Laparoscopic Conversion from Gastric Banding to Roux-en-Y Gastric Bypass
Wednesday, November 12, 2008
Earlier this week, I blogged about the rather frequent occurence (upto 30%) of band and port complications seen with laparoscopic adjustable gastric banding (LABG). I also mentioned that other complications of this surgically simple procedure, like band migration, pouch-enlargement, esophageal dilation, or port-site infections, can require reoperation or conversion to roux-en-Y gastric bypass (RYGB).
Fortunately, this conversion can be done laparoscopically with a high rate of success.
That, at least, is the gist of a report by Langer and colleagues from the Medical University of Vienna, Austria, in this month’s issue of Obesity Surgery, who addressed the poor long-term outcome in a growing number of LABG patients, due to primary inadequate weight loss or secondary weight regain.
The aim of this study was to prospectively assess the safety and efficacy of laparoscopic conversion to Roux-en-Y gastric bypass (RYGBP) in 25 patients, who failed LABG due to inadequate weight loss (n = 10) or uncontrollable weight regain (n = 15).
All procedures were completed laparoscopically within a mean duration of 219 +/- 52 (135-375) min with no significant complications. This shows that revisional surgery, while possible, takes significantly longer than a primary RYGBP (which generally takes around 90 mins).
Following conversion to RYGBP, mean body weight was reduced by 14%, 18% and 24% at 3, 6, and 12 months, respectively. No statistically significant differences were found comparing weight loss within these two groups.
Thus, while this study shows that it is technically possible to convert failed LABG to RYGBP with good results, it also reemphasizes the fact that a significant number of LABG patients will fail in the long-term and will need reoperation.
Although, LABG remains a simple and relatively successful bariatric option in the short term, all patients planning to undergo LABG should be warned of the relatively high long-term failure rates of this procedure and should be given the option of undergoing RYGBP as a primary intervention. All bariatric surgical centres should offer both procedures to their patients and be prepared to convert failed LABGs to RYGBPs.
AMS
Edmonton, Alberta
Thursday, November 13, 2008
I have always warned patients of a re-operation rate of up to 30%, though obviously I
hope my own rate doesn’t approach that, quite…and I have yet to meet anyone who
balks at that warning. I suspect that once you, as a patient, get past the warnings
about the mortality rate, and still think bariatric surgery is a better risk than
remaining morbidly obese, not much else is going to faze you.
I have seen several reports in the literature and on posters at the ASMBS meetings I
have attended about conversion from failed restrictive procedures to gastric bypass.
All of them counsel that while it is possible to convert, the complication rate from
the second operation is increased, up to 4x in some reports. (Including mortality!)
A better question might be, is it worth doing any conversion operation for an outright
failure of treatment? The bulk of the literature I have seen suggests that the weight
loss after a redo or conversion operation is never as good as average results after a
‘first-time’ operation. This makes one wonder if the first failure demonstrates that
the patient is not suitable for a surgical approach to their problem. Perhaps we
should save this scarce resource for patients more likely to succeed.
Not to say that I haven’t done conversions…especially when it isn’t an obvious
treatment failure, but when it might be due to complications of a less well designed
procedure (fixed gastric banding, vertical banded gastroplasty, horizontal stapled
gastroplasty without division).
Lawrence Farries