Lap-Band As A Revisional Procedure For Failed Vertical Gastroplasty

A recent study, conducted by Vivane Thill and colleagues, examined the cases of 40 patients who underwent laparoscopic adjustable banding (LAGB) as a revisional procedure, in order to evaluate the feasibility, safety, and efficiency of converting failed vertical gastroplasty (VG) to laparoscopic adjustable banding (LAGB). Their results, published in the February 2009 issue of Obesity Surgery and summarized below, indicate that conversion to LAGB is a reasonable option for correcting failing VG procedures.

Vertical Gastroplasty

Until recent years, vertical gastroplasty was one of the most frequently performed bariatric procedures worldwide. VG is a restrictive procedure designed to induce weight loss by limiting food intake. Also known as stomach stapling, it works by permanently stapling a part of the stomach to create a smaller pre-stomach pouch, which serves as the new stomach and is able to hold less food. Additionally, a prosthetic mesh or silastic ring is wrapped around the stomach outlet, in order to prevent stretching and slow the emptying of food.

Revisional Bariatric Surgery

Although VGs have been shown to result in a satisfactory reduction in weight, patients are frequently unable to maintain this weight loss. More than half of patients who undergo the procedure may eventually require revisional surgery, with the most common reasons for VG failure being disruption of the staple line, excessive enlargement of the newly created stomach pouch, and inefficiency of the prosthetic mesh or silastic ring.

Procedures that can be performed as an alternative to failed VGs include restoration of VG, gastric bypass, gastric banding (LAGB), and the more recent sleeve gastrectomy. When performed as a revisional procedure, these bariatric surgeries are associated with a higher complication rate than initial bariatric surgery interventions. Restoration of VG is not generally recommended, as it often results in additional revisional procedures and the placement of several staple lines may induce ischemia. Although Roux-en-Y gastric bypass is the most frequently suggested revisional procedure, the morbidity rate of this choice is significant. In addition, nutritional aspects are a concern for malabsorptive procedures such as gastric bypass.

Converting a failed VG to LAGB, the focus of this study, may be a good option for several reasons. VG and gastric banding are both restrictive procedures and as such work similarly, inducing weight loss by restricting the amount of food intake. Since VG often results in satisfying weight gain initially, in the absence of technical problems, replacing it with another restrictive procedure seems like a reasonable course of action. LAGB also has the advantage of being a less technically demanding revisional surgery, reportedly safe and with a low rate of morbidity. Malnutrition is not a concern, and resulting weight loss is substantial.

Gastric Banding As A Revisional Procedure

The study looked at 40 patients, average age 39 years, who underwent LAGB as a revisional surgery for vertical gastroplasty that failed for one of the common reasons discussed above: staple line rupture, pouch dilation, or inefficient stoma. The revisional procedures all took place at Brugmann University Hospital between August 2001 and June 2008. All patients had experienced efficient weight loss after their initial VG procedure, but were qualified for revisional surgery due to uncontrolled weight regain, with or without frequent vomiting.

The revisional surgical procedures took an average of 132 minutes to perform and resulted in an average hospital stay of 3.1 days. All patients received band adjustment according to their needs, and had a postoperative follow-up an average of 18 months after undergoing the revisional LAGB. The patients' BMI dropped from an average of 38.9 before the procedure to 30.7 at follow-up. There was no mortality in any of the conversions of VG to LAGB, and there was a minor morbidity rate of 12.5%. These postoperative complications were an incarcerated incisional hernia requiring small bowel resection, a band erosion with partial intragastric migration that necessitated band removal, access port infection, and tubing disconnection. Although there were no cases of the gastric band slipping, the authors note that an increased risk of band erosion after converting VG to LAGB is not impossible.

Conclusion

Conversion of failed vertical gastroplasty to gastric banding appears to be a safe and efficient technique with an acceptably low morbidity rate. The satisfying results of this conversion make LAGB a reasonable option for revisional bariatric surgery.

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