Sleeve Gastrectomy As A Revisional Approach For Failed Adjustable Gastric Banding

A recent study by Emeka Acholonu and colleagues at The Bariatric & Metabolic Institute (Section of Minimally Invasive Surgery, Department of General & Vascular Surgery, Cleveland Clinic Florida) reviewed data from 15 previously completed surgeries with the aim of investigating the effectiveness and safety of laparoscopic sleeve gastrectomy (LSG) as a revisional approach in patients with failed laparoscopic adjustable gastric banding (LAGB). The study was published in the journal Obesity Surgery in 2009.

Lap Band Failure – Reoperation / Revision Rates

LAGB is a frequently performed restrictive bariatric surgery that is considered a safe and effective treatment for obesity. It has grown in popularity since its introduction in the early 1990s, thanks to satisfactory weight loss results, resolution of comorbidities, and a low rate of operative morbidity. However, there is an increasing body of evidence suggesting that LAGB is prone to certain failures and complications. While five-year results show a loss of 54-58% of excess weight, it also appears that the rate of failures and complications increase with time. The annual rate of reoperation for LAGB procedures is typically in the 3 – 4.7% range, but may be as high as 9.4%.

Gastric Bypass and Biliopancreatic Diversion as Revisional Options For Failed LAGB

In the event of major complications or unsatisfactory weight loss, revisional procedures are often considered. If the LAGB failure was the result of band-related deficiency, replacing or correcting the band placement may be an option. Other traditional approaches are conversion to Roux-en-Y gastric bypass (RYGB) or biliopancreatic diversion (BPD), both restrictive and malabsorptive procedures that limit food intake and bypass part of the intestines so less food is absorbed. RYGB and BPD have been shown to be effective responses to failed LAGB, but are not without complications. When performed as a revisional procedure, RYGB and BPD surgeries are often tedious, challenging, and technically demanding. Studies have found that revision to RYGB can result in major complications, such as a splenectomy for bleeding and an internal hernia-necessitating repair, and revision to BPD has a relatively high complication rate of 62%.

Sleeve Gastrectomy as a Revisional Option For Failed LAGB

Another procedure, laparoscopic sleeve gastrectomy (LSG), is now being recognized for several potential uses. The sleeve gastrectomy was initially used as the restrictive portion of the BPD procedure, but has since become an increasingly popular primary treatment for morbid obesity because of its safety and effectiveness. Excess weight loss after an LSG has been shown to be a satisfactory 40.7% at 3 months and 52.8% at 6 months post-procedure. LSGs current uses include first stage treatment for supermorbidly obese and high-risk patients, and it is being considered as a potential revisional procedure for failed or complicated LAGB.

The Study

Acholonu and colleagues examined data from all 15 patients who underwent revisional surgery from LAGB to LSG at the Cleveland Clinic Florida during the period of May 2005 to May 2009. Data reviewed included operative time, length of hospital stay, postoperative complications, and amount of weight reduction following the surgery. The three men and twelve women were indicated for revisional surgery for a variety of reasons, the most common being poor weight loss (5 patients), weight regains (4 patients), and band slippage and gastroesophageal reflux (4 patients). One patient experienced poor weight loss, band slippage, and reflux, and another slippage and duodenal fistula. The average time between initial LAGB placement and conversion to LSG was 34.7 months.

The data showed that the average operative time was 120 minutes, followed by a hospital stay that lasted for an average of 5.5 days. Prior to the revisional surgery to LSG, average weight was 233.02, and average Body Mass Index (BMI) 38.66. Average weight loss and average excess BMI loss post-surgery was as follows:

  • 2 months: 20.7 pounds lost; 28.9% excess BMI lost (11 patients reported)
  • 6 months: 48.3 pounds; 64.2% BMI (11 patients)
  • 1 year: 57.2 pounds; 65.3% (7 patients)
  • 18 months: 60.1 pounds; 65.7% (5 patients)
  • 24 months: 2 patients reported for the first time, one with a 5 pound and 8.8% loss, the other with a 22 pound and 35.7% loss.

Conclusion

The study authors conclude that, while a failed restrictive procedure like LAGB can be changed to a malabsorptive procedure such as RYGB or BPD, conversion to LSG may be more appropriate for some patients. While not many studies have been conducted on conversion of LAGB to LSG, one prior study of 8 patients with a mean BMI of 50.5 found that the operation, which took an average of 90 minutes plus a 4 day hospital stay, resulted in excess weight loss of 22% at 2 months, 47% at 6 months, and 57% at 1 year. These results show that, in the short-term, the conversion to LSG appears to have efficacy comparable to other bariatric procedures and possibly greater safety.

LSG is becoming a more commonly performed procedure, and its use as a revisional procedure after failed LAGB is a feasible option. However, as with all revisional procedures, conversion to LSG is associated with significant complications when compared to LSG performed as a primary procedure. In addition, the safety of performing LSG after gastric band erosions has yet to be evaluated.

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