Research Original Invstigation
Gastric Bypass for Failed Gastric Banding
28. Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012; 366(17):1567-1576.
34. Favretti F, Segato G, Ashton D, et al. Laparoscopic adjustable gastric banding in 1,791 consecutive obese patients: 12-year results. Obes Surg. 2007;17(2):168-175.
40. Benotti P, Wood GC, Winegar DA, et al. Risk factors associated with mortality after Roux-en-Y gastric bypass surgery. Ann Surg. 2014;259(1):123130.
29. Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012;366 (17):1577-1585.
35. Weber M, Müller MK, Michel JM, 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;238(6):827-834.
41. Rebibo L, Mensah E, Verhaeghe P, et al. Simultaneous gastric band removal and sleeve gastrectomy: a comparison with front-line sleeve gastrectomy. Obes Surg. 2012;22(9):1420-1426.
30. Van Dessel E, Hubens G, Ruppert M, Balliu L, Weyler J, Vaneerdeweg W. Roux-en-Y gastric bypass as a re-do procedure for failed restricive gastric surgery. Surg Endosc. 2008;22(4):1014-1018. 31. Cadière GB, Himpens J, Bazi M, et al. Are laparoscopic gastric bypass after gastroplasty and primary laparoscopic gastric bypass similar in terms of results? Obes Surg. 2011;21(6):692-698. 32. Hinojosa MW, Varela JE, Parikh D, Smith BR, Nguyen XM, Nguyen NT. National trends in use and outcome of laparoscopic adjustable gastric banding. Surg Obes Relat Dis. 2009;5(2):150-155. 33. O’Brien PE, MacDonald L, Anderson M, Brennan L, Brown WA. Long-term outcomes after bariatric surgery: fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature. Ann Surg. 2013; 257(1):87-94.
36. Gagner M, Gentileschi P, de Csepel J, et al. Laparoscopic reoperative bariatric surgery: experience from 27 consecutive patients. Obes Surg. 2002;12(2):254-260. 37. DeMaria EJ, Murr M, Byrne TK, et al. Validation of the Obesity Surgery Mortality Risk Score in a multicenter study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity. Ann Surg. 2007;246(4):578-584. 38. DeMaria EJ, Portenier D, Wolfe L. Obesity surgery mortality risk score: proposal for a clinically useful score to predict mortality risk in patients undergoing gastric bypass. Surg Obe Relat Dis. 2007;3(2):134-140. 39. Flancbaum L, Belsley S. Factors affecting morbidity and mortality of Roux-en-Y gastric bypass for clinically severe obesity: an analysis of 1,000 consecutive open cases by a single surgeon. J Gastrointest Surg. 2007;11(4):500-507.
42. 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;25(8):2626-2630. 43. Rosenthal RJ, Diaz AA, Arvidsson D, et al. International Sleeve Gastrectomy Expert Panel. International Sleeve Gastrectomy Expert Panel consensus statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis. 2012;8:8-19. 44. Coblijn UK, Verveld CJ, van Wagensveld BA, Lagarde SM. Laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy as revisional procedure after adjustable gastric band: a systematic review. Obes Surg. 2013;23(11):18991914.
Invited Commentary
Conversion of Adjustable Gastric Banding to Roux-en-Y Gastric Bypass Not as Optimal as Primary Gastric Bypass? Michel Gagner, MD, FRCSC
Once popular, adjustable gastric band operation rates are plummeting to new record lows worldwide because of poor weight loss, weight regain, and frequent reoperation due to slippage, erosions, hiatal hernias or reflux, and mechanical device failures. During the Longitudinal Assessment of Bariatric Surgery study,1 Related article page 780 laparoscopic adjustable gastric banding (LAGB) at 3 years had only a median of 15.9% of baseline weight loss compared with 31.5% for Roux-en-Y gastric bypass (RYGB). Also, there were 77 subsequent procedures following 610 LAGBs during 3 years vs 4 subsequent procedures in more than 1691 RYGBs. Hence, conversion of adjustable gastric banding to another intervention (sleeve gastrectomy, gastric bypass, or duodenal switch) is on the rise. In this issue of JAMA Surgery, Thereaux et al2 have retrospectively reviewed their prospective database of a singleuniversity surgical center and compared primary gastric bypass with revision gastric bypass, mainly bands revised to gastric bypass. However, the authors looked only at 30-day outcomes because one would be interested in weight loss differences over time, marginal ulcer incidence, gastric pouch enlargement, and 786
gastroesophageal reflux disease, with or without hiatal hernias and esophagitis. In 831 patients who had primary gastric bypass and in 177 patients who had conversion of gastric banding to gastric bypass, the 30-day major outcome rates were similar (7.8% and 8.5%, respectively). Their article diverges from previous Longitudinal Assessment of Bariatric Surgery data in which revision surgery was associated with more severe complications.3 In that study, compared with those undergoing revision surgery, primary surgery patients with obesity were younger and more likely to be male, weigh more, and have more comorbidity. This was not the case in the 2013 series, in which conversion from LAGB to RYGB was associated with a higher percentage of female patients and with fewer comorbidities.1 Therefore, one can conclude that the groups were not comparable and were highly selected before surgery. In the earlier study,3 operative time for revision procedures was longer and associated with greater blood loss, and adverse outcomes were more frequent after revision surgery (15.1% vs 5.3%, P < .001). There is not always an easy reversal or removal of an adjustable gastric band. The foreign body is known to have caused severe capsular reactions, taking the left lobe of the liver, diaphragm, gastric remnant, superior pole of the spleen, and pan-
JAMA Surgery August 2014 Volume 149, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Georgia User on 06/01/2015
jamasurgery.com
Gastric Bypass for Failed Gastric Banding
Original Invstigation Research
creas posteriorly. Hence, this dissection time is added to the procedure, and longer operating time in bariatric surgery under a pneumoperitoneum of 15 mm Hg increases the likelihood of complications, such as thromboembolism, and gastric pouch construction may not be optimal. Thereaux et al2 have not provided the number of stapling events required to fashion their pouch; a safe margin from the band would be necessary to create a healthier and well-vascularized anastomosis. The leftover capsule remodels to become thinner over time, and the gastric pouch is likely to expand to an unusual size, causing a higher risk for marginal ulceration. A larger pouch is also likely to increase the frequency of weight regain later (beyond 3 years), and a few patients may need a second revision. In that sense, a 2-stage approach may be more desirable. Attention in opening the gastrogastric tunnel, where the band was located, may be important also to create a smaller pouch and to resist the temp-
tation to staple around. However, this procedure may cause a higher leak rate. The recently published series by Delko et al4 demonstrated the percentage of excess weight loss in primary RYGB to be significantly higher at 70% vs 45% in revision RYGB (P < .002) after 24 months. Revision RYGB performed as a 1-stage procedure showed less effective excess weight loss than primary RYGB interventions. The capsular reaction superior to the band may also limit the crus dissection because LAGB has been associated with a higher incidence of gastroesophageal reflux disease with hiatal hernia.5 The unrepaired hiatal hernia may cause the gastric pouch, with its anastomosis, to migrate transthoracically and become a later problem. Hence, a longer follow-up period is needed for revision gastric bypass after LAGB. Time will tell whether it has the same safety and general outcomes as primary RYGB.
ARTICLE INFORMATION
REFERENCES
Author Affiliations: Herbert Wertheim College of Medicine, Florida International University, Miami; Hôpital du Sacre Coeur, Montreal, Quebec, Canada.
1. Courcoulas AP, Christian NJ, Belle SH, et al; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA. 2013;310 (22):2416-2425.
Corresponding Author: Michel Gagner, MD, FRCSC, Department of Surgery, Hôpital du Sacre Coeur, 315 Place D’Youville, Ste 191, Montreal, QB H2Y 0A4, Canada ([email protected]). Published Online: June 18, 2014. doi:10.1001/jamasurg.2014.634. Conflict of Interest Disclosures: Dr Gagner reported receiving honoraria for speaking engagements from Ethicon, Covidien, Gore, MID, Transenterix, and Boehringer Laboratories and reported owning equity in Transenterix.
2. Thereaux J, Veyrie N, Barsamian C, et al. Similar postoperative safety between primary and revisional gastric bypass for failed gastric banding [published online June 18, 2014]. JAMA Surg. doi:10 .1001/jamasurg.2014.625.
non-LapBand primary and revisional bariatric surgical procedures from the Longitudinal Assessment of Bariatric Surgery study. Surg Obes Relat Dis. 2010;6(1):22-30. 4. Delko T, Köstler T, Peev M, Esterman A, Oertli D, Zingg U. Revisional versus primary Roux-en-Y gastric bypass: a case-matched analysis. Surg Endosc. 2014;28(2):552-558. 5. Azagury DE, Varban O, Tavakkolizadeh A, Robinson MK, Vernon AH, Lautz DB. Does laparoscopic gastric banding create hiatal hernias? Surg Obes Relat Dis. 2013;9(1):48-52.
3. Inabnet WB III, Belle SH, Bessler M, et al. Comparison of 30-day outcomes after
jamasurgery.com
JAMA Surgery August 2014 Volume 149, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Georgia User on 06/01/2015
787
Gastric Bypass for Failed Gastric Banding
28. Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012; 366(17):1567-1576.
34. Favretti F, Segato G, Ashton D, et al. Laparoscopic adjustable gastric banding in 1,791 consecutive obese patients: 12-year results. Obes Surg. 2007;17(2):168-175.
40. Benotti P, Wood GC, Winegar DA, et al. Risk factors associated with mortality after Roux-en-Y gastric bypass surgery. Ann Surg. 2014;259(1):123130.
29. Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012;366 (17):1577-1585.
35. Weber M, Müller MK, Michel JM, 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;238(6):827-834.
41. Rebibo L, Mensah E, Verhaeghe P, et al. Simultaneous gastric band removal and sleeve gastrectomy: a comparison with front-line sleeve gastrectomy. Obes Surg. 2012;22(9):1420-1426.
30. Van Dessel E, Hubens G, Ruppert M, Balliu L, Weyler J, Vaneerdeweg W. Roux-en-Y gastric bypass as a re-do procedure for failed restricive gastric surgery. Surg Endosc. 2008;22(4):1014-1018. 31. Cadière GB, Himpens J, Bazi M, et al. Are laparoscopic gastric bypass after gastroplasty and primary laparoscopic gastric bypass similar in terms of results? Obes Surg. 2011;21(6):692-698. 32. Hinojosa MW, Varela JE, Parikh D, Smith BR, Nguyen XM, Nguyen NT. National trends in use and outcome of laparoscopic adjustable gastric banding. Surg Obes Relat Dis. 2009;5(2):150-155. 33. O’Brien PE, MacDonald L, Anderson M, Brennan L, Brown WA. Long-term outcomes after bariatric surgery: fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature. Ann Surg. 2013; 257(1):87-94.
36. Gagner M, Gentileschi P, de Csepel J, et al. Laparoscopic reoperative bariatric surgery: experience from 27 consecutive patients. Obes Surg. 2002;12(2):254-260. 37. DeMaria EJ, Murr M, Byrne TK, et al. Validation of the Obesity Surgery Mortality Risk Score in a multicenter study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity. Ann Surg. 2007;246(4):578-584. 38. DeMaria EJ, Portenier D, Wolfe L. Obesity surgery mortality risk score: proposal for a clinically useful score to predict mortality risk in patients undergoing gastric bypass. Surg Obe Relat Dis. 2007;3(2):134-140. 39. Flancbaum L, Belsley S. Factors affecting morbidity and mortality of Roux-en-Y gastric bypass for clinically severe obesity: an analysis of 1,000 consecutive open cases by a single surgeon. J Gastrointest Surg. 2007;11(4):500-507.
42. 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;25(8):2626-2630. 43. Rosenthal RJ, Diaz AA, Arvidsson D, et al. International Sleeve Gastrectomy Expert Panel. International Sleeve Gastrectomy Expert Panel consensus statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis. 2012;8:8-19. 44. Coblijn UK, Verveld CJ, van Wagensveld BA, Lagarde SM. Laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy as revisional procedure after adjustable gastric band: a systematic review. Obes Surg. 2013;23(11):18991914.
Invited Commentary
Conversion of Adjustable Gastric Banding to Roux-en-Y Gastric Bypass Not as Optimal as Primary Gastric Bypass? Michel Gagner, MD, FRCSC
Once popular, adjustable gastric band operation rates are plummeting to new record lows worldwide because of poor weight loss, weight regain, and frequent reoperation due to slippage, erosions, hiatal hernias or reflux, and mechanical device failures. During the Longitudinal Assessment of Bariatric Surgery study,1 Related article page 780 laparoscopic adjustable gastric banding (LAGB) at 3 years had only a median of 15.9% of baseline weight loss compared with 31.5% for Roux-en-Y gastric bypass (RYGB). Also, there were 77 subsequent procedures following 610 LAGBs during 3 years vs 4 subsequent procedures in more than 1691 RYGBs. Hence, conversion of adjustable gastric banding to another intervention (sleeve gastrectomy, gastric bypass, or duodenal switch) is on the rise. In this issue of JAMA Surgery, Thereaux et al2 have retrospectively reviewed their prospective database of a singleuniversity surgical center and compared primary gastric bypass with revision gastric bypass, mainly bands revised to gastric bypass. However, the authors looked only at 30-day outcomes because one would be interested in weight loss differences over time, marginal ulcer incidence, gastric pouch enlargement, and 786
gastroesophageal reflux disease, with or without hiatal hernias and esophagitis. In 831 patients who had primary gastric bypass and in 177 patients who had conversion of gastric banding to gastric bypass, the 30-day major outcome rates were similar (7.8% and 8.5%, respectively). Their article diverges from previous Longitudinal Assessment of Bariatric Surgery data in which revision surgery was associated with more severe complications.3 In that study, compared with those undergoing revision surgery, primary surgery patients with obesity were younger and more likely to be male, weigh more, and have more comorbidity. This was not the case in the 2013 series, in which conversion from LAGB to RYGB was associated with a higher percentage of female patients and with fewer comorbidities.1 Therefore, one can conclude that the groups were not comparable and were highly selected before surgery. In the earlier study,3 operative time for revision procedures was longer and associated with greater blood loss, and adverse outcomes were more frequent after revision surgery (15.1% vs 5.3%, P < .001). There is not always an easy reversal or removal of an adjustable gastric band. The foreign body is known to have caused severe capsular reactions, taking the left lobe of the liver, diaphragm, gastric remnant, superior pole of the spleen, and pan-
JAMA Surgery August 2014 Volume 149, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Georgia User on 06/01/2015
jamasurgery.com
Gastric Bypass for Failed Gastric Banding
Original Invstigation Research
creas posteriorly. Hence, this dissection time is added to the procedure, and longer operating time in bariatric surgery under a pneumoperitoneum of 15 mm Hg increases the likelihood of complications, such as thromboembolism, and gastric pouch construction may not be optimal. Thereaux et al2 have not provided the number of stapling events required to fashion their pouch; a safe margin from the band would be necessary to create a healthier and well-vascularized anastomosis. The leftover capsule remodels to become thinner over time, and the gastric pouch is likely to expand to an unusual size, causing a higher risk for marginal ulceration. A larger pouch is also likely to increase the frequency of weight regain later (beyond 3 years), and a few patients may need a second revision. In that sense, a 2-stage approach may be more desirable. Attention in opening the gastrogastric tunnel, where the band was located, may be important also to create a smaller pouch and to resist the temp-
tation to staple around. However, this procedure may cause a higher leak rate. The recently published series by Delko et al4 demonstrated the percentage of excess weight loss in primary RYGB to be significantly higher at 70% vs 45% in revision RYGB (P < .002) after 24 months. Revision RYGB performed as a 1-stage procedure showed less effective excess weight loss than primary RYGB interventions. The capsular reaction superior to the band may also limit the crus dissection because LAGB has been associated with a higher incidence of gastroesophageal reflux disease with hiatal hernia.5 The unrepaired hiatal hernia may cause the gastric pouch, with its anastomosis, to migrate transthoracically and become a later problem. Hence, a longer follow-up period is needed for revision gastric bypass after LAGB. Time will tell whether it has the same safety and general outcomes as primary RYGB.
ARTICLE INFORMATION
REFERENCES
Author Affiliations: Herbert Wertheim College of Medicine, Florida International University, Miami; Hôpital du Sacre Coeur, Montreal, Quebec, Canada.
1. Courcoulas AP, Christian NJ, Belle SH, et al; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA. 2013;310 (22):2416-2425.
Corresponding Author: Michel Gagner, MD, FRCSC, Department of Surgery, Hôpital du Sacre Coeur, 315 Place D’Youville, Ste 191, Montreal, QB H2Y 0A4, Canada ([email protected]). Published Online: June 18, 2014. doi:10.1001/jamasurg.2014.634. Conflict of Interest Disclosures: Dr Gagner reported receiving honoraria for speaking engagements from Ethicon, Covidien, Gore, MID, Transenterix, and Boehringer Laboratories and reported owning equity in Transenterix.
2. Thereaux J, Veyrie N, Barsamian C, et al. Similar postoperative safety between primary and revisional gastric bypass for failed gastric banding [published online June 18, 2014]. JAMA Surg. doi:10 .1001/jamasurg.2014.625.
non-LapBand primary and revisional bariatric surgical procedures from the Longitudinal Assessment of Bariatric Surgery study. Surg Obes Relat Dis. 2010;6(1):22-30. 4. Delko T, Köstler T, Peev M, Esterman A, Oertli D, Zingg U. Revisional versus primary Roux-en-Y gastric bypass: a case-matched analysis. Surg Endosc. 2014;28(2):552-558. 5. Azagury DE, Varban O, Tavakkolizadeh A, Robinson MK, Vernon AH, Lautz DB. Does laparoscopic gastric banding create hiatal hernias? Surg Obes Relat Dis. 2013;9(1):48-52.
3. Inabnet WB III, Belle SH, Bessler M, et al. Comparison of 30-day outcomes after
jamasurgery.com
JAMA Surgery August 2014 Volume 149, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Georgia User on 06/01/2015
787
