OBES SURG DOI 10.1007/s11695-014-1332-9
Revisional Bariatric Surgery Following Failed Primary Laparoscopic Sleeve Gastrectomy: A Systematic Review Douglas Cheung & Noah J. Switzer & Richdeep S. Gill & Xinzhe Shi & Shahzeer Karmali
# Springer Science+Business Media New York 2014
Abstract Revisional bariatric surgery following laparoscopic sleeve gastrectomy (LSG) failure presents a clinical challenge for the bariatric surgeon. Limited evidence exists in selecting the appropriate revisional operation: laparoscopic gastric bypass (LGB), laparoscopic re-sleeve gastrectomy (LRSG), or other surgical intervention (OSI), to address weight regain. We systematically reviewed the literature to assess the efficacy of existing revisional surgery. A comprehensive search of electronic databases (e.g., Medline, Embase, Scopus, Web of Science, and the Cochrane Library) was completed. All randomized controlled trials, non-randomized comparison study, and case series were included. Eleven primary studies (218 patients) were identified and included in the systematic review. Studies were grouped into three main categories: LGB, LRSG, and OSI. Preoperative body mass index (BMI) was 41.9 kg/m2 (LGB), 38.5 kg/m2 (LRSG), and 44.4 kg/m2 (OSI). After conversion to LGB, BMI decreased to 33.7 and 35.7 kg/m2 at 12 and 24 months of follow-up, respectively. Excess weight loss (EWL) was 60 and 48 % over the same periods. After LRSG, BMI decreased to 30.4 and 35.3 kg/m2 with corresponding EWL of 68 and 44 %, at 12 and 24 months, respectively. After OSI, BMI decreased to 27.3 kg/m2 with an EWL of 75 % at 24-month follow-up Douglas Cheung and Noah J. Switzer are co-first authors. D. Cheung Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada N. J. Switzer : R. S. Gill : S. Karmali Department of Surgery, University of Alberta, Edmonton, Alberta, Canada X. Shi : S. Karmali (*) Center for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandria Hospital, 10240 Kingsway, Edmonton, Alberta T5H 3V9, Canada e-mail: [email protected]
but could not be analyzed due to incomplete data collection in primary studies. Both LGB and LRSG achieve effective weight loss following failed LSG. The less technically challenging nature of LRSG may be more widely applicable. Further research is required to elicit sustainability in longterm weight loss benefits. Keywords Sleeve gastrectomy . Weight regain . Weight recidivism . Revisional surgery . Failure bariatric surgery
Introduction Morbid obesity, as defined as individuals with a body mass index (BMI)≥40 or BMI≥35 with obesity-related complications, is an increasingly significant cause of global morbidity and mortality [1, 2]. While pharmacological, dietary, and lifestyle management options remain the mainstay of treatment for less severe cases, bariatric surgery has been proven to be effective in the management of morbid obesity and its complications [3, 4]. Laparoscopic sleeve gastrectomy (LSG) has become increasingly popular as a primary bariatric procedure over the last 15 years due to its simplicity, relative safety, and efficacy in weight loss while leaving patients with an intact gastrointestinal (GI) tract [5–9]. Despite good success rates, LSG procedures may inevitably fail, as defined by insufficient weight loss, weight regain, surgical complication, and poor comorbidity control, such as gastroesophageal reflux disease (GERD) [10, 11]. Failure is usually multifactorial involving poor adherence to prescribed lifestyle modifications, procedural failure, and operator error [12–14]. Increasingly, as the prevalence of LSG rises, the need for robust options in revisional therapy after failure also becomes progressively more important. Revisional bariatric procedures are technically challenging due to tissue fibrosis and altered anatomy following the primary procedure [15, 16].
The result is a higher complication rate, ranging between 0 and 46.3 % [17–19]. Moreover, there is only limited or experiential data available for sleeve gastrectomy procedures . Long-term data is needed to support and evaluate the alternatives for subsequent revisional therapy following LSG. The currently accepted options for those LSG patients who require revisional therapy after failure are as follows: laparoscopic re-sleeve gastrectomy (LRSG), conversion to the “gold standard” bariatric procedure—laparoscopic Roux-en-Y gastric bypass (LRYGB) or omega loop mini gastric bypass (LMGB), or conversion to a lesser performed procedure including biliopancreatic diversion and duodenal switch (BPDDS), and butterfly gastroplasty (LBG) [21–23]. We therefore aimed to evaluate the efficacy of different revisional surgical procedures by systematically reviewing the literature for revisional surgery following a failed primary LSG procedure.
Methods A comprehensive search of electronic databases (e.g., Medline, Embase, Scopus, Web of Science, and the Cochrane Library) using search terms “_Laparoscopic Sleeve Gastrectomy, AND failed or failure or reoperation* or redo* or revise or revision* or repeat” was completed, and conference abstracts were also searched. All randomized controlled trials, non-randomized comparison study, and case series were included. All human studies limited to English were included. The reference list of included studies was also checked to identify missing studies in the primary search. Two independently reviewers (D.C. and N.S) screened abstracts, reviewed full text versions of all studies classified, and extracted data. All comparison studies included in the systematic review were assessed independently by two reviewers (D.C. and N.S) for methodological quality using the Cochrane risk of bias (RoB) tools. Disagreements were resolved by re-extraction or third party adjudication. Assessment of Study Eligibility We systematically reviewed each study according to the following criteria: (1) There were no study format restrictions for the systematic review due to the limited evidence available; (2) LSG was the primary bariatric surgery; (3) patients had “failed” the primary LSG, defined as significant weight regain; (4) LSG was not the primary of a planned two-part staged procedure; (5) the study reported follow-up data on BMI and/or excess weight loss (EWL); (6) follow-up time was at least 6 months; (7) the study enrolled at least five patients; and (8) if any disparity existed between the conference proceedings and a later published article, the initial presented results were used .
Outcomes of Interest The primary outcomes of interest were BMI (kg/m2) and EWL (%) at 3, 6, 12 18, and 24 months. Secondary outcomes included symptomatic GERD resolution and demographic data for age, sex, and study location. Because of the heterogeneity of the data, a meta-analysis could not be run.
Results A total of 660 studies were identified using our search criteria for screening (Fig. 1). Of 120 studies screened on their titles and abstracts after an assessment according to our eligibility criteria, 97 did not meet the basic data requirements on revisional surgery following failed LSG and were excluded. Of 23 remaining for review, 12 were excluded based on insufficient primary outcomes and follow-up. Thus, a total of 11 primary studies (218 patients) were identified that met our inclusion criteria for the systematic review and were assessed by full manuscript. These included one controlled study and ten case series [24–34]. No randomized controlled trial was included. Studies were grouped into three categories: (1) LSG to laparoscopic gastric bypass (LGB), (2) LSG to LRSG, and (3) other surgical intervention (OSI), including LSG to one of BPDDS or LBG. The LGB group included both LRYGB and LMGB procedures. In total, 114 patients underwent revision from LSG to LGB, 45 underwent LRSG, and 59 underwent OSI. Baseline characteristics were organized by article (Table 1) and in aggregate (Table 2). Patient demographics across the three groups were similar with a weighted mean age of 45.3, 43.9, and 36.9 years and percentage of women of 61, 83, and 84 % for the LGB, LRSG, and other surgical management, respectively. Weighted mean preoperative BMI was 41.9 kg/m2 in the LGB group, 38.5 kg/m2 in the LRSG group, and 44.4 kg/m2 for the OSI group. After conversion to LGB, BMI decreased gradually to 38.9 kg/m2 at 3 months and less, 36.5 kg/m2 at 6 months, 33.7 kg/m2 at 12 months, 36.1 kg/m2 at 18 months, and 35.7 kg/m2 at 24 months and greater of follow-up (Fig. 2). Percentage of EWL was 27, 37, 60, 58, and 48 % over the same periods (Fig. 3). After LRSG, BMI decreased to 35.1 kg/ m2 at 3 months and less, 34.0 kg/m2 at 6 months, 30.4 kg/m2 at 12 months, and 35.3 kg/m2 at 24 months and greater, with a corresponding EWL of 50, 48, 68, and 44 % over the same periods of follow-up, respectively (Figs. 2 and 3). There appeared to be no difference in BMI and EWL outcomes between LGB and LRSG after 24 months. After OSI, due to incomplete data collection at the specific time points of analysis, BMI decreased to 27.3 kg/m2 with an EWL of 75 % at
Fig. 1 Systematic review inclusion criterion
24 months and greater follow-up. These findings are summarized in Table 3. Symptomatic GERD resolution was also assessed as a secondary outcome and reported in three studies. Complete resolution was achieved in all cases (n=15). These findings are summarized in Table 4.
Discussion After failure of a primary laparoscopic sleeve gastrectomy, numerous revisional surgical options exist for bariatric surgeons . Our study is the first to date to systematically review the literature to determine which technique is the most efficacious for weight loss following failed LSG. The results of our systematic review support that both LGB and LRSG are viable options for revisional surgery. There does not appear to be a significant difference in efficacy (defined as the BMI and EWL outcomes) between LGB and LRSG at 24 months and greater of follow-up. Although it seems that there was a notably larger initial drop in both BMI and EWL for LRSG versus LGB (68 vs 60 %, respectively) at 3 months, this equalized by the full 24-month follow-up interval (44 vs 48 %, respectively). Final mean weighted BMI across both groups were similar at 35.3 kg/m2 for the
LRSG and 35.7 kg/m2 for the LGB. While both groups offer very similar results, we speculate that LRSG may be a more feasible option in practice since it is less technically challenging . Other surgical interventions, mainly BPDDS and LBG, displayed a promising trend toward increased weight loss following revision that was greater than that of both LRSG and LGB (75 % at 24 months, BMI 27.3 kg/m2). However, due to a paucity of follow-up, it is unclear whether this will be sustained or replicable by other institutions. Further research with long-term follow-up is necessary to determine whether this represents a significant increase over other surgical management. Sleeve gastrectomy was originally conceived as the first stage of a planned two-part staged procedure prior to a duodenal switch, ultimately making BPDDS a seemingly natural candidate for revisional therapy following failed LSG [36, 37]. However, in our systematic review, the majority of primary articles studying LSG to BPDDS were excluded as conversion to BPDDS was premeditated and planned, rather than being a true “revisional” procedure for failure. Despite this, primary studies have shown that a staged two-step operation with BPDDS leads to successful patient outcomes and excellent weight loss [38, 39]. As conversion to BPDDS does not require manipulation of the stomach, it has the advantage of a decreased gastric leak rate and overall, does not confer additive risk to the patient with respect to postoperative complications rates compared to a primary BPDDS procedure . BPDDS has been also well described as an effective revisional procedure following other failed bariatric surgeries (RYGB, gastric banding) with stable and significant weight loss outcomes [41–43]. Notably though, this remains a complex procedure and may require higher maintenance postoperatively for the patient and the surgical team due to significant complication rates [44, 45]. Further studies will be needed to elicit the long-term weight loss outcomes and complication rates following failed LSG to BPDDS conversion. An important observation uncovered by this review was that weight loss following revisional surgery was at its highest absolute number, corresponding to the troughs shown in Figs. 2 and 3, at the 1-year mark, and there was a consistent weight regain trend following that time period. Langer et al. addressed this issue by reporting that “weight regainer” patients after SG might be more susceptible to be “weight regainers” following conversion . If poor dietary and lifestyle regimens have not been addressed by a multidisciplinary team following failure of the primary operation, then the revisional surgery will be at increased risk to fail as well . Other risk factors that need to be reviewed by the surgical team prior to any intervention consist of psychological factors, including psychiatric comorbidities, and lack of patient compliance with follow-up [47, 48].
OBES SURG Table 1 Study details and patient demographics by article Author
Sample Sex Age Pre-op size (n) (M/F) (years) BMI (kg/ m2)
Definition of failure
AbdelGalil et al.b Chevallier et al.
Jan. 2010 to Jan2013
Laparoscopic butterfly gastroplasty
Weight loss 50 %
Oct. 2006 to France Dec. 2012
Insufficient weight loss or weight regain
Dapri et al.a Dapri et al.a Gautier et al.a Iannelli et al.
Nov. 2003 to Dec. 2009 Nov. 2003 to Dec. 2009 Oct. 2006 to Jul. 2011 Oct. 2005 to Apr. 2010
Retrospective 15 case series Case series 13
Laparoscopic omega loop mini gastric bypass Laparoscopic re-sleeve gastrectomy Laparoscopic duodenal switch Laparoscopic Roux-en-Y gastric bypass Laparoscopic re-sleeve gastrectomy
Langer Dec. 2003 to Austria et al.a Sep. 2009 Poland Lech et al.b N/A
Retrospective 8 case series Case series 10
Nienhuijs et al.b
Netherlands Prospective 29 case series
Rebibo et al.
Jun. 2007 to Jan. 2011
Retrospective 15 case series
van Rutte et al.
Aug. 2006 to Netherlands Prospective 18 Jul. 2011 case series
Wadhawan N/A et al.b
Indicates that the study reported outcomes for multiple procedures
Only abstract was available; no article available or pending publication
Currently, most decisions to pursue revisional bariatric surgery are based on the comfort and preference of individual surgeons and centers, rather than clear evidence . LSG has historically been part of a two-step procedure (initial LSG followed by conversion to BPDDS or LRYGB) . A recent survey of 88 bariatric surgeons (average of 295 operations/ surgeon with 2–8-year experience with LSG) reported that the majority preferred conversion to BPDDS if failure was Table 2 Patient demographics by revisional procedure
Hyperphagia (volume eating) Polyphagia (too many meals) Insufficient weight loss, GERD Excess weight loss