Laparoscopic reoperative approach after open bariatric surgery

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Laparoscopic reoperative
approach after
open bariatric surgery
PAOLO GENTILESCHI, FRANCESCA LIROSI, DOMENICO BENAVOLI, GIUSEPPE SICA, NICOLA DI LORENZO,
MARCO VENZA, IDA CAMPERCHIOLI, MARCO D’ELETTO, PIERPAOLO SILERI, ACHILLE L. GASPARI
Department of Surgery – University of Rome Tor Vergata – Policlinico Tor Vergata, Rome
Correspondence to: Dott. Paolo Gentileschi – Via A. Bosio, 13 – 00161 Roma
Riassunto
Scopo dello studio è valutare la tecnica laparoscopica nei reinterventi bariatrici
dopo chirurgia open. Tra gennaio 2003 e luglio 2007, 26 pazienti, già precedentemente sottoposti a chirurgia bariatrica laparotomica, hanno necessitato di un
reintervento. Nello specifico, il primo intervento era rappresentato da: bendaggio
gastrico (GB) in 19 casi, gastroplastica verticale (VBG) in 3, bypass digiuno-ileale
(J-I BP) in 2, bypass gastrico (RYGB) in 2. Il reintervento è stato giustificato da
insufficiente calo ponderale in 14 pazienti, band slippage in 7 casi, erosione protesica in 3 e malassorbimento grave in 2 pazienti. Il BMI medio preoperatorio era
45 kg/m2. Sono state effettuate 26 procedure laparoscopiche; 3 pazienti hanno
richiesto un terzo intervento. Undici pazienti con GB sono stati sottoposti a rimozione, 7 convertiti in RYGB mentre un GB è stato rimosso e sostituito; 2 pazienti con J-I BP hanno necessitato una ricostruzione intestinale; 3 VBG sono state
convertite in RYGB laparoscopico (LRYGB); 1 RYGB è stato convertito in bypass
gastrico laparoscopico con ansa lunga e in un paziente con fistola gastro-gastrica dopo RYGB la fistola è stata resecata. Ulteriori procedure sono rappresentate
da 1 GB laparoscopico (LGB), 1 LRYGB e una diversione bilio-pancreatica laparoscopica (LBPD). Si è resa necessaria una conversione laparotomica in 5 casi
(5/29, 17.2%). Le complicanze precoci comprendono un caso di pneumotorace
e 6 casi di infezione delle ferite (24,1%). La mortalità è stata nulla, con un followup medio di 36,2 mesi e un BMI medio postoperatorio di 34,3 kg/m2.
Parole chiave: chirurgia bariatrica laparoscopica, reinterventi
Summary
Laparoscopic reoperative approach after open bariatric surgery. P.
Gentileschi, F. Lirosi, D. Benavoli. G. Sica, N. Di Lorenzo, M. Venza, I. Camperchioli,
M. D’Eletto, P. Sileri, A.L. Gaspari
Introduction
Morbid obesity is a major health
problem in most developed countries, and bariatric surgery has a
well tried and tested record in resolving or markedly improving
most associated co-morbidities.
An increasing number of patients
require long-term revision of a
failed bariatric operation either for
unsatisfactory weight loss or for
complications.Van Gemert et al reported a 56% incidence of revision
after primary vertical banded gastroplasty (VBG) compared with a
12% incidence of revision after gastric by-pass1. In other series, revisional procedures have been performed in 10% to 25% of patients
who had initially undergone VBG
or in 5% to 13% of patients who had
either a VBG or GBP2. Jones in his
review reported a 1.4% revision requirement3. A revisional procedure
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is associated with a higher rate of
postoperative complications and is
usually performed with a traditionally open approach1.
The aim of this study was to determine the safety and efficacy of a
laparoscopic approach to reoperative operations after open
bariatric surgery.
Materials
and methods
We studied prospectively 26 patients who underwent laparoscopic reoperative bariatric surgery between January 2003 and July 2007
at the University of Rome Tor
Vergata, Department of Surgery.
There were 22 women and 4 men.
Mean age was 40.5 years (range:
28 to 56 years). Mean initial preoperative BMI was 49.7 kg/m2 (range:
Fig. 1. Band erosion.
43.6 to 55.4 kg/m2).The 26 primary
operations were open gastric
banding (GB) in 19 cases, open
vertical banded gastroplasty
(VBG) in 3 cases, jejuno-ileal bypass (J-I BP) in 2 cases, and open
The aim of the study was to evaluate the laparoscopic approach to reoperative
bariatric surgery. From January 2003 to July 2007, 26 obesity surgery patients
were referred to our Institution for revision. Nineteen patients previously had an
open gastric banding, 3 an open vertical banded gastroplasty, 2 an open jejunoileal by-pass (J-I BP) and 2 an open gastric by-pass. Indications for re-operation
were insufficient weight loss in 14 patients, band slippage in 7, band erosion in 3
and severe malabsorptive syndrome in 2. Mean preoperative BMI was 45 kg/m2.
Twenty-six laparoscopic re-operative procedures were performed. Three patients
required a third operation. Eleven gastric banding patients underwent band
removal, 7 gastric banding patients were converted to an open gastric by-pass,
1 band was removed and simultaneously re-placed, the 2 jejuno-ileal by-pass
patients underwent an intestinal restoration, 3 vertical banded gastroplasty
patients were converted to laparoscopic gastric by-pass, 1 open gastric by-pass
patient was converted to a laparoscopic long-limb gastric by-pass and in 1
patient with a gastro-gastric fistula after open gastric by-pass the fistula was
resected. Further procedures included 1 laparoscopic gastric banding, 1 laparoscopic gastric bypass and 1 laparoscopic bilio-pancreatic diversion. Conversion
to laparotomy was needed in 5 cases (5/29, 17.2%). Early complications included 1 case of pneumothorax and 6 cases of wound infection (24.1%). Mortality
was zero. The mean follow-up was 36.2 months. Mean postoperative BMI was
34.3 kg/m2. Laparoscopic reoperative bariatric surgery is feasible, safe and effective after open bariatric surgery.
Key words: laparoscopic bariatric surgery, reinterventions
Chir Ital 2009; 61, 2: 137-141
138
gastric by-pass (RYGB) in 2 cases.
Indications for re-operation were
insufficient weight loss in 14 patients, band slippage in 7, band
erosion (Fig. 1) in 3 and severe
malabsorptive syndrome in 2.After
the primary operation, the lowest
mean BMI was 41.8 kg/m2 (range:
24 to 47 kg/m2), which increased
to 45 kg/m 2 before reoperation
(range: 24.2 to 51.8 kg/m2). On average the reoperation was performed 22 months after the primary procedure (range: 0 to 34
months).
A complete preoperative work-up
was undertaken in all patients.
Upper endoscopy together with
contrast swallow were performed,
and medical clearance from internal medicine and psychiatry was
obtained. All patients were thoroughly instructed and gave informed consent 24 hours before
surgery. None of the patients received bowel preparations prior to
surgery and the cases were all
started laparoscopically. We evaluated operative time, morbidity and
mortality rates and weight reduction at follow-up visits.
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Laparoscopic reoperative approach after open bariatric surgery
Results
We performed open reoperative
procedures only as conversion of a
laparoscopic reoperative attempt.
Eleven GB patients underwent
band removal (Fig. 2), 7 GB patients were converted to a RYGB
(Figs. 3, 4, and 5), 1 band was removed and simultaneously replaced, the 2 J-I BP patients underwent intestinal restoration, 3 VBG
patients were converted to a laparoscopic RYGB (LRYGB), 1
RYGB patient was converted to a
laparoscopic long limb gastric bypass and in 1 patient with a gastrogastric fistula after RYGB the fistula was resected. Further procedures included 1 laparoscopic GB
(LGB), 1 LRYGB, and 1 laparoscopic bilio-pancreatic diversion.
Mean operative time was 168 minutes (range: 90 to 260 min). In patients with simple band removal,
mean operative time was 100 minutes (range: 90 to 120 min). In the
remaining patients, mean operative time was 180 minutes (range:
120 to 260 min). Seven patients
(24.1%) experienced complications. One case of pneumothorax
occurred in a patient who, following a gastric banding erosion, was
found to have the band adherent
to the left diaphragm. During dissection, a pleural injury occurred
which was treated by chest tube
insertion. The other 6 patients had
wound infections successfully
treated with drainage and antibiotic therapy.Three patients later required a third operation for insufficient weight loss. One patient with
a previous J-I BP who underwent
an intestinal restoration had a
LGB, one received a laparoscopic
bilio-pancreatic diversion after a
long limb RYGB, and one had a la-
Fig. 2. Band removal.
Fig. 3. Band removal and gastric pouch.
Fig. 4. Roux-en-Y gastric by-pass.
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Fig. 5. Stapling of gastric pouch after band removal.
paroscopic RYGB after gastric
band removal. In total, conversion
to laparotomy was needed in five
cases (5/29, 17.2%), in all cases for
severe adhesions.
Mean hospital stay was 6.5 days
(range; 4 to 14 days). All patients
were followed up by regular outpatient clinical appointments. The
mean follow-up was 36.2 months
(range: 22 to 44). At present, mean
BMI is 34.3 kg/m 2 (range:, from
24.5 to 44.6 kg/m2).
Discussion
Revisional bariatric procedures
are performed in 2% to 25% of patients previously submitted to a
primary operation2. There are no
specific rules to define the appropriateness of reoperative obesity
surgery. It can be indicated either
for late complications or for insufficient weight loss.
Complications of procedures such
as stenosis with gastric obstruction after VBG or metabolic complications after jejunoileal bypass
140
are obvious indications for reoperative surgery. Long-term complications after RYGB include bowel
obstruction, anastomotic stricture,
incisional hernia, marginal ulceration, and nutritional deficiencies.
Other reasons for reoperation after
RYGB can be a proximal gastric
pouch and stoma dilatation. Late
complications of gastric banding
include band slippage, access-port
infection, port and tubing problems and band erosion. Staple line
disruption accounted for most surgical failures in VBG patients before the use of cutting staplers to
divide the stomach. Since then,
reasons for reoperation after VBG
consist in stoma stenosis, band
erosion, incorrect band size,
pouch and stoma dilatation.When
a serious complication occurs, surgeons should consider the patient
suitable for a revisional procedure. Furthermore, when correcting a complication of a bariatric
operation, surgeons should not only perform a procedure that corrects the complication but also
provide continued assistance to
avoid weight regain.
On the other hand, the most common indication for reoperation is
insufficient weight loss. All
bariatric operations have some incidence of failure.The definition of
failure includes insufficient weight
loss, inadequate resolution of comorbidities, and development of
side effects negatively influencing
lifestyle. Insufficient weight loss following restrictive procedures can
also be caused by dietary changes
in patients who have learned to eat
high-calorie liquid foods.
There is clear evidence that conversion of a vertical banded gastroplasty can be successfully performed, RYGB usually being the
operation of choice .
In a large series of patients reported by Behrns et al, revisional procedures included conversion to
VBG in 33%, RYGB in 52% and biliopancreatic diversion. They concluded that conversion to RYGB
provided more effective weight loss
than VBG4. Sugerman et al reported
a series of 53 patients who underwent VBG and conversion to RYGB
with an excess weight loss of 67%
but with a complication rate of
50%5. Jones reported only a 13%
complication rate for a series of
141 patients undergoing reoperative surgery to convert from failed
bariatric procedures to RYGB6.
The use of gastric banding as a reoperative procedure has also been
successfully reported in several
centres. O’Brien et al described
the use of open gastric banding to
revise failed gastroplasty for 50 patients with a 3-year weight loss of
47% of excess weight7.A similar experience was reported by Kyzer et
al8, placing gastric banding in 37
patients who had a failed gastroplasty or RYGB, resulting in a good
weight loss with low postoperative
complications and reoperations.
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Laparoscopic reoperative approach after open bariatric surgery
Failed RYGB is usually treated by
adding a malabsorptive component to the procedure, as described
by Fobi9 and by Sugerman5. Both
authors reported a good decrease
in BMI in their patients but at the
cost of a high incidence of protein
malnutrition.
To date, the use of operative laparoscopy in revisional bariatric
surgery is infrequent in the literature, with the majority of authors
describing a traditional open approach. However, with the passage
of time and increased experience,
we will continue to see much
more interest in the laparoscopic
approach in the future.
Gagner et al reported their experience with a laparoscopic conversion of 27 patients with failed
open or laparoscopic gastroplasty,
gastric banding or RYGB 10. The
complication rate was 22% and a
satisfactory decrease in BMI was
achieved.
The use of a laparoscopic biliopancreatic diversion after failed
laparoscopic gastric banding was
reported by Fielding and co-workers 11. A 40% excess weight loss
was observed with a 6.3% complication rate.
Using a laparoscopic approach,
we observed a complication rate
of 24.1% with no mortality and a
conversion rate of 17.2%.
Although our follow-up is relatively short, only three patients required a third operation for insufficient weight loss and all of the
remaining patients are doing well.
Mean post-operative BMI is 34.3
kg/m2, i.e. below the range of morbid obesity. We experienced a
high conversion rate because of
the technical difficulties involved
in dealing with adhesions and inflammatory conditions. We believe that the high conversion rate
was associated in our experience
with the low complication rate be-
cause the laparoscopic attempt
did not jeopardise the procedure.
As a result of this careful behaviour we observed no postoperative anastomotic leaks. For these
reasons, we believe that laparosocopic reoperative surgery must be
performed by surgeons well
trained in both bariatric and laparoscopic surgery. In our experience, the laparoscopic approach
proved to be feasible, safe and effective, but there is nothing wrong
with converting to the open technique, if necessary, or in cases
where the latter approach will actually decrease the surgical risk.
The conversion of a failed restrictive procedure was performed using an RYGB as the procedure of
choice. Although the number of
patients is small, we observed a
44% BMI drop on converting LGB
patients to RYGB, resulting in an
average BMI of 28, down from the
original 50.
5. Sugerman HJ, Kellum JM Jr, DeMaria
EJ, Reines HD. Conversion of failed or
complicated vertical banded gastroplasty to gastric bypass in morbid obesity.
Am J Surg 1996; 171:263-9.
9. Fobi MA, Lee H, Igwe D Jr, James E,
Stanczyk M, Eyong P, Felahy B, Tambi
J. Revision of failed gastric bypass to
distal Roux-en-Y gastric bypass: a review of 65 cases. Obes Surg 2001;
11:190-5.
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SOCIETÀ ITALIANA
DI CHIRURGIA
111° CONGRESSO
Rimini
25-28 ottobre 2009
Rimini Palacongressi
Presidente:
Gianfranco Francioni