Fayad C, Varela E,

Wilson SE. Use and outcomes of laparoscopic

versus open gastric bypass at academic medical

centers. J Am Coll Surg 2007 Aug;205(2):248-55.

192


35. Spivak H, Beltran OR, Slavchev P, Wilson EB.

Laparoscopic revision from LAP-BAND to gastric

bypass. Surg Endosc 2007 Aug;21(8):1388-92.

36. Acholonu E, McBean E, Court I, Bellorin

O, Szomstein S, Rosenthal RJ. Safety and

short-term outcomes of laparoscopic sleeve

gastrectomy as a revisional approach for failed

laparoscopic adjustable gastric banding in the

treatment of morbid obesity. Obes Surg 2009

Dec;19(12):1612-6.

37. Goitein D, Feigin A, Segal-Lieberman G, Goitein

O, Papa MZ, Zippel D. Laparoscopic sleeve

gastrectomy as a revisional option after gastric

band failure. Surg Endosc 2011 Aug;25(8):2626-

30.

38. Iannelli A, Schneck AS, Ragot E, Liagre A,

Anduze Y, Msika S, et al. Laparoscopic sleeve


gastric banding and vertical banded gastroplasty.

Obes Surg 2009 Sep;19(9):1216-20.

39. Jacobs M, Gomez E, Romero R, Jorge I, Fogel

R, Celaya C. Failed restrictive surgery: is sleeve

gastrectomy a good revisional procedure? Obes

Surg 2011 Feb;21(2):157-60.

40. Dapri G, Cadiere GB, Himpens J. Feasibility

and technique of laparoscopic conversion of

adjustable gastric banding to sleeve gastrec-

tomy. Surg Obes Relat Dis 2009 Jan;5(1):72-6.

41. Birkmeyer NJ, Dimick JB, Share D, Hawasli A,

English WJ, Genaw J, et al. Hospital complication

rates with bariatric surgery in Michigan. JAMA

2010 Jul 28;304(4):435-42.

42. Brethauer SA, Hammel JP, Schauer PR.

Systematic review of sleeve gastrectomy as

staging and primary bariatric procedure. Surg


43. Flum DR, Belle SH, King WC, Wahed AS, Berk P,

Chapman W, et al. Perioperative safety in the

longitudinal assessment of bariatric surgery. N

Engl J Med 2009 Jul 30;361(5):445-54.

44. Aurora AR, Khaitan L, Saber AA. Sleeve

gastrectomy and the risk of leak: a systematic

analysis of 4,888 patients. Surg Endosc 2012

Jun;26(6):1509-15.

45. Leslie DB, Dorman RB, Anderson J, Serrot FJ,

Kellogg TA, Buchwald H, et al. Routine upper

gastrointestinal imaging is superior to clinical

signs for detecting gastrojejunal leak after

laparoscopic Roux-en-Y gastric bypass. J Am

Coll Surg 2012 Feb;214(2):208-13.

46. Lee WJ, Huang MT, Yu PJ, Wang W, Chen TC.

Laparoscopic vertical banded gastroplasty and

laparoscopic gastric bypass: a comparison. Obes

Surg 2004 May;14(5):626-34.

47. Al Harakeh AB. Complications of laparoscopic

Roux-en-Y gastric bypass. Surg Clin North Am

2011 Dec;91(6):1225-37, viii.

48. Ballesta C, Berindoague R, Cabrera M, Palau M,

Gonzales M. Management of anastomotic leaks

after laparoscopic Roux-en-Y gastric bypass.

Obes Surg 2008 Jun;18(6):623-30.

49. Lujan JA, Frutos MD, Hernandez Q, Cuenca JR,

Valero G, Parrilla P. Experience with the circular

stapler for the gastrojejunostomy in laparoscopic

gastric bypass (350 cases). Obes Surg 2005

Sep;15(8):1096-102.

50. Nguyen NT, Hinojosa M, Fayad C, Varela E,

Wilson SE. Use and outcomes of laparoscopic

versus open gastric bypass at academic medical

centers. J Am Coll Surg 2007 Aug;205(2):248-55.

193


51. Olbers T, Fagevik-Olsen M, Maleckas A, Lonroth

H. Randomized clinical trial of laparoscopic

Roux-en-Y gastric bypass versus laparoscopic

vertical banded gastroplasty for obesity. Br J

Surg 2005 May;92(5):557-62.

52. Westling A, Gustavsson S. Laparoscopic vs

open Roux-en-Y gastric bypass: a prospective,

randomized trial. Obes Surg 2001 Jun;11(3):284-

92.

53. Capella JF, Capella RF. Gastro-gastric

fistulas and marginal ulcers in gastric bypass

procedures for weight reduction. Obes Surg 1999

Feb;9(1):22-7.

54. Sapala JA, Wood MH, Sapala MA, Flake TM, Jr.

Marginal ulcer after gastric bypass: a prospective

3-year study of 173 patients. Obes Surg 1998

Oct;8(5):505-16.

55. Updated position statement on sleeve

gastrectomy as a bariatric procedure. Surg Obes

Relat Dis 2012 May;8(3):e21-e26.

56. Gill RS, Birch DW, Shi X, Sharma AM, Karmali S.

Sleeve gastrectomy and type 2 diabetes mellitus:

a systematic review. Surg Obes Relat Dis 2010

Nov;6(6):707-13.

57. Fischer L, Hildebrandt C, Bruckner T, Kenngott H,

Linke GR, Gehrig T, et al. Excessive weight loss

after sleeve gastrectomy: a systematic review.

Obes Surg 2012 May;22(5):721-31.

10

193


51. Olbers T, Fagevik-Olsen M, Maleckas A, Lonroth

H. Randomized clinical trial of laparoscopic

Roux-en-Y gastric bypass versus laparoscopic

vertical banded gastroplasty for obesity. Br J

Surg 2005 May;92(5):557-62.

52. Westling A, Gustavsson S. Laparoscopic vs

open Roux-en-Y gastric bypass: a prospective,

randomized trial. Obes Surg 2001 Jun;11(3):284-

92.

53. Capella JF, Capella RF. Gastro-gastric

fistulas and marginal ulcers in gastric bypass

procedures for weight reduction. Obes Surg 1999

Feb;9(1):22-7.

54. Sapala JA, Wood MH, Sapala MA, Flake TM, Jr.

Marginal ulcer after gastric bypass: a prospective

3-year study of 173 patients. Obes Surg 1998

Oct;8(5):505-16.

55. Updated position statement on sleeve

gastrectomy as a bariatric procedure. Surg Obes

Relat Dis 2012 May;8(3):e21-e26.

56. Gill RS, Birch DW, Shi X, Sharma AM, Karmali S.

Sleeve gastrectomy and type 2 diabetes mellitus:

a systematic review. Surg Obes Relat Dis 2010

Nov;6(6):707-13.

57. Fischer L, Hildebrandt C, Bruckner T, Kenngott H,

Linke GR, Gehrig T, et al. Excessive weight loss

after sleeve gastrectomy: a systematic review.

Obes Surg 2012 May;22(5):721-31.

10

194


Table 1 Supplemental: 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-Gazala1 2011 Prospective

consecutive series

14.6 ± 9.7 1 0 1 0 0 1 1 1 1 1 7

Ardestani1, 2010 Prospective

consecutive series

44.4 ± 9.4 1 1 1 0 0 1 0 1 1 1 7

Hamza, 20102 Retrospective

consecutive studies

12.9 ± 7.9 1 0 1 0 1 1 1 1 0 1 7

HIi, 2012 Prospective

consecutive series

36 1 1 1 0 0 0 1 1 1 1 7

Khoursheed2, 2010 Retrospective

consecutive series

15.83

(1-48)

1 0 1 0 0 1 1 1 0 1 6

Langer, 2008 Prospective

consecutive series

12 1 1 1 1 0 1 1 1 1 1 9

Mognol, 2004 Prospective

consecutive series

7.3

(3-18)

1 0 1 1 1 1 1 1 1 1 9

Moore, 2008 Prospective

consecutive series

18 1 1 1 0 1 1 1 1 0 1 8

Muller3, 2007 Prospective

consecutive series

36

(24-60)

1 1 1 0 1 0 1 0 1 1 7

Niewenhove, van

2011. 2 step

Retrospective

consecutive series

9 (3-21) 1 1 0 1 1 0 1 1 0 1 7

Nieuwenhove, van

2011, 1 step

Retrospective

consecutive series

10

(4-23)

1 1 0 1 1 0 1 1 0 1 7

Robert, 2011 Prospective

consecutive series

22

(3-72)

1 1 1 0 1 1 1 1 1 1 9

Spivak, 2007 Prospective

consecutive series

15.7

(12-26)

1 1 1 0 0 1 1 1 1 1 8

Topart4, 2009 Retrospective

consecutive series

12 1 1 1 0 1 1 1 1 0 1 8

Wageningen5, van

2006

Prospective

consecutive series.

12 ± 12 1 1 1 0 1 0 1 1 1 1 8

Weber3, 2003 Prospective

consecutive series

12 1 1 1 0 0 0 0 1 1 1 6

Acholonu, 2009 Prospective

consecutive series

6

(2-24)

1 0 1 0 0 0 1 1 1 1 6

Table 1 (continued)

194


Table 1 Supplemental: Quality rate of included articles

Publication

Description of

Study

Follow-up

Median ± SD


1 2 3 4 5 6 7 8 9 10

Abu-Gazala1 2011 Prospective

consecutive series

14.6 ± 9.7 1 0 1 0 0 1 1 1 1 1 7

Ardestani1, 2010 Prospective

consecutive series

44.4 ± 9.4 1 1 1 0 0 1 0 1 1 1 7

Hamza, 20102 Retrospective

consecutive studies

12.9 ± 7.9 1 0 1 0 1 1 1 1 0 1 7

HIi, 2012 Prospective

consecutive series

36 1 1 1 0 0 0 1 1 1 1 7

Khoursheed2, 2010 Retrospective

consecutive series

15.83

(1-48)

1 0 1 0 0 1 1 1 0 1 6

Langer, 2008 Prospective

consecutive series

12 1 1 1 1 0 1 1 1 1 1 9

Mognol, 2004 Prospective

consecutive series

7.3

(3-18)

1 0 1 1 1 1 1 1 1 1 9

Moore, 2008 Prospective

consecutive series

18 1 1 1 0 1 1 1 1 0 1 8

Muller3, 2007 Prospective

consecutive series

36

(24-60)

1 1 1 0 1 0 1 0 1 1 7

Niewenhove, van

2011. 2 step

Retrospective

consecutive series

9 (3-21) 1 1 0 1 1 0 1 1 0 1 7

Nieuwenhove, van

2011, 1 step

Retrospective

consecutive series

10

(4-23)

1 1 0 1 1 0 1 1 0 1 7

Robert, 2011 Prospective

consecutive series

22

(3-72)

1 1 1 0 1 1 1 1 1 1 9

Spivak, 2007 Prospective

consecutive series

15.7

(12-26)

1 1 1 0 0 1 1 1 1 1 8

Topart4, 2009 Retrospective

consecutive series

12 1 1 1 0 1 1 1 1 0 1 8

Wageningen5, van

2006

Prospective

consecutive series.

12 ± 12 1 1 1 0 1 0 1 1 1 1 8

Weber3, 2003 Prospective

consecutive series

12 1 1 1 0 0 0 0 1 1 1 6

Acholonu, 2009 Prospective

consecutive series

6

(2-24)

1 0 1 0 0 0 1 1 1 1 6

Table 1 (continued)

195


Publication

Description of

Study

Follow-up

Median ± SD


1 2 3 4 5 6 7 8 9 10

Berende, 2011 Prospective

consecutive series

13.8

(2-46)

1 1 1 0 0 0 1 0 1 1 6

Dapri, 2008 Prospective

consecutive series

18.6 ± 14.8

(1-59)

1 0 1 0 0 0 1 1 1 1 6

Foletto, 2009 Prospective

consecutive series

20

(3-36)

1 1 1 0 0 0 1 0 1 1 6

Goitein, 2011 Prospective 17

(1-39)

1 0 1 0 0 1 1 1 1 1 7

Himpens, 2010 Retrospective 32.6 ± 14.8 1 0 0 0 0 0 1 1 0 1 4

Iannelli Prospective 13.4

(1-36)

1 0 1 0 0 1 1 1 1 1 7

Jacobs, 2010 Prospective 26

(5-40)

1 0 0 0 0 1 1 1 1 1 6

1 Revision to multiple procedures (e.g. gastric sleeve, RYGB, biliopancreatic diversion) 2 Multiple primary procedures 3Comparing LRYGB and rebanding 4 Comparing primary and secondary RYGB 5 Comparing open and laparoscopic revisions

Quality rate Points: 1 Points: 0

Definition of study objectives Clear Unclear/ no

Statistical method described Yes No

Possible bias in inclusion/ exclusion Not present Present/unclear

Different types of treatment besides the evaluated one Not present Present/unclear

Different technique in patients from same series (learning curve) No Yes/not defined

Differences in population of compared groups No Yes/not defined

Measures of outcome Defined Had to be calculated

Eventual commercial interest related to techniques and/or

certain devices

Devices not cited Devices cited

Prospective data collection Yes No

More than 10 patients Yes No

Maximum points 10

10

195


Publication

Description of

Study

Follow-up

Median ± SD


1 2 3 4 5 6 7 8 9 10

Berende, 2011 Prospective

consecutive series

13.8

(2-46)

1 1 1 0 0 0 1 0 1 1 6

Dapri, 2008 Prospective

consecutive series

18.6 ± 14.8

(1-59)

1 0 1 0 0 0 1 1 1 1 6

Foletto, 2009 Prospective

consecutive series

20

(3-36)

1 1 1 0 0 0 1 0 1 1 6

Goitein, 2011 Prospective 17

(1-39)

1 0 1 0 0 1 1 1 1 1 7

Himpens, 2010 Retrospective 32.6 ± 14.8 1 0 0 0 0 0 1 1 0 1 4

Iannelli Prospective 13.4

(1-36)

1 0 1 0 0 1 1 1 1 1 7

Jacobs, 2010 Prospective 26

(5-40)

1 0 0 0 0 1 1 1 1 1 6

1 Revision to multiple procedures (e.g. gastric sleeve, RYGB, biliopancreatic diversion) 2 Multiple primary procedures 3Comparing LRYGB and rebanding 4 Comparing primary and secondary RYGB 5 Comparing open and laparoscopic revisions

Quality rate Points: 1 Points: 0

Definition of study objectives Clear Unclear/ no

Statistical method described Yes No

Possible bias in inclusion/ exclusion Not present Present/unclear

Different types of treatment besides the evaluated one Not present Present/unclear

Different technique in patients from same series (learning curve) No Yes/not defined

Differences in population of compared groups No Yes/not defined

Measures of outcome Defined Had to be calculated

Eventual commercial interest related to techniques and/or

certain devices

Devices not cited Devices cited

Prospective data collection Yes No

More than 10 patients Yes No

Maximum points 10

10

196


Table 7: Supplemental, long term complications RYGB and SG

Author

Total of

patients

Gastro-

gastric

fistulae

Stenosis at the gatro-

jejunostomy/ Small

bowel obstruction

Marginal

Ulcer

Port-site

hernia

Internal

Hernia

Abu-Gazala - - - - -

Ardestani - - - - -

Hamza - - - - -

Hii 82 0 22 2 0 0

Khoursheed - - - - -

Langer 25 1 1 0 1 0

Mognol 70 0 3 3 0 0

Moore - - - - -

Muller 30 0 1 0 0 0

Nieuwenhove 37 0 3 0 0 0

Robert 85 0 1 0 2 0

Spivak 55 0 0 0 0 1

Topart 58 0 0 0 1 0

Wageningen 26 0 1 0 0 0

Weber 32 0 2 0 0 0

Total 478 1 31 5 4 1

Total percentage 100% 0.2% 6.4% 1.0% 0.8% 0.2%

Author

Total of

patients

Gastro-

gastric

fistulae


jejunostomy/ Small

bowel obstruction

Marginal

Ulcer

Port-site

hernia

Internal

Hernia

Chronic

Anemia

Acholonu - - - - - -

Berende - - - - - -

Dapri - - - - - -

Foletto - - - - - -

Goitein 46 - - - - -1

(2x PC)

Himpens 40 0 0 0 0 1 0

Iannelli - - - - - -

Jacobs - - - - - -

Total 40/86 0 0 0 0 1 1

Total percentage 100% 0% 0% 0% 0% 2.5% /

1.2%

2.5% /

1.2%

196


Table 7: Supplemental, long term complications RYGB and SG

Author

Total of

patients

Gastro-

gastric

fistulae


jejunostomy/ Small

bowel obstruction

Marginal

Ulcer

Port-site

hernia

Internal

Hernia

Abu-Gazala - - - - -

Ardestani - - - - -

Hamza - - - - -

Hii 82 0 22 2 0 0

Khoursheed - - - - -

Langer 25 1 1 0 1 0

Mognol 70 0 3 3 0 0

Moore - - - - -

Muller 30 0 1 0 0 0

Nieuwenhove 37 0 3 0 0 0

Robert 85 0 1 0 2 0

Spivak 55 0 0 0 0 1

Topart 58 0 0 0 1 0

Wageningen 26 0 1 0 0 0

Weber 32 0 2 0 0 0

Total 478 1 31 5 4 1

Total percentage 100% 0.2% 6.4% 1.0% 0.8% 0.2%

Author

Total of

patients

Gastro-

gastric

fistulae


jejunostomy/ Small

bowel obstruction

Marginal

Ulcer

Port-site

hernia

Internal

Hernia

Chronic

Anemia

Acholonu - - - - - -

Berende - - - - - -

Dapri - - - - - -

Foletto - - - - - -

Goitein 46 - - - - -1

(2x PC)

Himpens 40 0 0 0 0 1 0

Iannelli - - - - - -

Jacobs - - - - - -

Total 40/86 0 0 0 0 1 1

Total percentage 100% 0% 0% 0% 0% 2.5% /

1.2%

2.5% /

1.2%

197


10

197


10

Documents

CHAPTER 10 10.pdf · CHAPTER 10 Laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy as revisional procedure after adjustable gastric band-a systematic review-9WLE