OBES SURG DOI 10.1007/s11695-013-0895-1 ORIGINAL CONTRIBUTIONS Laparoscopic Removal of Poor Outcome Gastric Banding with Concomitant Sleeve Gastrectomy Aayed R. Alqahtani & Mohamed Elahmedi & Hussam Alamri & Rafiuddin Mohammed & Fatima Darwish & Ali M. Ahmed # Springer Science+Business Media New York 2013 Abstract Background Laparoscopic adjustable gastric banding (LAGB) has a significant incidence of long-term failure, which may require an alternative revisional bariatric procedure to remediate. Unfortunately, there is few data pinpointing which specific revisional procedure most effectively addresses failed gastric banding. Recently, it has been observed that laparoscopic sleeve gastrectomy (LSG) is a promising primary bariatric procedure; however, its use as a revisional procedure has been limited. This study aims to evaluate the safety and efficacy of LSG performed concomitantly with removal of a poor-outcome LAGB. Methods A retrospective review was performed on patients who underwent LAGB removal with concomitant LSG at King Saud University in Saudi Arabia between September 2007 and April 2012. Patient body mass index (BMI), percentage of excess weight loss (%EWL), duration of operation, length of hospital stay, complications after LSG, and indications for revisional surgery were all reviewed and compared to those of patients who underwent LSG as a primary procedure. Results Fifty-six patients (70 % female) underwent conversion of LAGB to LSG concomitantly, and 128 (66 % female) patients underwent primary LSG surgery. The revisional and primary LSG patients had similar preoperative ages (mean age 33.5±10.7 vs. 33.6±9.0 years, respectively; p=0.43). However, revisional patients had a significantly lower BMI at the time of surgery (44.4±7.0 kg/m2 vs. 47.9±8.2; p<0.01). A. R. Alqahtani (*) : M. Elahmedi : H. Alamri : R. Mohammed : F. Darwish Department of Surgery, College of Medicine, King Saud University, PO Box: 84147, Riyadh 11671, Saudi Arabia e-mail: qahtani@yahoo.com A. M. Ahmed King Fahad Medical City, Riyadh, Saudi Arabia Absolute BMI postoperative reduction at 24 months was 14.33 points in the revision group and 18.98 points in the primary LSG group; similar %EWL was achieved by both groups at 24 months postoperatively (80.1 vs. 84.6 %). Complications appeared in two (5.5 %) revisional patients and in nine (7.0 %) primary LSG patients. No mortalities occurred in either group. Conclusions Conversion of LAGB by means of concomitant LSG is a safe and efficient procedure and achieves similar outcomes as primary LSG surgery alone. Keywords Gastric Banding . Revision . Concomitant Sleeve Gastrectomy . Obesity . Bariatric Introduction When laparoscopic adjustable gastric banding (LAGB) first gained popularity more than 10 years ago, the procedure demonstrated promising early results, with low perioperative morbidity and mortality [1]. Unfortunately, multiple studies have since shown significant long-term failure rates. Mittermair et al. reported 688 complications in 396 LAGB patients during 10 years of follow-up; out of a total 785 patients in this study, 251 (32 %) needed remedial surgery [2]. Poor 10-year outcomes after gastric banding in 186 super-obese (BMI ≥ 50 kg/m 2) patients have also been reported, where more than 50 % of those patients required band removal due to complications [3]. Additionally, LAGB-induced excess weight loss has been documented to be as low as 34 % after follow-up one and a half years later [4]. Several procedures have been investigated to determine the most effective revisional option to address failed gastric banding [5–10]. The literature provides some information about less complicated procedures such as simple band OBES SURG removal and rebanding [5] and more complex procedures including Roux-en-Y gastric bypass [6–8] and biliopancreatic diversion [9, 10]. However, review of these procedural alternatives suggests that the optimum method to address failed gastric banding remains unsettled. Laparoscopic sleeve gastrectomy (LSG) has gained popularity as a primary bariatric surgery procedure [11]. A recent systematic review of 123 published studies that included 12,129 patients who underwent sleeve gastrectomy showed mean percentage excess weight loss (%EWL) of 64.3 and 66.0 % after 2 and 3 years, respectively [12]. These results demonstrate the effectiveness of LSG as a primary bariatric procedure. The reoperation rate after primary sleeve gastrectomy in this review was 6.8 %, showing a major difference in the incidence of reoperation following LSG when compared to the incidence of reoperation after LAGB (32 %) [2]. More recently, LSG has been investigated as a revision procedure [4, 13–15]. However, the safety and efficacy of performing LSG at the time of gastric band removal has not been sufficiently examined and requires further study. Our successful experience with LSG as a primary procedure encouraged us to evaluate its efficacy as a reoperative solution for failed gastric banding, especially when performed concomitantly at the time of band removal [16]. Materials and Methods With an IRB approval, a retrospective review was performed on the demographic, clinical, surgical, and follow-up data from all patients who underwent LSG as a revision operation for failed LAGB between September 2007 and April 2012. These data were compared to data from a group of patients who underwent LSG as the primary procedure at the same institution; revisional and primary LSG procedures were both performed by a single surgeon. In addition, indications for revision, body mass index (BMI), %EWL, duration of surgery, length of hospital stay, and complications after LSG were also reviewed in each group. BMI and %EWL were assessed in both groups preoperatively and at 3, 6, 12, and 24 months postoperatively. Excess weight loss (EWL) was calculated corresponding to ideal body weight [EWL=initial weight loss − (height (m)2 × 25)]. Unless otherwise stated, all results are reported as mean±standard deviation. Surgical Technique Primary LSG was performed on the study subjects as previously described [16, 17]. For the revision, initial procedural steps were similar to those described in the LSG, followed by freeing of the anterior abdominal wall adhesions and separating the liver from the anterior gastric wall to the angle of His (Fig. 1). The total circumference of the band was exposed by releasing the gastro gastric tunnel covering the band using a hook or scissors. The band was then transected in the middle and removed. The fibrous ring around the upper part of the stomach at the site of the band was disrupted and complete mobilization of the fundus and the upper part of the stomach was achieved by releasing all fundal adhesions to the left diaphragm. The greater curvature of the stomach was freed from the greater omentum using LigaSure® (Covidien, Mansfield, MA, USA), dissecting proximally until the left crus and angle of His were reached, and distally towards the pylorus, sparing 2 cm of the antrum. Under guidance, a 36-F orogastric tube was then passed all the way to the duodenum through the pylorus, therefore securing its position and allowing for stapling along a clear, well-demarcated and fixed route. Through this maneuver, we also ensure accurate stapling at a desired, fixed, and reproducible distance from the pylorus. At 2 cm from the pylorus, the stomach was transected using Echelon-60 (Ethicon Endosurgery, Cincinnati, OH, USA) loaded with one green and then four to five gold cartridges (rarely green at the previous band fibrous ring). Occasionally, stomach oversewing is performed at the areas where it appeared thickened or inflamed. The excluded part of the stomach was extracted from the abdomen through the enlarged right-side 12-mm trocar site. The fascial defect at the enlarged 12-mm trocar site was then closed with an absorbable suture (EndoClose®, Covidien). No nasogastric tube or intra-abdominal drainage was utilized in these cases. Unless there is some indication of postoperative leak, contrast study is not routinely performed and is selectively indicated based on patient vital signs and clinical evaluation. Results Between September 2007 and April 2012, 56 (70 % female) patients underwent LAGB removal and concomitant LSG, and 128 (66 % female) patients underwent LSG as a primary operation. The preoperative age of revision and primary LSG patients was similar (mean 33.5 ± 10.7 years vs. 33.6 ± 9.0 years; p=0.43). The revision patients had a significantly lower BMI at the time of surgery (44.4±7.0 kg/m2 vs. 47.9± 8.2; p<0.01). The reasons for band removal and revision LSG indications included regained weight, unsatisfactory weight loss, port malfunction, tube leakage, band slippage, and gastric outlet obstruction (Table 1). The mean operative time for revision was significantly higher when compared to primary LSG (129±35 vs. 99± 31 min; p<0.01). The mean hospital stay after LAGB conversion to LSG was 2.6±0.9 days and 3.1 days after primary LSG (p-value 0.28). Absolute postoperative BMI reduction OBES SURG Fig. 1 Concomitant conversion of adjustable gastric banding to sleeve gastrectomy. a Exposed gastric banding, b transected band, c fibrous ring, d divided fibrous ring and mobilized fundus, e sleeve gastrectomy at 24 months was 14.33 points in the revision group and 18.98 points in the primary LSG group (Fig. 2). Mean %EWL was similar between revision and primary LSG patients at each follow-up visit (Fig. 3). After revision, %EWL at 3, 6, 12, and 24 months postoperatively were 30.5, 48.4, 66.4, and 80.1 %, respectively. After primary LSG, % EWL was 33.3, 53.9, 71.9, and 84.6 % respectively. The degree of excess weight loss was not found to be associated with the indication for revision (p-value=0.97). Follow-up rate for revision patients was 77, 63, 56, and 53 %. Complications observed throughout the 2-year follow-up period appeared in two (5.5 %) revision patients (one pneumonia and one wound infection). Complications were seen in nine (7.0 %) primary LSG patients, including one leak (reoperated), one pulmonary embolism, two staple line bleeds, two pneumonia, two significant nausea and vomiting, and one wound infection. There was no statistically significant difference between the two groups, all patients recovered uneventfully, and there were no mortalities in either group. Discussion LAGB remains one of the most widely performed bariatric procedures worldwide; however, long-term follow-up has 50 48.09 Primary LSG Revisional 45 Table 1 Laparoscopic adjustable gastric banding outcomes that led to revision 44.4 41.65 40 Weight regain Alone With band slippage Poor weight loss Alone With band slippage Port malfunction Tube leakage Band slippage alone Band slippage with gastric outlet obstruction Total (N=56) 39.21 BMI Reasons for band revision 23 11 35 36.41 35.83 31.84 30.07 30 31.83 29.11 9 8 2 1 1 1 25 20 Baseline 3Months 6Months 12Months 24Months Follow Up Fig. 2 Mean absolute BMI loss in revisional patients compared to primary LSG patients during their follow-up periods OBES SURG 90 84.60 80 80.13 71.87 %EWL 70 66.42 60 53.91 50 Primary LSG 48.37 40 Revisional 33.31 30 30.48 20 3Months 6Months 12Months 24Months Follow Up Fig. 3 Mean % excess weight loss in Revisional patients compared to Primary LSG patients during their follow-up periods demonstrated significant failures [2–4, 18]. In those instances where continued use of gastric banding becomes untenable, controversy exists regarding which revisional bariatric procedure is most efficacious to address failed LAGB. Results of simple refixation or rebanding have been reported in several studies, with complication rates ranging from 0 to 41 % [19], and additional reoperation for all possible indications have been reported in up to 45 % of patients [6]. In one study, 10 % of patients developed a second band slippage requiring reoperation [20], while another study showed second band erosion in 17 % of patients [21]. A review of 193 patients in four cohort studies who underwent rebanding showed no BMI change after 12 months [10]. In fact, weight gain after band revision has even been reported [6]. Conversion to RYGB has been associated with high complication rates approaching 40 % [22], with the need for reoperation reaching 20 % [6, 19]. Subsequent patient follow-up revealed BMI loss ranges from 6.1 [6] to 13.2 points [23]. Interestingly enough, weight loss following revisional LRYGB was significantly less than that following primary LRYGB (71.6 vs. 48.4 %) [24]. Our review showed promising weight loss results after both revisional and primary LSG (80.1 vs. 84.6 %). A recent study comparing revisional and primary LRYGB reported a 15 % complication rate for both procedures, whereas the complication rate in our patients were 5.5 % in revisional patients and 7.0 % in the primary LSG patients. Moreover, a recent study conducted on 72 patients with revisional RYGB postgastric banding reported an early complication incidence rate of 11 %, along with late complications occurring in 19.44 % of patients after conversion to RYGB [25]. In those studies where failed LAGB was resolved by conversion to biliopancreatic diversion (BPD) and duodenal switch (DS) [9, 10], the %EWL was reported to be between 44 % [26, 27] and 71.1 % after 12 to 28 months [19, 28], compared to 66.4 and 80.1 % EWL in our revision patients after 12- and 24month follow-ups. Moreover, revisional BPD/DS was followed by significant complications, severe nutritional deficiencies, and failure in 6 to 62 % of patients [19]. Evidence regarding LSG as a reoperative solution is limited to small case series. In the studies available, complication rate Table 2 Previous studies on laparoscopic sleeve gastrectomy as a revision procedure Author Yea Patients of LAGB or VG conversion to LSG (n) Concomitant conversion to LSG (n) Acholonu E Lalor PF Tucker O Iannelli A Frezza E Uglioni B Dapri G Jacobs M Goitein D 2008 2008 2008 2009 2009 2009 2009 2010 2010 15 16 10 41 10 29 27 32 46 13 0 0 Berende CA Current study Total 2011 2012 28 56 310 % EWL/EBL after conversion to LSG Mean operative time (min) 0 32 26 22.3 EBL – – 42.7 EWL 55 EWL 60 EBL 34.8 EWL 60 EWL 48 EWL 120 (85–180) – – 117 ( 90–165) 87 132 (90–240) – – 118 (70–250) 15 56 142 49.3 EWL 80.1 EWL 50.2 99 (54–221) 129.9 (60–213) 133.8 a b b Follow-up period (months) 24 T 45.7 M 13.4 M 24 M 18.6 M 26 T 36 T 13.8 M 24 T Complications after conversion to LSG (n ) Bleeding Leakage Others – – – – – – 1 1 – 1 – 1 1 – – 4 – 6 1 1 – 2 – – 4 – 5 – 30 – 2 LABG laparoscopic adjustable gastric banding, VG vertical gastric banding, LSG laparoscopic sleeve gastrectomy, EBL excess BMI loss, EWL excess weight loss, T total follow-up period, M mean follow-up period a LSG conversion performed as a two-stage procedure b Time of band removal before LSG conversion was not stated OBES SURG ranged from 0 to 33 %, and excess weight loss ranged between 34 and 60 % (Table 2). Undergoing the LSG procedure helped to resolve or improve co-morbidities present in patients after failed LAGB by 32 and 28 %, respectively [29]. In addition, no mortality has been reported. However, few studies have evaluated the safety and efficacy of performing sleeve gastrectomy simultaneous with removal. In this experience, using LSG as a revisional procedure, patients achieved excess weight loss similar to that observed with primary LSG and better than what was reported with reoperative gastric bypass [30]. Percentage excess weight loss at 24-month follow-up (80.1 %) observed in this study has even exceeded %EWL of patients undergoing SG as a primary surgery in previous studies (46.1 to 75.0 %) [12], suggesting that the surgical technique may play a part in the degree of weight lost. Indications for LAGB revision reported in the literature are not different than those that led to the revision in our study, with weight loss issues and band slippage being the most common indications [18]. No patients in our series had symptoms of esophageal dysmotility or dysphagia as complaints that significantly interfered with the quality of life or were the sole indication for surgery. The similar weight loss in the revision group when compared to those with primary LSG is of great clinical and scientific importance. The overall 2-year %EWL attained by revision patients exceeded 80 % and was similar to the 85 % attained by primary LSG patients. The weight loss slopes are also strikingly similar, confirming that revision and primary LSG behave identically. Concomitant conversion of LAGB to LSG has demonstrated effective results concerning BMI loss and lower complication rates when compared to other procedures. One study had detected leakage in two patients (7.6 %) undergoing concomitant conversion to LSG, eventually resulting in a negative swallow study [14], and another revealed a 33 % incidence of leak [29]. Berende and colleagues also reported bleeding in 20 % of concomitant conversions. However, our revisional LSG group had shown no leak, bleeding, or any other significant complication. Taken together, these results suggest that sleeve gastrectomy at the time of gastric band removal is both a safe and effective procedure. Conclusion LSG as a revisional procedure after LAGB has been shown to be safe, with a minimal complication rate, when compared to other revisional procedures as well as when compared to primary LSG. Furthermore, the efficacy of LSG as a reoperative procedure has been shown in the current study with a similar %EWL as primary LSG. Additionally, LSG can be safely performed at the time of band removal. Acknowledgments The authors extend their appreciation to the Deanship of Scientific Research at King Saud University for funding this work through research group no RGP-VPP-186. The authors also acknowledge the contribution from the Shaikh Ali Alshehri Obesity Chair and Chair team members Ms. Nesma Mustafa, Layla Alfarra, Mounira AlSaleh, and Manal Medhat. They also thank the participants who took part in the study. Disclosures Aayed R. Alqahtani, Mohamed Elahmedi, Hussam Alamri, Rafiuddin Mohammed, Fatima Darwish, and Ali M. Ahmed have no conflicts of interest or financial ties to disclose. References 1. O’Brien PE, Dixon JB, Laurie C, et al. Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program: A randomized trial. Ann Intern Med. 2006;144:625–33. 2. Mittermair RP, Obermüller S, Perathoner A, et al. Results and complications after Swedish adjustable gastric banding—10 years experience. Obes Surg. 2009;19:1636–41. 3. 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