Revisional Bariatric Surgery

Avens Publishing Group t ing Innova t ions JInvi Obes Bariatrics June 2015 Volume 2, Issue 2 © All rights are reserved by Bairdain et al. Case Report Open Access Journal Av of In Revisional Bariatric Surgery Obesity and Bariatrics Ke ywords: Re visio na l b a ria tric surg e ry; Exc e ss b o d y we ig ht lo ss; C o mo rb id c o nd itio ns Abstra c t Ba c kg round : To e luc id a te p e rc e nt e xc e ss b o d y we ig ht lo ss (%EBWL) g a ine d fro m re visio na l surg e ry a nd to d e te rmine re so lutio n o f c o mo rb id c o nd itio ns g ive n the o b e sity e p id e mic . Me thods: All p a tie nts und e rg o ing re visio na l b a ria tric surg e ry fro m 2002 to 2012 we re a na lyze d . Ma in o utc o me me a sure s we re %EBWL, re so lutio n o f c o mo rb id c o nd itio ns a nd c o mp lic a tio ns. De sc rip tive sta tistic s a nd p a ire d t-te sts we re c o mp ute d . Re sults: 251 c a se s we re p e rfo rme d . Initia l me a n b o d y ma ss ind e x wa s 48.1 kg / m 2 (+/ - 9.4). Hyp e rte nsio n (32%) a nd tre a tme nt fa ilure (37.5%) we re mo st c o mmo nly re p o rte d . Me a n p e rc e nta g e d iffe re nc e b e twe e n re o p e ra tio n a nd la st we ig ht a nd o rig ina l a nd re o p e ra tio n we ig ht wa s 27.9% (29.5%), p <0.001. Pro p o rtio ns o f a ll c o mo rb id c o nd itio ns d e c re a se d , b ut no ne sta tistic a lly. No d e a ths o c c urre d , ho we ve r 22% e xp e rie nc e d a t le a st o ne c o mp lic a tio n. Conc lusions: G re a te r %EBWL o c c urs b e twe e n re visio n surg e ry a nd la st fo llo w-up . No c o mo rb id c o nd itio n d e c re a se d . Furthe r re se a rc h is ne e d e d to d e te rmine the o p tima l timing fo r re visio na l surg e ry to o p timize %EBWL a nd re so lutio n o f c o mo rb id c o nd itio n. Background Obesity and its associated co-morbid complications continue to increase. Severe morbid obesity is a pandemic that afects both adults and adolescents in which surgery has proven to be the only efective means to provide for long-term weight loss and apparent resolution of comorbid conditions as compared to medical management [1-4]. As acceptance of bariatric surgical interventions has increased, the numbers of both primary and revisional surgical interventions have also increased. For example, according to the American Society of Metabolic and Bariatric Surgery (ASMBS), the number of primary bariatric procedures has increased from approximately 13,000 procedures in 1998 to 220, 000 procedures in 2008 respectively [5]. Revisional bariatric surgery entails knowledge of the primary surgical intervention, as well as expertise with regards to non-virginal operative ields. Herein, we aimed compare the percent excess body weight loss (%EBWL) and body mass index (BMI) between each bariatric procedure, as well between primary, revisional procedure, and inal outcome measures. Secondary aims included identifying whether there was a particular bariatric operation that predicted a higher resolution of comorbid conditions and predicted less associated complications. Methods Following institutional board approval, data from a retrospective case review of all patients undergoing revisional bariatric surgical interventions, excluding port revisions of laparoscopic gastric banding procedures (LAGB), at one academic medical center were analyzed from a prospective, longitudinal database. Information from 2002 to 2012 was collected. Demographic, clinical, co-morbid conditions and complications were compared between revisional groups. Weight loss was expressed as percent excess body weight loss (%EBWL), deined as the diference between initial weight and Sigrid Bairdain1*, Mark Cleary2, Heather J. Litman3, Bradley C. Linden4 and David B. Lautz5 1 Department of Surgery, Boston Children’s Hospital, Boston, MA, USA 2 Department of Surgery, Brigham and Women’s Hospital, Boston, MA, USA 3 Clinical Research Center, Boston Children’s Hospital, Boston, MA, USA 4 Pediatric Surgical Associates, Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN, USA 5 Department of Surgery, Emerson Hospital-Harvard Medical School, Concord, MA, USA *Address for Correspondence Sigrid Bairdain, MD, MPH, Surgical Research Fellow, Department of Surgery, Boston Children’s Hospital, 300 Longwood Avenue, Fegan Building, 3rd Floor, Boston, MA 02115, USA, E-mail: Sigrid.bairdain@childrens.harvard.edu Submission: 15 May 2015 Accepted: 15 June 2015 Published: 20 June 2015 Reviewed & Approved by: Dr. Francesco Saverio Papadia, Assistant Professor of Surgery, University of Genoa School of Medicine, Italy Dr. Radwan Kassir, Department of General and Bariatric surgery, University Hospital Center of Saint-Étienne, France current weight, divided by the diference of the initial weight and ideal weight. he ideal body weight and was calculated from the 1983 Metropolitan Life Insurance Company tables [6]. Percent EBWL was calculated at each revision and last clinic visit. he main outcome measure was %EBWL. Secondary outcome measures included resolution of comorbid conditions and associated complications. For the purposes of this study, patients were grouped into 4 revision types: 1) conversion from one bariatric surgical procedure to another; 2) revision of a previous operation with no conversion; 3) reversal and 4) exploration. Conversion surgeries included: GP-to Laparoscopic Roux-en-Y Gastric Bypass (LRYGB), Jejunoileal Bypass (JIB) to LRYGB, Laparoscopic Adjustable Gastric Banding (LAGB) to LRYGB, LAGB to Laparoscopic Sleeve Gastrectomy (LSG), and Vertical Banded Gastroplasty (VBG) to LRYGB. Revisional surgeries included: open revision bypass, open revision jejunojejunal (JJ), laparoscopic revision JJ, and laparoscopic revision bypass. Reversal surgeries included: open reversal RYGB, laparoscopic reversal RYGB, reversal VBG, and open Entero Cutaneous-Fistula (ECF) takedown. Overall indications for revision were divided into the following categories: 1) pain; 2) obstruction; 3) failure to thrive; 4) development of an enterocutaneous istula; 5) treatment failure; 6) gastrointestinal issues primarily related to gastroesophageal relux and ulcers and 7) medically or nutritional-related issues. All patients met the criteria for bariatric surgery established by the National Institutes of Health Consensus Development Panel with patients having a body mass index (BMI) of >40 kg/m2, or >35 kg/ m2 in the presence of obesity related comorbidities. All had failed to maintain weight loss by non-surgical means. All patients were Citation: Bairdain S, Cleary M, Litman HJ, Linden BC, Lautz DB. Revisional Bariatric Surgery. J Obes Bariatrics. 2015;2(2): 5. Citation: Bairdain S, Cleary M, Litman HJ, Linden BC, Lautz DB. Revisional Bariatric Surgery. J Obes Bariatrics. 2015;2(2): 5. ISSN: 2377-9284 required to attend a public information session given by one of the surgeons and be assessed by both a clinical psychiatrist and dietician. Preoperative investigations were guided by the patient history and type of surgery. Routine investigations included an upper gastrointestinal barium study for all patients. he decision for each particular revisional surgical intervention was made by the patient ater an extensive period of counseling and education. Revisional bariatric patients were recovered in a surgical ward by staf experienced in management of postoperative bariatric patients. All patients were reviewed in outpatient clinic at 2 weeks, as well as regularly assessed for vitamin and mineral deiciencies and treated accordingly. Descriptive statistics for continuous and categorical variables were presented, as appropriate. Paired t-tests were computed to assess outcome measure diferences between original and last follow-up. Results From 2002-2012, a total of 251 revisional bariatric operations were performed, 28% of which underwent more than one subsequent operation. Baseline demographic data was included in Table 1. Eighty-ive percent (n=213) were female. Mean age at the time of the original operation was 39 years (+/- 12 years) (Table 1). he most common (51%) original operation was a Laparoscopic Roux-En-Y Gastric Bypass (RYGB). he most common indication for revision of the primary surgical procedure was treatment failure/failure to lose weight (n=94, 37.5%); other etiologies found independently or concurrently included istulas (n=84, 33.5%) and previous technical complications (n=31, 12.4%). Of note, the majority of istulas (gastrogastric istulas) were identiied concurrently during the revision for treatment failure/failure to lose weight (Table 1). Approximately 6.5% (n=97/251) were considered conversion surgeries, 55% (n=139/251) were considered revisional surgeries, 2.7% (n=7/251) were considered reversal surgeries and 1.5% (n=4/251) were considered exploratory surgeries (Table 2A). Ninety percent (n=226) of the operations were performed laparoscopically. At the time of the original operation, mean body mass index (BMI) was 48.1 kg/m2 (+/- 9.4) and decreased on average to 40.4 kg/m2 (+/10.4) prior to the irst re-operative surgery and 34.0 kg/m2 (+/- 8.8) at the last hospital visit (Table 2B). he mean diference, in pounds (lbs), between pre-reoperation and original was 7.7 lbs. (s.d. 8.4 lbs, p<0.001, paired t-test) and between last clinic visit and original operation was 14.1 lbs (s.d. 7.3 lbs, p <0.001, paired t-test). he mean percentage diference between reoperation and last weight (%EBWL) and original and reoperation weight (%EBWL) was 27.9% (29.5%, p <0.001, paired t-test). he most common comorbid conditions were hypertension (32%), obstructive sleep apnea (21%), asthma (19%) and diabetes (18%) (Table 1). here was a decrease in the proportions of all comorbid conditions between the original and last visit, but none reached statistical signiicance. At the original operation, 41/224 (18.3%) had Diabetes Mellitus (DM). At irst revision, 41/249 (16.5%) had DM, whereas, at last visit, 24/236 (10.2%) had DM. he procedure with the largest proportional change of DM was the laparoscopic conversion of the laparoscopic-adjusted gastric banding (LAGB surgery) to Roux-En-Y Gastric Bypass (RYGB); however, this diference did not reach statistical signiicance (p=0.47) (Table 3). J Obes Bariatrics 2(2): 5 (2015) Table 1: Preliminary descriptive information regarding the dataset (n=251). Characteristic N (%) or Mean (standard deviation) Gender (female) 213 (84.9%) Age at original surgery 39.2 (11.7) Original surgery type VBG 9 (3.6%) LAGB 88 (35.1%) LRYGB 128 (51.0%) Open RYGB 22 (8.8%) Other 4 (1.5%) Original weight 291.3 (66.4) Original height 65.2 (3.6) Original Body Mass Index (BMI) 48.1 (9.4) Ideal Body Weight (IBW) 135.6 (12.3) DM 41 (18.3%) HTN 72 (31.9%) OSA 48 (21.4%) Asthma 42 (18.9%) Age at second operation 45.1 (10.7) Weight at reoperation 245.4 (71.9) Body Mass Index (BMI) at reoperation 40.4 (10.4) %EBWL 30.4 (33.7) DM at second operation 41 (16.5%) HTN at second operation 81 (32.5%) OSA at second operation 56 (22.5%) ASH at second operation 40 (16.1%) Indication for Revision Pain 14 (5.6%) Obstruction or Technical 31 (12.4%) Failure to thrive 3 (1.2%) Fistula 84 (33.5%) Treatment Failure 94 (37.5%) Gastrointestinal issues 6 (2.4%) Medical protracted issues 19 (7.6%) Perioperative complications 54 (21.5%) DM at third operation 24 (10.2%) HTN at third operation 47 (19.9%) OSA at third operation 29 (12.2%) Surgical time (minutes) 234 (90) Length of stay Median (IQR): 3 (2,5) Length of follow-up (mos.) Median (IQR): 11 (5, 27) Last weight 206.4 (59.9) Last Body Mass Index (BMI) 34.0 (8.8) Last %EBWL 58.3 (32.2) Estimated blood loss* 155.7 (29.0) *Median (IQR): 0 (0,300); VBG: Vertical Banding; LAGB: Laparoscopic Gastric Banding; LRYGB: Laparoscopic Roux-En-Y Gastric Bypass; Open RYGB: Open Roux-en-Y Gastric Bypass; DM: Diabetes; Mellitus; HTN: Hypertension; OSA: Obstructive Sleep Apnea; %EBWL: Percent Excess Body weight loss Page - 02 Citation: Bairdain S, Cleary M, Litman HJ, Linden BC, Lautz DB. Revisional Bariatric Surgery. J Obes Bariatrics. 2015;2(2): 5. ISSN: 2377-9284 Table 2A: Indications and procedures performed for bariatric cohort. Original Surgery Number (#) Procedure Revised To VBG 9 LRYGB Conversion LAGB 8 LSG Conversion LAGB 80 LRYGB Conversion LRYGB 25 RYGB LRYGB Open RYGB 83 22 LRYGB LRYGB 9 LRYGB LRYGB 7 Native anatomy LRYGB 4 LRYGB Pertinent Operative Characteristics (if Applicable) How it Was Coded Open Revision of the Pouch (n=21) Open Revision of GJ (n=3) Open Revision of JJ (n=1) Remant Gastrectomy in 11 patients (44%) Main Indication for Revision Treatment Failure Treatment Failure Treatment Failure Revision Treatment Failure Revision Treatment Failure Revision Pain Laparoscopic Reversal Reversal Protracted Medical Issues Laparoscopic lysis of adhesions Exploration Laparoscopic Revision of Gastric Pouch Remnant Gastrectomy in 51 patients (50%) Laparoscopic Revision of the J-J anastomosis Pain BMI: Body Mass Index; VBG: Vertical Banding; LAGB: Laparoscopic Gastric Banding; LSG: Laparoscopic Sleeve; LRYGB: Laparoscopic Roux-en-Y gastric Bypass; Open RYGB: Open Roux-en-Y Gastric Bypass Table 2B: BMI changes over time and per operative intervention. Mean (standard deviation) Operations N Between original and prereoperation Between pre-reoperation and last Between original and last VBG 9 4.4 (5.9) 10.5 (6.2) 14.9 (4.3) LAGB 88 2.9 (4.5) 8.5 (5.0) 11.4 (5.6) LRYGB 128 10.6 (9.0) 4.6 (6.7) 15.2 (8.3) Open RYGB 22 11.0 (7.2) 5.9 (6.3) 16.9 (4.2) Other 4 2.9 (7.9) 7.8 (9.9) 10.8 (1.9) BMI: Body mass Index; VBG: Vertical Banding; LAGB: Laparoscopic Gastric Banding; LRYGB: Laparoscopic Roux-en-Y Gastric Bypass; Open RYGB: Open Rouxen-Y Gastric Bypass Regarding hypertension, 72/226 (31.9%) reported it originally, 81/249 (32.5%) had it at irst revision and 47/236 (19.9%) at the inal visit. Comparing those who had hypertension at last follow-up to the others, the percentages are quite similar between the various operations (p=0.68). Regarding OSA, 48/224 (21.4%) reported it originally, 56/249 (22.5%) had it at irst revision and 29/237 (12.2%) had it a last visit. Of those with improved OSA status, LAGB has a slightly higher proportion that those with no change in OSA status (p=0.26). Regarding asthma, 42/224 (18.8%) reported it originally, 40/249 (16.1%) had it at irst revision and 22/237 (9.3%) had it a last visit. Among those with improved asthma status, most either had LAGB or LRYGB surgeries and this was similar to those without improved asthma status (p=0.73) (Table 3). Median intraoperative time was 234 minutes and median length of hospital stay was 3 days (range 2-5 days) (Table 1). Overall, there were 21.5% of cases that had perioperative complications (54/251); however, no deaths occurred. he distributions with and without complications difer according to surgery type (Fisher’s exact test, p<0.001). Among those who had complications, the highest proportion of complications occurred within LRYGB and included postoperative bleeding and obstruction (Table 4). J Obes Bariatrics 2(2): 5 (2015) Discussion Revisional bariatric surgery is now commonplace. In our study, it appears that greater %EBWL occurred between revision surgery and last clinic visit than between the original surgery and irst reoperation. here was not a single comorbid condition that decreased statistically signiicantly during the study period; however, all of them had a downward trend. Overall, complications did occur; however, there was no mortalities reported. hese results are not unlike contemporary research on revisional bariatric surgery. he reported incidence of reoperation in bariatric surgery ranges from 5-57%, but the quality and integrity of what is reported is sometimes questioned [3,7-9]. Previous studies have grouped their patients based on the etiologies for revisional surgery [10]. However, given that a majority of our patients were referred to a tertiary weight loss center for inadequate weight loss, we chose to group our patients based on the type of revision surgery performed. he majority of our patients beneitted from either laparoscopic conversion of their primary procedure to a RYGB or revision of their primary procedure. Success, as deined by a %EBWL>50, was achieved in our cohort at the last clinic visit (%EBWL of 58.3%) and was consistent with current literature on the Page - 03 Citation: Bairdain S, Cleary M, Litman HJ, Linden BC, Lautz DB. Revisional Bariatric Surgery. J Obes Bariatrics. 2015;2(2): 5. ISSN: 2377-9284 Tables 3A-3D: Changes in Percentages (%) of Comorbid Conditions over time and per Operation. Diabetes (DM) Surgery type No change in DM status Improved DM status VBG 3 (1.6%) 0 LAGB 67 (34.9%) 9 (52.9%) LRYGB 98 (51.0%) 8 (47.1%) Open RYGB 22 (11.5%) 0 Hypertension No change in hypertension status Surgery type Improved hypertension status VBG 3 (1.7%) 0 LAGB 65 (37.4%) 13 (35.1%) LRYGB 87 (50.0%) 19 (51.4%) 18 (10.3%) 4 (10.8%) Open RYGB Obstructive Sleep Apnea Surgery type No change in OSA status Improved OSA status VBG 3 (1.7%) 0 LAGB 63 (35.0%) 14 (46.7%) LRYGB 92 (51.1%) 14 (46.7%) Open RYGB 21 (11.7%) 1 (3.3%) Surgery type No change in Asthma status Improved Asthma status VBG 3 (1.7%) 0 Asthma LAGB 65 (35.7%) 12 (42.9%) LRYGB 91 (50.0%) 15 (53.6%) Open RYGB 21 (11.5%) 1 (3.6%) VBG: Vertical Banding; LAGB: Laparoscopic Gastric Banding; LRYGB: Laparoscopic Roux-en-Y Gastric Bypass; Open RYGB: Open Roux-en-Y Gastric Bypass; DM: Diabetes Mellitus; HTN: Hypertension; OSA: Obstructive Sleep Apnea Tables 4A: Complication data. Surgery type No complications Complications VBG 8 (4.1%) 1 (1.9%) LAGB 82 (41.6%) 6 (11.1%) LRYGB 89 (45.2%) 39 (72.2%) Open RYGB 17 (8.6%) 5 (9.3%) Among those who had complications, the highest proportion was of type LRYGB. The distributions with and without complications differ according to surgery type (Fisher’s exact test, p<0.001). VBG: Vertical Banding; LAGB: Laparoscopic Gastric Banding; LRYGB: Laparoscopic Roux-en-Y Gastric Bypass; Open RYGB: Open Roux-en-Y gastric Bypass Tables 4B: Complication data. efectiveness of transitioning or revising the roux-en Y gastric bypass [3,8,10-14]. Unlike other contemporary literature, there appeared to be fewer revisions for gastrointestinal complaints, failure to thrive or medicallyprotracted conditions [3,15,16]. he percentages of revision cases in our cohort for technical and mechanical complications, as well as istulas, were consistent with previously reported literature with most cases attempted laparoscopically [3,10,17]. It was interesting that istulas were oten found concurrently with treatment failure cases; however, further studies are needed to elucidate whether this plays a larger role in weight loss in our cohort. We did not necessarily see an increased rate of complications with performing these operations laprascopically, as revisional bariatric surgery is oten quoted as having a complication rate of between 10-50% [8,10,18,19]. Our complication was approximately 22%, albeit, 28% of our cohort had more than one operation. We believe that this approach may be taken and does not necessarily increase the rate of complication at high-volume centers. Juxtaposed to the previously reported operative mortality rates of less than 2.5%, we had no mortalities in our series [8,10,11,13]. Surprisingly none of our comorbid medical conditions reached a statistical signiicant decrease following re-operations. According to one of the most recent review papers by the American Society for Metabolic and Bariatric Surgery Revision Task Force, resolution of comorbid conditions must be considered as important as and/ or more important than reduction in %EBWL and BMI [9]. Given that our study had a shorter follow-up, these conditions may become signiicant over time. Further long-term studies are needed to elucidate this. Despite this study’s strengths, one limitation is that given our institution is a tertiary referral facility, oten we cannot control for loss to follow up, especially in the setting of a retrospective study following revision surgeries. Attrition is not uncommon following bariatric surgery and is possibly related to durable weight loss. In addition, since we are a high volume referral center, some patients choose to establish follow up care with bariatric surgeons closer to home and we do not have the long-term data on co-morbid conditions and longerterm %EBWL. Conclusion Revisional bariatric surgery is now a commonplace surgical intervention. Greater %EBWL occurs between revision surgery and last clinic visit than between the original surgery and reoperation. No single comorbid condition reached statistical signiicance during the study period; however, there was an overall decrease in the rates of hypertension, diabetes and obstructive sleep apnea. Further research is needed to determine the optimal timing for revisional bariatric surgery once initial treatment has failed to optimize excess weight loss and resolution of comorbid conditions. Revision Surgery type No complications Complications Conversion 91 (46.2%) 9 (16.7%) References Revision 100 (50.8%) 44 (81.5%) Reversal 3 (1.5%) 1 (1.9%) 1. Maggard MA, Shugarman LR, Suttorp M, Maglione M, Sugerman HJ, et al. (2005) Meta-analysis: surgical treatment of obesity. Ann Intern Med 142: 547559. Lap Exploration 3 (1.5%) 0 Among those who had complications, 82% were revisions which was different from those with no complications (Fisher’s exact test, p<0.001). J Obes Bariatrics 2(2): 5 (2015) 2. Sjöström L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, et al. (2004) Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 351: 2683-2693. Page - 04 Citation: Bairdain S, Cleary M, Litman HJ, Linden BC, Lautz DB. Revisional Bariatric Surgery. J Obes Bariatrics. 2015;2(2): 5. ISSN: 2377-9284 3. Spyropoulos C, Kehagias I, Panagiotopoulos S, Mead N, Kalfarentzos F (2010) Revisional bariatric surgery: 13-year experience from a tertiary Institution. Arch Surg 145: 173-177. 12. Fobi MA, Lee H, Igwe D Jr, Felahy B, James E, et al. (2001) Revision of failed gastric bypass to distal Roux-en-Y gastric bypass: a review of 65 cases. Obes Surg 11: 190-195. 4. Colquitt JL, Pickett K, Loveman E, Frampton GK (2014) Surgery for weight loss in adults. Cochrane Database Syst Rev 8: CD003641. 13. Jones KB Jr (2001) Revisional bariatric surgery--safe and effective. Obes Surg 11: 183-189. 5. Madura JA 2nd, Dibaise JK (2012) Quick ix or long-term cure? Pros and cons of bariatric surgery. F1000 Med Rep 4: 19. 14. Westling A, Ohrvall M, Gustavsson R (2002) Roux-en-Y gastric bypass after previous unsuccessful gastric restrictive surgery. J Gastrointest Surg 6: 206211. 6. (1983) 1983 metropolitan height and weight tables. Stat Bull Metrop Life Found 64: 3-9. 7. Buckwalter JA, Herbst CA Jr, Khouri RK (1985) Morbid obesity: second gastric operations for poor weight loss. Ann Surg 51: 208-211. 8. van Gemert WG, van Wersch MM, Greve JW, Soeters PB (1998) Revisional surgery after failed vertical banded gastroplasty: restoration of vertical banded gastroplasty or conversion to gastric bypass. Obes Surg 8: 21-28. 9. Brethauer SA, Kothari S, Sudan R, Williams B, English WJ, et al. (2014) Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force. Surg Obes Relat Dis 10: 952-972. 10. Nesset EM, Kendrick ML, Houghton SG, Mai JL, Thompson GB, et al. (2007) A two-decade spectrum of revisional bariatric surgery at a tertiary referral center. Surg Obes Relat Dis 3: 25-30. 11. Behrns KE, Smith DC, Kelly KA, Sarr MG (1993) Reoperative bariatric surgery. Lessons learned to improve patient selection and results. Ann Surg 218: 646-653. J Obes Bariatrics 2(2): 5 (2015) View publication stats 15. Skroubis G, Anesidis S, Kehagias I, Mead N, Vagenas K, et al. (2006) Rouxen-Y gastric bypass versus a variant of biliopancreatic diversion in a nonsuper obese population: prospective comparison of the eficacy and the incidence of metabolic deiciencies. Obes Surg 16: 488-495. 16. Skroubis G, Sakellaropoulos G, Pouggouras K, Mead N, Nikiforidis G, et al. (2002) Comparison of nutritional deiciencies after Roux-en-Y gastric bypass and after biliopancreatic diversion with Roux-en-Y gastric bypass. Obes Surg 12: 551-558. 17. Papasavas PK, Caushaj PF, McCormick JT, Quinlin RF, Hayetian FD, et al. (2003) Laparoscopic management of complications following Roux-en-Y gastric bypass for morbid obesity. Surg Endosc 17: 610-614. 18. Schwartz RW, Strodel WE, Simpson We, Griffen WO Jr (1998) Gastric bypass revision: lessons learned from 920 cases. Surgery 104: 806-812. 19. Benotti PN, Forse RA (1996) Safety and long-term eficacy of revisional surgery in severe obesity. Am J Surg 172: 232-235. Page - 05