1 2 3 Surgery for Obesity and Related Diseases ] (2015) 00–00 4 5 6 Original article 7 8 Q3 9 10 Q1 Q4 Masrius Nedelcua,b,*, Patrick Noela, Antonio Ianellic, Michel Gagnerd a 11 Hôpital Prive La Casamance, Aubagne, France b 12 Centre Hospitalier Universitaire Strasbourg, France c Hôpital Archet, Université de Nice, France 13 d Hôpital Du Sacre Cœur, Montréal, Canada 14 Received November 26, 2014; accepted February 9, 2015 15 16 17 Abstract Background: Laparoscopic sleeve gastrectomy (LSG) has rapidly become increasingly popular in 18 bariatric surgery. However, in the long-term follow-up, weight loss failure and intractable severe 19 reflux after primary LSG can necessitate further surgical interventions. 20 Q5 Objectives: ■■■ 21 Setting: Private hospital. 22 Methods: From October 2008 to October 2014, 61 patients underwent a revisional sleeve gas23 trectomy (ReSG). All patients with failure after primary LSG underwent radiologic evaluation, and 24 an algorithm of treatment was proposed. Results: Sixty-one patients (54 women, 7 men; mean age 40.8 yr) with a body mass index (BMI) of 25 39.4 kg/m² underwent ReSG. The primary LSG was performed for mean BMI of 46.2 kg/m² (range 26 35.4–77.9). The mean interval time from the primary LSG to ReSG was of 37.5 months (9–80 mo). 27 The indication for ReSG was insufficient weight loss in 28 patients (45.9%), weight regain in 29 28 patients (47.5%), and gastroesophageal reflux disease (GERD) in 4 patients. In 42 patients the 29 gastrografin swallow results were interpreted as primary dilation and in the remaining 19 cases as 30 secondary dilation. The computed tomography (CT) scan volumetry was obtained in 38 patients 31 with mean gastric volume of 436.3 cc (275–1056 cc). All cases were completed by laparoscopy with 32 no intraoperative incidents. The mean operative time was 39 minutes (range 29–70 min) and the 33 mean hospital stay was 3.5 days (range 3–16 d). One perigastric hematoma and 2 cases of gastric 34 stenosis were recorded. The mean BMI decreased to 29.2 kg/m2 (range 20.2–37.5); the mean 35 percentage of excess weight loss (%EWL) was 58.5% (⫾25.3) (P o .0004) for a mean follow-up of 20 months (range 6–56 mo). 36 Conclusion: The ReSG may be a valid option for failure of primary LSG. Further prospective 37 clinical trials are required to compare the outcomes of ReSG with those of laparoscopic Roux-en-Y 38 gastric bypass or duodenal switch for weight loss failure after LSG. (Surg Obes Relat Dis 39 2015;]:00–00.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved. 40 41 Keywords: Revised sleeve gastrectomy; Primary dilation; Secondary dilation 42 43 44 45 Laparoscopic sleeve gastrectomy (LSG) has rapidly obesity because of its efficacy and low complication rates, 46 become increasingly popular surgical procedure for morbid as well as the technical ease of performing it. The procedure 47 has several advantages over more complex bariatric proce48 dures, such as laparoscopic Roux-en-Y gastric bypass * 49 Correspondence: Marius Nedelcu, Digestive and Endocrine Surgery, (LRYGB) and duodenal switch (DS), and achieves a better 50 University Hospital of Strasbourg 1, Place de l’Hôpital, 67091, Strasbourg, quality of life over gastric banding. The past few years have France. 51 seen significant growth in procedure numbers, and LSG has E-mail: [email protected] 52 53 http://dx.doi.org/10.1016/j.soard.2015.02.009 54 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved. 55
Revised sleeve gastrectomy (re-sleeve)
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achieved becoming the most commonly performed bariatric procedure in France in 2011 and in the United States in 2013 [1,2]. This growth can be attributed to several advantages that LSG carries over more complex bariatric procedures, such as LRYGB or DS, and absence of the side effects of bypass procedures—specifically dumping syndrome, marginal ulcers, malabsorption, small bowel obstruction, and internal hernia—and a better quality of life over gastric banding [3–5]. Patients who have undergone LSG but have experienced weight loss failure (insufficient weight loss or weight regain) or have developed certain complications, such as gastroesophageal reflux disease (GERD), can be treated surgically by a second intervention, such as revisional sleeve gastrectomy (ReSG) [6–10], LRYGB [11] or biliopancreatic diversion with DS (BPD-DS) [12–14]. Singleanastomosis duodenoileal (SADI) bypass with sleeve gastrectomy represents a new alternative to standard DS, but limited results have been reported in the literature [15] and must be validated over time. The rising numbers of LSG procedures now being performed (France: 480 cases in 2005 versus 13,557 cases in 2011) will likely be followed by increasing numbers of patients who have experienced weight loss failure and will seek conversion to another bariatric procedure. It is also necessary to know the extent and causes of failures of LSG as well as the indications and outcomes of revision after LSG. This study assessed the efficacy, tolerability, and outcomes of a laparoscopic ReSG. Methods All patients who underwent ReSG for LSG failure between October 2008 and October 2014 were included in this study. The requirements for revisional surgery were
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insufficient weight loss at 18 months after the surgery (o50% of excess weight loss [EWL]), progressive weight regain after an initial successful weight loss (defined as EWL 450%), or symptomatic GERD (persistent heartburn despite maximum proton pomp inhibitor [PPI] treatment with mild esophagitis on upper endoscopy). A multidisciplinary team that included a nutritionist, endocrinologist, psychologist, and surgeon routinely evaluated each patient according to a standardized protocol. Only patients for whom the psychiatric and nutritional clearance was obtained were further considered for a standard algorithm to indicate the revisional bariatric procedure (Fig. 1). ReSG was proposed as a revisional strategy if the barium swallow indicated an upper gastric pouch dilation or a huge, unresected fundus. A computed tomography (CT) scan volumetry followed if the barium swallow test was negative for the upper part sleeve dilation or was inconclusive. The residual gastric volume was measured by filling the gastric remnant with carbon dioxide, as follows. The patient was given a sodium bicarbonate solution (4 g in 10 cL of water) to drink, followed by a tartaric acid solution (4 g in 10 cL of water). After the tartaric acid intake, low-dose CT acquisitions were made at 30 and 60 seconds. Volume was measured using Myrians software (Microsoft Inc., Redwood City, CA) and expressed in cubic centimeters (cc). If volumetry exceeded 250 cc, ReSG was considered. If it was o250 cc, patients were referred to the gastroenterologist for assessment of their GERD. Depending on patient characteristics (postoperative commitment to follow-up of the first procedure, patient’s employment, family support) and the results of GERD assessment, a procedural decision of conversion to LRYGB or DS was made. The patients who required ReSG were identified from our prospective bariatric patient registry (October 2008– October 2014). During this period, 12 LRYGB and 9 DS
Fig. 1. Bariatric algorithm of laparoscopic sleeve gastrectomy failure. CT ¼ computed tomography; GERD ¼ gastroesophageal reflux disease; DS ¼ duodenal switch; SADI ¼ single-anastomosis duodenoileal bypass; LRYGB ¼ laparoscopic Roux-en-Y gastric bypass.
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procedures were performed for residual gastric volume of o250 cc. Since January 2014, 5 cases of SADI were performed as an alternative procedure of standard DS. All procedures were performed laparoscopically at Casamance Private Hospital, Aubagne, France, by the same surgeon (PN) who performed 1753 LSG during the same period. Data assessed included patient demographic characteristics (age, gender), BMI before and after initial LSG or before and after ReSG, and time interval between the 2 procedures. Furthermore, indications for revisional surgery, operative parameters, morbidity, and mortality were included. Early complications were defined as leakage, bleeding, stenosis, and other unexpected events within 30 postoperative days. The radiologic studies were reviewed and the dilation was classified as primary or secondary. A primary dilation was defined as an upper posterior gastric pouch incompletely dissected during the initial procedure as a result of learning curve or difficult cases (supersuperobesity) with poor posterior exposure and incomplete visualization of the left crus of the diaphragm (Fig. 2). A secondary dilation was defined as a homogeneous dilated gastric tube of 4250 mL in volume at CT scan volumetry, seen later during follow-up. The mechanisms involved are narrowing of the gastric incisura during the primary operation with Fig. 3. Secondary dilation—uniform dilation of the gastric tube.
consequent gastric upstream dilation of the remnant stomach, natural history of LSG, the use of a large calibration bougie, a patient’s eating habits, planned second procedure, or a combination of these mechanisms (Fig. 3). ReSG efficiency was analyzed for those patients with a minimum follow-up of 12 months. Twenty-three patients operated on between October 2013 and October 2014 were excluded from analysis of the weight loss after ReSG. Results are expressed as mean ⫾ standard deviation. A P value o .05 was considered to be significant. Comparison data of LSG and ReSG were analyzed by means of the Mann-Whitney U test. Statistical analysis was performed using the SPSS statistical package, Version 11.5 (SSPS Inc., Chicago, IL).
Surgical technique W E B 4 C / F P O
Fig. 2. Primary dilation.
The pneumoperitoneum was created using a Veress needle inserted in the left hypochondrium. Only 3 trocars were used. The initial LSG was performed in a similar manner with 3-port approach [16]. Liver retraction necessitated 1 additional port in 4 cases. Any intraperitoneal attachment between the left lobe of the liver and the anterior gastric surface was carefully dissected. The greater curvature was dissected next to expose the previous staple line.
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All adhesions were divided between the stomach and the pancreas, taking care not to injure the splenic artery. Once the mobilization of the stomach was completed as previously described [17], the anesthesiologist inserted a 36F orogastric bougie (MidSleeves) to reach the pylorus, and different applications of a linear stapler Echelon 60–4.1 mm (Ethicon Endo-Surgery Inc., Cincinnati, OH) were fired. Methylene blue test was performed. A nonsystematic drain was left in place along the staple line only for difficult cases. Nasogastric (NG) tubes were not used in the postoperative period. Results Of the 1753 patients who underwent LSG in our department from October 2008 to October 2014, 61 underwent revisional surgery (3.48%). Preoperative workup data
perigastric hematoma identified by CT scan with vomiting on postoperative day (POD) 2. An endoscopic stent was deployed and the patient was discharged on liquid diet. At 4 weeks, the CT scan and upper endoscopy were normal and the stent was removed. In 2 other cases (patients 39 and 51) at 1 and 2 weeks postoperative, respectively, the patients developed progressive dysphagia. An upper endoscopy revealed the same finding—a stenosis of the midpart of the gastric sleeve— and the decision of stent deployment was made in both cases. In one case, the stenosis was rectified after 4 weeks when the stent was removed. The other patient needed 2 additional endoscopic pneumatic dilation sessions of the stenosis. The procedure was performed with an achalasia balloon (Rigiflexs balloon 30–35 mm) over a stainless steel or super-stiff guidewire with stepwise increments in dilation pressure from 15 to 25 psi. Inflating the balloon under radiologic guidance enables correction of the axis of the gastric tube. To be efficient, the treatment must be aggressive, and in our experience, we have not had any cases of iatrogenic staple line disruption.
Sixty-one patients (54 women, 7 men; mean age 40.8 yr) with an average BMI of 39.4 (⫾ 1.32) undergoing ReSG in our department were enrolled in the present study. Twentyfive (40.9%) patients had their original LSG surgery performed at another hospital and were subsequently referred for weight loss failure. The remaining 36 patients’ primary procedures were performed in our department. Before the primary LSG, 41 patients (67.2%) out of 61 had already had laparoscopic adjustable gastric banding (LAGB) with weight loss failure. Six patients had multiple gastric band procedures for technical failures. Twenty patients (32.8%) were super-obese (BMI 450 kg/m2) before LSG, and 5 patients (8.2%) were super-super-obese (BMI 460 kg/m2). The median BMI before the SG was 46.2 kg/m2 (⫾ 1.29; range 35.4–77.9). After the initial LSG, a median BMI of 39.4 kg/m2 (⫾ 1.43; range 21.9–48.2) was achieved. Revision was performed after a median period of 37.4 months (range 9–80 mo). The indications for ReSG were insufficient weight loss for 28 patients (45.9%), weight regain for 29 patients (47.5%), and symptomatic GERD for 4 patients. The analysis of barium swallow indicated primary dilation (upper gastric pouch) in 42 cases, and in the remaining 19 cases the radiologic findings were compatible with a secondary dilation (gastric tube dilation). The CT scan volumetry (38 cases) revealed a mean gastric volume of 436.3 cc (range 275–1056 cc).
We have analyzed the weight loss results for 38 patients operated on from October 2008 through October 2013. Follow-up was accomplished for 33 patients (86.8%); 2 patients were lost to follow-up. A 53-year-old woman diagnosed with uterine cancer 4 months after the ReSG and 2 patients who underwent ReSG for GERD were excluded from the group analyzed for weight loss analysis. Twenty-five patients had a former LAGB before their LSG. Our team performed the primary LSG procedures in 27 out 38 patients, and the other 11 were performed in other hospitals. The mean BMI before the primary LSG was 43.2 kg/m2 (⫾ 1.37; range 33.8–67.1). The minimal BMI recorded after the primary LSG was 34.6 kg/m2 (⫾ 1.27; range 31.9– 59.8), and the mean %EWL was 51.2% (⫾ 26.2) at a mean follow-up of 19.2 months. The ReSG was performed after a mean of 37.4 months for a mean BMI of 38.1 kg/m2 (⫾ 1.34; range 35.2–59.8). At a mean follow-up of 19.9 months (range 12–72 mo) after ReSG, the mean BMI and % EWL was 29.8 kg/m2 (range 20.2–41) and 62.7% (⫾ 29.2), respectively (P o .0004), and 9 patients achieved an ideal weight. The mean and standard deviations of these groups are illustrated in Fig. 4.
Intraoperative data and postoperative outcomes
Discussion
All cases were completed by laparoscopy with no intraoperative complications. Mean operative time was 39 min (range 29–70 min) and the mean hospital stay was 3.5 days (range 3–16 d). In the immediate postoperative period, 1 complication was recorded: Patient 12 developed a
LSG is considered to be a technically straightforward procedure, but the surgical technique is one of the major determinants of the success of this procedure. Removal of the entire gastric fundus is a key point. The left crus of the diaphragm must be systematically visualized. Our technique
Postoperative follow-up
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Fig. 4. Weight loss (mean and standard deviation)—before and after primary laparoscopic sleeve gastrectomy (LSG) and before and after re-sleeve (ReSG).
includes the following: the posterior aspect of the fundus is grasped repeatedly with forceps operated by the right hand, while the left hand releases the stapler and pulls laterally before the stapler is definitively clamped and fired [16]. Recent studies comparing LSG with LRYGB show equal efficacy of both procedures in terms of weight loss and improvement of co-morbidities [18–21]. As bariatric procedures are performed more commonly, the number of revisions will also rise. We found that the best way to approach these patients is to first perform a full history and then to assess their BMI and their alimentary habits. All patients with a history suggestive of maladaptive eating disorders because of their bariatric surgery underwent further psychological evaluation and were treated before consideration for surgical revision. The next step was to document their anatomy with a barium swallow to look for evidence of primary or secondary dilation of the gastric sleeve. For nonconclusive results on upper GI series a volumetric CT scan was done. Revisional bariatric surgery after LSG is becoming more common because of the rapid increase of patients undergoing this procedure as treatment for morbid obesity. The problem of insufficient weight loss and weight regain after LSG is an issue as for other bariatric procedures. Possible explanations for LSG failure include the following: dilation of the residual stomach, calibration of the stomach with an excessively large gastric bougie [22], and incomplete section of the gastric fundus (from where ghrelin is secreted) [23]. For the LSG, the risk of dilation in time with weight loss failure is a constant source of debate. Facing 42 patients with primary dilation (upper gastric pouch), this question came up rapidly among the authors: Has this part of the stomach undergone secondary dilation or was it incompletely dissected from the beginning? The answer remains unknown; a prospective randomized study based on CT scan volumetry would be needed. With the development of CT scan gastric volumetry, it will be easier to
differentiate between secondary and primary dilation, because the former provides useful details such as the position of the staple line and the integrity of the angle of His that are in favor of a primary dilation. Braghetto et al. [24] reported data on 15 LSG patients undergoing CT scan gastric volumetry on POD 3 and, repeatedly, at 24–36 months after surgery; they found that the mean gastric volume had increased from 108 to 250 mL. None of these patients experienced weight regain, and the authors concluded that the gastric capacity increased after LSG sleeve gastrectomy even when a narrow gastric tubulization was performed. Langer et al. [25] prospectively studied 23 patients (15 morbidly obese, 8 super-obese) via upper gastrointestinal contrast studies and found that the dilation occurred in only 1 patient, whereas weight regain after initial successful weight loss occurred in 3 more patients, at a mean follow-up of 20 months. Yehoshua et al. [26] investigated the role of the intraluminal pressure in the process of dilation of the gastric tube. The preoperative mean volume of the entire stomach was 1553 cc (600–2000 cc) and that of the sleeved stomach 129 cc (90–220 cc). Results indicated that the sleeve has a higher mean pressure of 43 mm Hg when filled with saline (range 32–58 mm Hg) compared with the removed stomach, which had a mean pressure of 26 mm Hg (range 12–47 mm Hg). The study concluded that the notably higher pressure in the sleeve reflects its markedly lesser distensibility compared with that of the whole stomach and that of the removed fundus. Unfortunately, there is a paucity of significant data to help the surgeon decide which revisional procedure to choose. Nonetheless, in the setting of weight loss failure after LSG, many bariatric centers advocate LRYGB as standard revisional procedure despite no long-term followup data. DS and more recently SADI represent other promising options in this patient population. Because of the superior weight loss seen with the DS compared with other bariatric procedures, interest has grown in using this
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Table 1 Literature review of long-term follow-up after LSG Author
Journal (yr)
Patients
Follow-up—yr (rate)
Mean %EWL
Himpens et al. [28] Rawlins et al. [29] Braghetto et al. [30] Catheline et al. [31] Eid et al. [32] Sieber et al. [33]
Ann Surg (2010) Surg Obes Relat Dis (2013) Surg Lap Endosc Percutan Tech (2012) J Visc Surg (2013) Ann Surg (2012) Surg Obes Relat Dis (2014)
30 49 60 45 23 54
6 5 5 5 5 5
53.3% 86% 57.3% 50.7% 49.5% 57.4%
(78%) (100%) (11%) (82%) (79%) (91%)
%EWL ¼ percentage of excess weight loss.
procedure in the treatment of morbidly obese patients who fail in other surgical therapy [27]. The DS or SADI can be proposed only to patients with a serious commitment to a follow-up program and who can understand detailed information about risks and severe side effects of malabsorption. The ReSG has already been described as a revision of LSG/DS itself. Although the operation seems to be technically easier, without conversions and acceptable complication rates, the follow-up was too short to conclude on its efficiency [6–10]. To date, no prospective trial has been done to adequately determine which revisional bariatric procedure should be carried out in the setting of inadequate weight loss or excessive weight regain after LSG. The literature data are sparse regarding the long-term followup after LSG, and the results illustrated in the Table 1 are highly variable. Himpens et al. [28] reported a 3-year followup %EWL of 77.5% and a 6-year %EWL of 53.3%, with patients receiving only LSG. Their conclusion was that the weight regain and de novo gastroesophageal reflux symptoms (21%) appear between the third and the sixth postoperative year. In our opinion, some of the patients had undissected fundus or upper gastric dilation that could explain some of the failures. We must mention that this study was conducted on patients operated between November 2001 and October 2002 when the learning curve for LSG may also be responsible for some of the negative results, as a result of incomplete left crus exposure and full posterior fundic dissection. In our opinion, the weight loss after both ReSG and primary LSG depends on the learning curve and are technically dependent. For primary LSG, the incomplete removal of the gastric fundus seems to be the most reliable hypothesis causing weight regain. In some cases of incomplete removal of the fundus, a small unrecognized hiatal hernia might be associated. A transthoracic stomach may be missed while performing LSG in the presence of a hiatal hernia. Intraoperative exploration of the esophageal hiatus is advised whenever a hiatal hernia is suspected, and we can avoid undissected fundus and repair the crura when necessary. This hypothesis has been sustained by Soricelli et al. [34]. To avoid unnecessary dissection, Heacock et al. [35] attempted to improve the preoperative diagnostic accuracy of hiatal hernia by using right anterior oblique (RAO) esophagogram technique rather than the commonly used upright technique and comparing it with the gold standard of intraoperative detection.
They analyzed a total of 388 patients who underwent preoperative esophagograms (69 upright, 388 RAO), reporting sensitivity of 50% and specificity of 97% for upright esophagogram and sensitivity of 70% and specificity of 77% for RAO esophagogram. The use of RAO technique for preoperative esophagogram is more sensitive for the diagnosis of hiatal hernia than upright esophagogram. The undissected fundus is a risk factor for GERD, and the ReSG with hiatal hernia repair represents a valid treatment option as reported by Parikh and Gagner [36]. In our experience we had 4 patients who had complete remission of the reflux symptomatology after ReSG. Literature data on the effect of LSG for GERD are contradictory. Petersen et al. [37] have reported on 37 patients undergoing LSG in whom the lower esophageal sphincter pressure increased significantly after surgery, independent of the weight loss. The stationary esophageal manometry for lower sphincter preoperatively had a pressure of 11 mm Hg, increasing significantly to 24 mm Hg postoperatively. Compared with the malabsorptive procedures, ReSG offers several advantages, including increasing the restriction and decreasing the gastric output; lessening dumping syndrome by preserving the pylorus; decreasing risk of anemia, osteoporosis, and protein and vitamin deficiency (excepting B12 and thiamine level); and requiring shorter operative times.
Conclusion We report the indications and short-term outcomes of revisional surgery after failed LSG. ReSG is a feasible and well-tolerated surgical approach for patients experiencing postLSG weight regain and is best applied when the gastric pouch is too large after the original LSG. This dilation may be responsible in the long term for weight regain, weight loss insufficiency, or GERD. Long-term results of ReSG are anticipated to prove efficiency. Further prospective randomized clinical trials are required to compare the outcomes of ReSG with those of LRYGB or DS for weight loss failure after LSG.
Disclosures Authors M. Nedelcu, P. Noel, and A. Iannelli have no conflicts of interest or financial ties to disclose. M. Gagner
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has honorarium for speaking engagements from Ethicon Endosurgery, Covidien, MID, Transenterix, and Gore. Appendix Supplementary data Supplementary data associated with this article can be found in the online version http://dx.doi.org/10.1016/j. soard.2015.02.009. References [1] Lazzati A, Guy-Lachuer R, Delaunay V, Szwarcensztein K, Azoulay D. Bariatric surgery trends in France: 2005-2011. Surg Obes Relat Dis 2014;10(2):328–34. [2] Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23(4):427–36. [3] Fezzi M, Kolotkin RL, Nedelcu M, et al. Improvement in quality of life after laparoscopic sleeve gastrectomy. Obes Surg 2011;21 (8):1161–7. [4] Freeman RA, Overs SE, Zarshenas N, Walton KL, Jorgensen JO. Food tolerance and diet quality following adjustable gastric banding, sleeve gastrectomy and Roux-en-Y gastric bypass. Obes Res Clin Pract 2014;8(2):e115–200. [5] Strain GW, Kolotkin RL, Dakin GF, et al. The effects of weight loss after bariatric surgery on health-related quality of life and depression. Nutr Diabetes 2014;4:e132. [6] Gagner M, Rogula T. Laparoscopic reoperative sleeve gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg 2003;13(4):649–54. [7] Baltasar A, Serra C, Pérez N, Bou R, Bengochea M. Re-sleeve gastrectomy. Obes Surg 2006;16(11):1535–8. [8] Dapri G, Cadière GB, Himpens J. Laparoscopic repeat sleeve gastrectomy versus duodenal switch after isolated sleeve gastrectomy for obesity. Surg Obes Relat Dis. 2011;7(1):38–43. [9] Iannelli A, Schneck AS, Noel P, Ben Amor I, Krawczykowski D, Gugenheim J. Re-sleeve gastrectomy for failed laparoscopic sleeve gastrectomy: a feasibility study. Obes Surg 2011;21(7):832–5. [10] Rebibo L, Fuks D, Verhaeghe P, Deguines JB, Dhahri A, Regimbeau JM. Repeat sleeve gastrectomy compared with primary sleeve gastrectomy: a single-center, matched case study. Obes Surg. 2012 Dec;22(12):1909–15. [11] Regan JP, Inabnet WB, Gagner M, Pomp A. Early experience with two-staged laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 2003;13(6):861–4. [12] Iannelli A, Schneck AS, Topart P, Carles M, Hébuterne X, Gugenheim J. Laparoscopic sleeve gastrectomy followed by duodenal switch in selected patients versus single-stage duodenal switch for superobesity: case-control study. Surg Obes Relat Dis 2013;9(4):531–8. [13] Gumbs AA, Pomp A, Gagner M. Revisional bariatric surgery for inadequate weight loss. Obes Surg 2007;17(9):1137–45. [14] Gagner M, Boza C. Laparoscopic duodenal switch for morbid obesity. Expert Rev Med Devices 2006;3(1):105–12. [15] Sánchez-Pernaute A, Rubio MÁ, Pérez Aguirre E, Barabash A, Cabrerizo L, Torres A. Single-anastomosis duodenoileal bypass with sleeve gastrectomy: metabolic improvement and weight loss in first 100 patients. Surg Obes Relat Dis 2013;9(5):731–5. [16] Noel P, Iannelli A, Sejor E, Schneck AS, Gugenheim J. Laparoscopic sleeve gastrectomy: how I do it. Surg Laparosc Endosc Percutan Tech 2013;23(1):e14–6. [17] Noel P, Nedelcu M, Nocca D. The revised sleeve gastrectomy, technical considerations. Surg Obes Relat Dis 2013;9(6):1029–32.
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[18] Karamanakos SN, Vagenas K, Kalfarentzos F. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Ann Surg 2008;247(3):401–7. [19] Peterli R, Borbély Y, Kern B, et al. Early results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. Ann Surg 2013;258(5):690–4. [20] Kehagias I, Karamanakos SN, Argentou M, et al. Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for the management of patients with BMI o 50 kg/m2. Obes Surg 2011;21(11):1650–6. [21] Leyba JL, Aulestia SN, Llopis SN. Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for the treatment of morbid obesity. A prospective study of 117 patients. Obes Surg 2011;21(2):212–6. [22] Weiner RA, Weiner S, Pomhoff I, et al. Laparoscopic sleeve gastrectomy—influence of sleeve size and 120 resected gastric volume. Obes Surg 2007;17(10):1297–305. [23] Lin E, Gletsu N, Fugate K, et al. The effects of gastric surgery on systemic ghrelin levels in the morbidly obese. Arch Surg 2004;139(7):780–4. [24] Braghetto I, Cortes C, Herquiñigo D, et al. Evaluation of the radiological gastric capacity and evolution of the BMI 2–3 years after sleeve gastrectomy. Obes Surg 2009;19(9):1262–9. [25] Langer FB, Bohdjalian A, Falbervawer FX, et al. Does gastric dilatation limit the success of sleeve gastrectomy as a sole operation for morbid obesity? Obes Surg 2006;16(2):166–71 [26] Yehoshua RT, Eidelman LA, Stein M, et al. Laparoscopic sleeve gastrectomy—volume and pressure assessment. Obes Surg 2008;18 (9):1083–8. [27] Carmeli I, Golomb I, Sadot E, Kashtan H, Keidar A. Laparoscopic conversion of sleeve gastrectomy to a biliopancreatic diversion with duodenal switch or a Roux-en-Y gastric bypass due to weight loss failure: our algorithm. Surg Obes Relat Dis 2014;11(1):79–85. [28] Himpens J, Dobbeleir J, Peeters G. Long-term results of laparoscopic sleeve gastrectomy for obesity. Ann Surg 2010;252(2):319–24. [29] Rawlins L, Rawlins MP, Brown CC, Schumacher DL. Sleeve gastrectomy: 5-year outcomes of a single institution. Surg Obes Relat Dis 2013;9(1):21–5. [30] Braghetto I, Csendes A, Lanzarini E, Papapietro K, Cárcamo C, Molina JC. Is laparoscopic sleeve gastrectomy an acceptable primary bariatric procedure in obese patients? Early and 5-year postoperative results. Surg Laparosc Endosc Percutan Tech 2012;22(6):479–86. [31] Catheline JM, Fysekidis M, Bachner I, et al. Five-year results of sleeve gastrectomy. J Visc Surg 2013;150(5):307–12. [32] Eid GM, Brethauer S, Mattar SG, Titchner RL, Gourash W, Schauer PR. Laparoscopic sleeve gastrectomy for super obese patients: fortyeight percent excess weight loss after 6 to 8 years with 93% followup. Ann Surg 2012;256(2):262–5. [33] Sieber P, Gass M, Kern B, Peters T, Slawik M, Peterli R. Five-year results of laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2014;10(2):243–9. [34] Soricelli E, Iossa A, Casella G, Abbatini F, Calì B, Basso N. Sleeve gastrectomy and crural repair in obese patients with gastroesophageal reflux disease and/or hiatal hernia. Surg Obes Relat Dis 2013;9(3):356–61. [35] Heacock L, Parikh M, Jain R, Balthazar E, Hindman N. Improving the diagnostic accuracy of hiatal hernia in patients undergoing bariatric surgery. Obes Surg 2012;22(11):1730–3. [36] Parikh M, Gagner M. Laparoscopic hiatal hernia repair and repeat sleeve gastrectomy for gastroesophageal reflux disease after duodenal switch. Surg Obes Relat Dis 2008;4(1):73–5. [37] Petersen WV, Meile T, Küper MA, Zdichavsky M, Königsrainer A, Schneider JH. Functional importance of laparoscopic sleeve gastrectomy for the lower esophageal sphincter in patients with morbid obesity. Obes Surg 2012;22(3):360–6.
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achieved becoming the most commonly performed bariatric procedure in France in 2011 and in the United States in 2013 [1,2]. This growth can be attributed to several advantages that LSG carries over more complex bariatric procedures, such as LRYGB or DS, and absence of the side effects of bypass procedures—specifically dumping syndrome, marginal ulcers, malabsorption, small bowel obstruction, and internal hernia—and a better quality of life over gastric banding [3–5]. Patients who have undergone LSG but have experienced weight loss failure (insufficient weight loss or weight regain) or have developed certain complications, such as gastroesophageal reflux disease (GERD), can be treated surgically by a second intervention, such as revisional sleeve gastrectomy (ReSG) [6–10], LRYGB [11] or biliopancreatic diversion with DS (BPD-DS) [12–14]. Singleanastomosis duodenoileal (SADI) bypass with sleeve gastrectomy represents a new alternative to standard DS, but limited results have been reported in the literature [15] and must be validated over time. The rising numbers of LSG procedures now being performed (France: 480 cases in 2005 versus 13,557 cases in 2011) will likely be followed by increasing numbers of patients who have experienced weight loss failure and will seek conversion to another bariatric procedure. It is also necessary to know the extent and causes of failures of LSG as well as the indications and outcomes of revision after LSG. This study assessed the efficacy, tolerability, and outcomes of a laparoscopic ReSG. Methods All patients who underwent ReSG for LSG failure between October 2008 and October 2014 were included in this study. The requirements for revisional surgery were
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insufficient weight loss at 18 months after the surgery (o50% of excess weight loss [EWL]), progressive weight regain after an initial successful weight loss (defined as EWL 450%), or symptomatic GERD (persistent heartburn despite maximum proton pomp inhibitor [PPI] treatment with mild esophagitis on upper endoscopy). A multidisciplinary team that included a nutritionist, endocrinologist, psychologist, and surgeon routinely evaluated each patient according to a standardized protocol. Only patients for whom the psychiatric and nutritional clearance was obtained were further considered for a standard algorithm to indicate the revisional bariatric procedure (Fig. 1). ReSG was proposed as a revisional strategy if the barium swallow indicated an upper gastric pouch dilation or a huge, unresected fundus. A computed tomography (CT) scan volumetry followed if the barium swallow test was negative for the upper part sleeve dilation or was inconclusive. The residual gastric volume was measured by filling the gastric remnant with carbon dioxide, as follows. The patient was given a sodium bicarbonate solution (4 g in 10 cL of water) to drink, followed by a tartaric acid solution (4 g in 10 cL of water). After the tartaric acid intake, low-dose CT acquisitions were made at 30 and 60 seconds. Volume was measured using Myrians software (Microsoft Inc., Redwood City, CA) and expressed in cubic centimeters (cc). If volumetry exceeded 250 cc, ReSG was considered. If it was o250 cc, patients were referred to the gastroenterologist for assessment of their GERD. Depending on patient characteristics (postoperative commitment to follow-up of the first procedure, patient’s employment, family support) and the results of GERD assessment, a procedural decision of conversion to LRYGB or DS was made. The patients who required ReSG were identified from our prospective bariatric patient registry (October 2008– October 2014). During this period, 12 LRYGB and 9 DS
Fig. 1. Bariatric algorithm of laparoscopic sleeve gastrectomy failure. CT ¼ computed tomography; GERD ¼ gastroesophageal reflux disease; DS ¼ duodenal switch; SADI ¼ single-anastomosis duodenoileal bypass; LRYGB ¼ laparoscopic Roux-en-Y gastric bypass.
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procedures were performed for residual gastric volume of o250 cc. Since January 2014, 5 cases of SADI were performed as an alternative procedure of standard DS. All procedures were performed laparoscopically at Casamance Private Hospital, Aubagne, France, by the same surgeon (PN) who performed 1753 LSG during the same period. Data assessed included patient demographic characteristics (age, gender), BMI before and after initial LSG or before and after ReSG, and time interval between the 2 procedures. Furthermore, indications for revisional surgery, operative parameters, morbidity, and mortality were included. Early complications were defined as leakage, bleeding, stenosis, and other unexpected events within 30 postoperative days. The radiologic studies were reviewed and the dilation was classified as primary or secondary. A primary dilation was defined as an upper posterior gastric pouch incompletely dissected during the initial procedure as a result of learning curve or difficult cases (supersuperobesity) with poor posterior exposure and incomplete visualization of the left crus of the diaphragm (Fig. 2). A secondary dilation was defined as a homogeneous dilated gastric tube of 4250 mL in volume at CT scan volumetry, seen later during follow-up. The mechanisms involved are narrowing of the gastric incisura during the primary operation with Fig. 3. Secondary dilation—uniform dilation of the gastric tube.
consequent gastric upstream dilation of the remnant stomach, natural history of LSG, the use of a large calibration bougie, a patient’s eating habits, planned second procedure, or a combination of these mechanisms (Fig. 3). ReSG efficiency was analyzed for those patients with a minimum follow-up of 12 months. Twenty-three patients operated on between October 2013 and October 2014 were excluded from analysis of the weight loss after ReSG. Results are expressed as mean ⫾ standard deviation. A P value o .05 was considered to be significant. Comparison data of LSG and ReSG were analyzed by means of the Mann-Whitney U test. Statistical analysis was performed using the SPSS statistical package, Version 11.5 (SSPS Inc., Chicago, IL).
Surgical technique W E B 4 C / F P O
Fig. 2. Primary dilation.
The pneumoperitoneum was created using a Veress needle inserted in the left hypochondrium. Only 3 trocars were used. The initial LSG was performed in a similar manner with 3-port approach [16]. Liver retraction necessitated 1 additional port in 4 cases. Any intraperitoneal attachment between the left lobe of the liver and the anterior gastric surface was carefully dissected. The greater curvature was dissected next to expose the previous staple line.
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All adhesions were divided between the stomach and the pancreas, taking care not to injure the splenic artery. Once the mobilization of the stomach was completed as previously described [17], the anesthesiologist inserted a 36F orogastric bougie (MidSleeves) to reach the pylorus, and different applications of a linear stapler Echelon 60–4.1 mm (Ethicon Endo-Surgery Inc., Cincinnati, OH) were fired. Methylene blue test was performed. A nonsystematic drain was left in place along the staple line only for difficult cases. Nasogastric (NG) tubes were not used in the postoperative period. Results Of the 1753 patients who underwent LSG in our department from October 2008 to October 2014, 61 underwent revisional surgery (3.48%). Preoperative workup data
perigastric hematoma identified by CT scan with vomiting on postoperative day (POD) 2. An endoscopic stent was deployed and the patient was discharged on liquid diet. At 4 weeks, the CT scan and upper endoscopy were normal and the stent was removed. In 2 other cases (patients 39 and 51) at 1 and 2 weeks postoperative, respectively, the patients developed progressive dysphagia. An upper endoscopy revealed the same finding—a stenosis of the midpart of the gastric sleeve— and the decision of stent deployment was made in both cases. In one case, the stenosis was rectified after 4 weeks when the stent was removed. The other patient needed 2 additional endoscopic pneumatic dilation sessions of the stenosis. The procedure was performed with an achalasia balloon (Rigiflexs balloon 30–35 mm) over a stainless steel or super-stiff guidewire with stepwise increments in dilation pressure from 15 to 25 psi. Inflating the balloon under radiologic guidance enables correction of the axis of the gastric tube. To be efficient, the treatment must be aggressive, and in our experience, we have not had any cases of iatrogenic staple line disruption.
Sixty-one patients (54 women, 7 men; mean age 40.8 yr) with an average BMI of 39.4 (⫾ 1.32) undergoing ReSG in our department were enrolled in the present study. Twentyfive (40.9%) patients had their original LSG surgery performed at another hospital and were subsequently referred for weight loss failure. The remaining 36 patients’ primary procedures were performed in our department. Before the primary LSG, 41 patients (67.2%) out of 61 had already had laparoscopic adjustable gastric banding (LAGB) with weight loss failure. Six patients had multiple gastric band procedures for technical failures. Twenty patients (32.8%) were super-obese (BMI 450 kg/m2) before LSG, and 5 patients (8.2%) were super-super-obese (BMI 460 kg/m2). The median BMI before the SG was 46.2 kg/m2 (⫾ 1.29; range 35.4–77.9). After the initial LSG, a median BMI of 39.4 kg/m2 (⫾ 1.43; range 21.9–48.2) was achieved. Revision was performed after a median period of 37.4 months (range 9–80 mo). The indications for ReSG were insufficient weight loss for 28 patients (45.9%), weight regain for 29 patients (47.5%), and symptomatic GERD for 4 patients. The analysis of barium swallow indicated primary dilation (upper gastric pouch) in 42 cases, and in the remaining 19 cases the radiologic findings were compatible with a secondary dilation (gastric tube dilation). The CT scan volumetry (38 cases) revealed a mean gastric volume of 436.3 cc (range 275–1056 cc).
We have analyzed the weight loss results for 38 patients operated on from October 2008 through October 2013. Follow-up was accomplished for 33 patients (86.8%); 2 patients were lost to follow-up. A 53-year-old woman diagnosed with uterine cancer 4 months after the ReSG and 2 patients who underwent ReSG for GERD were excluded from the group analyzed for weight loss analysis. Twenty-five patients had a former LAGB before their LSG. Our team performed the primary LSG procedures in 27 out 38 patients, and the other 11 were performed in other hospitals. The mean BMI before the primary LSG was 43.2 kg/m2 (⫾ 1.37; range 33.8–67.1). The minimal BMI recorded after the primary LSG was 34.6 kg/m2 (⫾ 1.27; range 31.9– 59.8), and the mean %EWL was 51.2% (⫾ 26.2) at a mean follow-up of 19.2 months. The ReSG was performed after a mean of 37.4 months for a mean BMI of 38.1 kg/m2 (⫾ 1.34; range 35.2–59.8). At a mean follow-up of 19.9 months (range 12–72 mo) after ReSG, the mean BMI and % EWL was 29.8 kg/m2 (range 20.2–41) and 62.7% (⫾ 29.2), respectively (P o .0004), and 9 patients achieved an ideal weight. The mean and standard deviations of these groups are illustrated in Fig. 4.
Intraoperative data and postoperative outcomes
Discussion
All cases were completed by laparoscopy with no intraoperative complications. Mean operative time was 39 min (range 29–70 min) and the mean hospital stay was 3.5 days (range 3–16 d). In the immediate postoperative period, 1 complication was recorded: Patient 12 developed a
LSG is considered to be a technically straightforward procedure, but the surgical technique is one of the major determinants of the success of this procedure. Removal of the entire gastric fundus is a key point. The left crus of the diaphragm must be systematically visualized. Our technique
Postoperative follow-up
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Fig. 4. Weight loss (mean and standard deviation)—before and after primary laparoscopic sleeve gastrectomy (LSG) and before and after re-sleeve (ReSG).
includes the following: the posterior aspect of the fundus is grasped repeatedly with forceps operated by the right hand, while the left hand releases the stapler and pulls laterally before the stapler is definitively clamped and fired [16]. Recent studies comparing LSG with LRYGB show equal efficacy of both procedures in terms of weight loss and improvement of co-morbidities [18–21]. As bariatric procedures are performed more commonly, the number of revisions will also rise. We found that the best way to approach these patients is to first perform a full history and then to assess their BMI and their alimentary habits. All patients with a history suggestive of maladaptive eating disorders because of their bariatric surgery underwent further psychological evaluation and were treated before consideration for surgical revision. The next step was to document their anatomy with a barium swallow to look for evidence of primary or secondary dilation of the gastric sleeve. For nonconclusive results on upper GI series a volumetric CT scan was done. Revisional bariatric surgery after LSG is becoming more common because of the rapid increase of patients undergoing this procedure as treatment for morbid obesity. The problem of insufficient weight loss and weight regain after LSG is an issue as for other bariatric procedures. Possible explanations for LSG failure include the following: dilation of the residual stomach, calibration of the stomach with an excessively large gastric bougie [22], and incomplete section of the gastric fundus (from where ghrelin is secreted) [23]. For the LSG, the risk of dilation in time with weight loss failure is a constant source of debate. Facing 42 patients with primary dilation (upper gastric pouch), this question came up rapidly among the authors: Has this part of the stomach undergone secondary dilation or was it incompletely dissected from the beginning? The answer remains unknown; a prospective randomized study based on CT scan volumetry would be needed. With the development of CT scan gastric volumetry, it will be easier to
differentiate between secondary and primary dilation, because the former provides useful details such as the position of the staple line and the integrity of the angle of His that are in favor of a primary dilation. Braghetto et al. [24] reported data on 15 LSG patients undergoing CT scan gastric volumetry on POD 3 and, repeatedly, at 24–36 months after surgery; they found that the mean gastric volume had increased from 108 to 250 mL. None of these patients experienced weight regain, and the authors concluded that the gastric capacity increased after LSG sleeve gastrectomy even when a narrow gastric tubulization was performed. Langer et al. [25] prospectively studied 23 patients (15 morbidly obese, 8 super-obese) via upper gastrointestinal contrast studies and found that the dilation occurred in only 1 patient, whereas weight regain after initial successful weight loss occurred in 3 more patients, at a mean follow-up of 20 months. Yehoshua et al. [26] investigated the role of the intraluminal pressure in the process of dilation of the gastric tube. The preoperative mean volume of the entire stomach was 1553 cc (600–2000 cc) and that of the sleeved stomach 129 cc (90–220 cc). Results indicated that the sleeve has a higher mean pressure of 43 mm Hg when filled with saline (range 32–58 mm Hg) compared with the removed stomach, which had a mean pressure of 26 mm Hg (range 12–47 mm Hg). The study concluded that the notably higher pressure in the sleeve reflects its markedly lesser distensibility compared with that of the whole stomach and that of the removed fundus. Unfortunately, there is a paucity of significant data to help the surgeon decide which revisional procedure to choose. Nonetheless, in the setting of weight loss failure after LSG, many bariatric centers advocate LRYGB as standard revisional procedure despite no long-term followup data. DS and more recently SADI represent other promising options in this patient population. Because of the superior weight loss seen with the DS compared with other bariatric procedures, interest has grown in using this
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Table 1 Literature review of long-term follow-up after LSG Author
Journal (yr)
Patients
Follow-up—yr (rate)
Mean %EWL
Himpens et al. [28] Rawlins et al. [29] Braghetto et al. [30] Catheline et al. [31] Eid et al. [32] Sieber et al. [33]
Ann Surg (2010) Surg Obes Relat Dis (2013) Surg Lap Endosc Percutan Tech (2012) J Visc Surg (2013) Ann Surg (2012) Surg Obes Relat Dis (2014)
30 49 60 45 23 54
6 5 5 5 5 5
53.3% 86% 57.3% 50.7% 49.5% 57.4%
(78%) (100%) (11%) (82%) (79%) (91%)
%EWL ¼ percentage of excess weight loss.
procedure in the treatment of morbidly obese patients who fail in other surgical therapy [27]. The DS or SADI can be proposed only to patients with a serious commitment to a follow-up program and who can understand detailed information about risks and severe side effects of malabsorption. The ReSG has already been described as a revision of LSG/DS itself. Although the operation seems to be technically easier, without conversions and acceptable complication rates, the follow-up was too short to conclude on its efficiency [6–10]. To date, no prospective trial has been done to adequately determine which revisional bariatric procedure should be carried out in the setting of inadequate weight loss or excessive weight regain after LSG. The literature data are sparse regarding the long-term followup after LSG, and the results illustrated in the Table 1 are highly variable. Himpens et al. [28] reported a 3-year followup %EWL of 77.5% and a 6-year %EWL of 53.3%, with patients receiving only LSG. Their conclusion was that the weight regain and de novo gastroesophageal reflux symptoms (21%) appear between the third and the sixth postoperative year. In our opinion, some of the patients had undissected fundus or upper gastric dilation that could explain some of the failures. We must mention that this study was conducted on patients operated between November 2001 and October 2002 when the learning curve for LSG may also be responsible for some of the negative results, as a result of incomplete left crus exposure and full posterior fundic dissection. In our opinion, the weight loss after both ReSG and primary LSG depends on the learning curve and are technically dependent. For primary LSG, the incomplete removal of the gastric fundus seems to be the most reliable hypothesis causing weight regain. In some cases of incomplete removal of the fundus, a small unrecognized hiatal hernia might be associated. A transthoracic stomach may be missed while performing LSG in the presence of a hiatal hernia. Intraoperative exploration of the esophageal hiatus is advised whenever a hiatal hernia is suspected, and we can avoid undissected fundus and repair the crura when necessary. This hypothesis has been sustained by Soricelli et al. [34]. To avoid unnecessary dissection, Heacock et al. [35] attempted to improve the preoperative diagnostic accuracy of hiatal hernia by using right anterior oblique (RAO) esophagogram technique rather than the commonly used upright technique and comparing it with the gold standard of intraoperative detection.
They analyzed a total of 388 patients who underwent preoperative esophagograms (69 upright, 388 RAO), reporting sensitivity of 50% and specificity of 97% for upright esophagogram and sensitivity of 70% and specificity of 77% for RAO esophagogram. The use of RAO technique for preoperative esophagogram is more sensitive for the diagnosis of hiatal hernia than upright esophagogram. The undissected fundus is a risk factor for GERD, and the ReSG with hiatal hernia repair represents a valid treatment option as reported by Parikh and Gagner [36]. In our experience we had 4 patients who had complete remission of the reflux symptomatology after ReSG. Literature data on the effect of LSG for GERD are contradictory. Petersen et al. [37] have reported on 37 patients undergoing LSG in whom the lower esophageal sphincter pressure increased significantly after surgery, independent of the weight loss. The stationary esophageal manometry for lower sphincter preoperatively had a pressure of 11 mm Hg, increasing significantly to 24 mm Hg postoperatively. Compared with the malabsorptive procedures, ReSG offers several advantages, including increasing the restriction and decreasing the gastric output; lessening dumping syndrome by preserving the pylorus; decreasing risk of anemia, osteoporosis, and protein and vitamin deficiency (excepting B12 and thiamine level); and requiring shorter operative times.
Conclusion We report the indications and short-term outcomes of revisional surgery after failed LSG. ReSG is a feasible and well-tolerated surgical approach for patients experiencing postLSG weight regain and is best applied when the gastric pouch is too large after the original LSG. This dilation may be responsible in the long term for weight regain, weight loss insufficiency, or GERD. Long-term results of ReSG are anticipated to prove efficiency. Further prospective randomized clinical trials are required to compare the outcomes of ReSG with those of LRYGB or DS for weight loss failure after LSG.
Disclosures Authors M. Nedelcu, P. Noel, and A. Iannelli have no conflicts of interest or financial ties to disclose. M. Gagner
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has honorarium for speaking engagements from Ethicon Endosurgery, Covidien, MID, Transenterix, and Gore. Appendix Supplementary data Supplementary data associated with this article can be found in the online version http://dx.doi.org/10.1016/j. soard.2015.02.009. References [1] Lazzati A, Guy-Lachuer R, Delaunay V, Szwarcensztein K, Azoulay D. Bariatric surgery trends in France: 2005-2011. Surg Obes Relat Dis 2014;10(2):328–34. [2] Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23(4):427–36. [3] Fezzi M, Kolotkin RL, Nedelcu M, et al. Improvement in quality of life after laparoscopic sleeve gastrectomy. Obes Surg 2011;21 (8):1161–7. [4] Freeman RA, Overs SE, Zarshenas N, Walton KL, Jorgensen JO. Food tolerance and diet quality following adjustable gastric banding, sleeve gastrectomy and Roux-en-Y gastric bypass. Obes Res Clin Pract 2014;8(2):e115–200. [5] Strain GW, Kolotkin RL, Dakin GF, et al. The effects of weight loss after bariatric surgery on health-related quality of life and depression. Nutr Diabetes 2014;4:e132. [6] Gagner M, Rogula T. Laparoscopic reoperative sleeve gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg 2003;13(4):649–54. [7] Baltasar A, Serra C, Pérez N, Bou R, Bengochea M. Re-sleeve gastrectomy. Obes Surg 2006;16(11):1535–8. [8] Dapri G, Cadière GB, Himpens J. Laparoscopic repeat sleeve gastrectomy versus duodenal switch after isolated sleeve gastrectomy for obesity. Surg Obes Relat Dis. 2011;7(1):38–43. [9] Iannelli A, Schneck AS, Noel P, Ben Amor I, Krawczykowski D, Gugenheim J. Re-sleeve gastrectomy for failed laparoscopic sleeve gastrectomy: a feasibility study. Obes Surg 2011;21(7):832–5. [10] Rebibo L, Fuks D, Verhaeghe P, Deguines JB, Dhahri A, Regimbeau JM. Repeat sleeve gastrectomy compared with primary sleeve gastrectomy: a single-center, matched case study. Obes Surg. 2012 Dec;22(12):1909–15. [11] Regan JP, Inabnet WB, Gagner M, Pomp A. Early experience with two-staged laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 2003;13(6):861–4. [12] Iannelli A, Schneck AS, Topart P, Carles M, Hébuterne X, Gugenheim J. Laparoscopic sleeve gastrectomy followed by duodenal switch in selected patients versus single-stage duodenal switch for superobesity: case-control study. Surg Obes Relat Dis 2013;9(4):531–8. [13] Gumbs AA, Pomp A, Gagner M. Revisional bariatric surgery for inadequate weight loss. Obes Surg 2007;17(9):1137–45. [14] Gagner M, Boza C. Laparoscopic duodenal switch for morbid obesity. Expert Rev Med Devices 2006;3(1):105–12. [15] Sánchez-Pernaute A, Rubio MÁ, Pérez Aguirre E, Barabash A, Cabrerizo L, Torres A. Single-anastomosis duodenoileal bypass with sleeve gastrectomy: metabolic improvement and weight loss in first 100 patients. Surg Obes Relat Dis 2013;9(5):731–5. [16] Noel P, Iannelli A, Sejor E, Schneck AS, Gugenheim J. Laparoscopic sleeve gastrectomy: how I do it. Surg Laparosc Endosc Percutan Tech 2013;23(1):e14–6. [17] Noel P, Nedelcu M, Nocca D. The revised sleeve gastrectomy, technical considerations. Surg Obes Relat Dis 2013;9(6):1029–32.
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