MANAGEMENT FOR FAILED BARIATRIC PROCEDURES

SURGERY - PROCEDURES, COMPLICATIONS, AND RESULTS
MANAGEMENT FOR FAILED
BARIATRIC PROCEDURES
SURGICAL STRATEGIES
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SURGERY - PROCEDURES,
COMPLICATIONS, AND RESULTS
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SURGERY - PROCEDURES, COMPLICATIONS, AND RESULTS
MANAGEMENT FOR FAILED
BARIATRIC PROCEDURES
SURGICAL STRATEGIES
JACQUES HIMPENS
AND
RAMON VILALLONGA
EDITORS
New York
Copyright © 2015 by Nova Science Publishers, Inc.
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CONTENTS
Foreword
vii
Kelvin Higa
Introduction
Chapter 1
ix
Revisional Bariatric Surgery for Weight Regain:
A Programmatic Approach
Eric J. DeMaria and Meredith A. Grzybowski
1
Chapter 2
Metabolic Failures and Bariatric Procedures
Pedro Paulo Caravatto, Tarissa Zanata Petry
and Ricardo Cohen
9
Chapter 3
Diagnostic Tools in Failed Bariatric Procedures
Rudolf Weiner, Islam A. El-Sayes
and Sylvia Weiner
23
Chapter 4
Adjustable Gastric Band Failures
J. W. M. Greve
57
Chapter 5
Failed Sleeve Gastrectomy
Ricard Corcelles and Antonio Lacy
73
Chapter 6
Reoperations for Roux-en-Y Gastric Bypass Failures
Jacques M. Himpens and Ramon Vilallonga
87
Chapter 7
Failed Minigastric Bypass: Surgical Strategies
Jean-Marc Chevallier
117
vi
Chapter 8
Chapter 9
Index
Contents
Surgical Procedures for Failure of Biliopancreatic
Diversion with Duodenal Switch (BPD-DS)
Simon Marceau, Simon Biron,
Frédéric-Simon Hould, Stefane Lebel,
Odette Lescelleur, Laurent Biertho
and Picard Marceau
Failed BPD
Giuseppe Maria Marinari, Vincenzo Borrelli
and Luc Lemmens
139
149
159
FOREWORD
The epidemic of obesity continues to challenge health care systems
because of its prevalence, chronicity and failure to respond to traditional nonsurgical treatment paradigms. Bariatric surgery has been proven to be safe and
effective through randomized controlled trials and long-term cohort studies for
BMI reduction, resolution or improvement of metabolic syndrome, quality of
life and longevity [1, 2, 3, 4, 5]. Despite the remarkable success of bariatric
surgery, the lack of standardization of many of our procedures in combination
with the heterogeneity of the disease contributes to long-term complications,
recidivism of weight and/or metabolic syndrome [6, 7]. Secondary procedures
are sometimes necessary to optimize performance of the original procedure or
to convert to a different anatomic construct depending on the response to
achieve the desired effect. This is consistent with our ethical values: to
provide life-long care for each individual patient. The editors and authors of
this book are to be congratulated for their ability to segregate and simplify the
complex topic of re-operative bariatric surgery. This is the first-of-its kind
guide for both novice and expert surgeons caring for some of the most
challenging of patient problems. After reading this book, you will understand
that “Failed Bariatric Procedures” is not about the inadequacies of our
operations, but the chasm that exists between our understanding of the disease
of obesity and the pathophysiology of our interventions [8].
Kelvin Higa, MD, FASMBS
REFERENCES
[1] Sjöström L, Narbro K, Sjöström CD, et al, and the Swedish Obese
Subjects Study. Effects of bariatric surgery on mortality in Swedish obese
subjects. N Engl J Med 2007; 357: 741–52.
[2] Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric
bypass surgery. N Engl J Med 2007; 357: 753–61.
[3] Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus
intensive medical therapy in obese patients with diabetes. N Engl J Med
2012; 366: 1567–76.
[4] Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus
conventional medical therapy for type 2 diabetes. N Engl J Med 2012;
366: 1577–85.
[5] Dixon JB, O‟Brien PE, Playfair J, et al. Adjustable gastric banding and
conventional therapy for type 2 diabetes: a randomized controlled trial.
JAMA 2008; 299: 316–23.
[6] Arterburn DE, Bogart A, Sherwood NE, et al. A multisite study of longterm remission and relapse of type 2 diabetes mellitus following gastric
bypass. Obes Surg 2013; 23: 93–102.
[7] Higa K, Ho T, Tercero F, Yunus T, Boone KB. Laparoscopic Roux- en-Y
gastric bypass: 10-year follow-up. Surg Obes Relat Dis 2011;7: 516–25.
[8] www.RevisionalBariatrics.com
INTRODUCTION
Brussels and Barcelona
Lectori Salutem,
Dear reader of Management for Failed Bariatric Procedures: Surgical
Strategies,
Before you start reading yet another book on the issue of bariatricmetabolic surgery, we would like to invite you to have a quick glance at the
name of the contributors to this composition. You will undoubtedly understand
that the editors succeeded in gathering one of the most select group of authors
specialized in the field of redo-bariatric surgery. Moreover, we believe that
every single contributing author excels in the particular field he/she was asked
to treat.
This book is meant to be essentially practical, but exhaustive as well to
allow the reader to be helped in almost all occasions of revisional weight loss
surgery he/she may encounter.
The format of the chapters is quite similar throughout to help readers with
swift research.
The figures and drawings should significantly enlighten the explanations
provided in the text. Finally, thanks to the diversity of the subjects, we believe
we kept the almost inevitable danger of overlapping subjects to a strict
minimum.
Remedial surgery becomes increasingly frequent in everyday bariatric
practice. This work aims at guiding the expert surgeon through some of the
most challenging situations he/she will encounter.
We sincerely hope you enjoy reading this book!
Jacques Himpens
AZ St-Blasius
Chief Department
Division of Bariatric Surgery
Kroonveldlaan 52, 9200
Dendermonde, Belgium.
Email: [email protected]
Ramon Vilallonga
Consultant surgeon
University Hospital Vall Hebron.
Endocrine, bariatric and metabolic Unit.
General Surgery Department.
Pg de la Vall Hebron 119-129
08035 Barcelona, Spain
Email: [email protected]
In: Management for Failed Bariatric Procedures
ISBN: 978-1-63483-753-8
Editors: J. Himpens and R. Vilallonga © 2015 Nova Science Publishers, Inc.
Chapter 1
REVISIONAL BARIATRIC SURGERY
FOR WEIGHT REGAIN:
A PROGRAMMATIC APPROACH
Eric J. DeMaria1, MD,
and Meredith A. Grzybowski2, ANP
1
Maryview Medical Center,
Bon Secours Surgical Specialists
Suffolk, Virginia, US
2
Maryview Medical Center, Bon Secours Health System
Portsmouth, Virginia, US
ABSTRACT
Revisional bariatric surgery is a significant endeavor because of
higher operative risks and poorer weight loss outcomes than primary
procedures. The decision to carry out such surgery must be taken by a
multidisciplinary team that confirms that the outcomes of the primary
procedure actually are not sufficient and, if this is the case, thoroughly
analyzes the causes of failure of the initial procedure. Causes for failure
include anatomical factors such as initially poorly performed
constructions or, conversely, acquired changes that counteract the activity
of a correctly performed surgical procedure. Evaluation of the anatomical
imperfection requires specific radiological and endoscopic techniques.

Email: [email protected]. Tel: (757) 483-3030.
2
Eric J. DeMaria and Meredith A. Grzybowski
Depending on the objective findings in combination with the subjective
complaints of the patient an adequate surgical strategy can be searched
for.
More often than not however behavioral/dietary flaws constitute the
essential part of the failure and must be addressed by patient re-education
and behavior modification.
OVERVIEW
Revisional bariatric surgery is a complex and evolving area of traditional
bariatric surgery. Although bariatric surgery provides a permanent tool to treat
obesity for the majority of patients, we are seeing a growing number return
with issues that need to be addressed by multidisciplinary comprehensive
treatment strategies. Although there may be surgical options, often the
procedures are difficult and often carry greater risk than the primary operation.
[1] More importantly, the benefit of the various surgical intervention have not
been proven in large cohort studies.
Our primary philosophy is to evaluate the patient‟s anatomy while asking
the question “does this procedure look like it is supposed to look?” In years
past, our approach was different in that we, and many others, considered only
major technical complications, like staple line disruption, to be of significance.
Now we are considering the patient in a comprehensive manner evaluating
their eating behavior and whether or not they still receive feedback from their
surgical „tool‟. Patients who do not receive feedback from a primarily
restrictive procedure such as gastroplasty, gastric bypass, or gastric banding
are considered likely to have anatomic changes that have led to a suboptimal
result. This hypothesis is further investigated by endoscopy and imaging
studies as well as comprehensive behavioral evaluation. This information is
collated and used to discuss treatment strategies and recommend options.
It is important to remember that, while bariatric surgery leads to complex
physiologic changes including changes in gut hormones such as ghrelin,
altered metabolic responses including a cancer-cachexia like syndrome, etc.
revisional surgery is not undertaken to restore or augment these responses.
Despite experience with many hundreds of revisional procedures, we do not
know if these procedures manipulate the physiology. Our focus is on the
traditional concepts of how bariatric surgery works, i.e., we manipulate
restriction and/or malabsorption. It is important to approach a planned
revisional intervention in these terms.
Revisional Bariatric Surgery for Weight Regain
3
CANDIDATES
Patients seek out revisional bariatric surgery for a multitude of reasons,
some because they have regained weight, some because they believe their
surgery has failed, and some because they experience physical problems that
they believe may be related to having bariatric surgery. [2] What is constant, is
that nearly all the patients that come to see the bariatric unit are unsatisfied
with their current weight and are looking for help to obtain a certain weight
loss goal or improve current comorbidities. We primarily see patients with
previous gastric bypass since that procedure has been performed open or
laparoscopically in our region of the United States for the past 20 plus years.
Therefore most of our review will cover our approach to the struggling gastric
bypass patient and how we evaluate them.
EDUCATION
Patients start the process by calling our program and are scheduled to
attend a bariatric revision seminar. They are then sent a packet of information
and paperwork to fill out and return. In addition to a health questionnaire and
release of medical information form used to obtain the initial surgery operative
note, the paperwork they are asked to fill out also contains a revision
testimonial in which we ask patients to describe in their own words why they
feel they need a revision of their bariatric surgery. Bariatric revision seminars
are held once per month and give patients general information on what to
expect with the evaluation process, types of testing performed, and surgical
and non-surgical options for revisional bariatric surgery such as reversal,
revision, conversion, and endoscopic procedures. Patients are also provided
with information from our program dietician about the nutritional evaluation
and key diet principles that bariatric patients should be aware of and follow.
Patients are then scheduled for an initial evaluation with the bariatric surgeon.
INITIAL EVALUATION
During the initial evaluation appointment we take the patient's past
bariatric history including what type of surgery was performed, what the
approach was (open or laparoscopic), when the surgery was done, and who
4
Eric J. DeMaria and Meredith A. Grzybowski
performed the surgery. We also want to know what their initial pre-operative
weight was and the lowest weight they obtained post operatively. This is
followed up by asking the patient if they experienced any post operative
complications, if they still feel the effects of their surgery, if they ever had
dumping syndrome, if they continue to have dumping syndrome now, and if
they are currently experiencing symptoms of GERD. Often times, patients do
not understand when asked if they feel the effect of their surgery and we have
to go into further detail asking if they have any sense of restriction with eating,
what types of foods they eat, and the quantity and quality of foods they are
able to consume. We also often run across patients who do not know what
dumping is or who were never educated post operatively on the type of diet
they were expected to follow. It follows a common pattern that the further out
patients are from initial surgery, the less likely they were to be educated on
diet, exercise, side effects, and overall what was expected of them
postoperatively. Another factor that is very common among patients seeking
out revisional bariatric surgery is the lack of follow up that they had with their
initial bariatric program. It would be safe to say that all of the patients we have
seen seeking revision have had as little as a 2 year to as much as 25 year gap in
follow up.
The most prominent reason for seeking revisional bariatric surgery in the
patients we have seen is weight regain, but one patient's regain is not always
the same as another. In the initial evaluation appointment we have to evaluate
further the factors behind the weight regain. We have seen patients come in
with as little as a 20 pound weight regain or patients who have regained past
their preoperative weight (>100 lbs.). Another variable is the amount of time
in which patients gained the weight. This can vary from less than 6 months to
over 10 years.
Much of the time we find that the patient‟s weight regain has resulted
from behavioral factors, but even these can be variable. Some patients
developed reactive hypoglycemia that was never diagnosed and are driven to
eat whatever is available due to alarmingly low blood sugars. Maladaptive
eating is a commonly seen issue among our patient population. Some patients
have issues with strictures, marginal ulcers, or chronic nausea and vomiting
leading them to eat foods that will easily pass through their pouch and
gastrojejunostomy. However, more often than not, many patients are
uncomfortable with the feeling of restriction from their initial surgery and try
to eat foods that will bypass this restrictive sensation. We have met many
patients who honestly believe something is wrong with their surgery because
they have an uncomfortable feeling in their chest when they eat certain foods
Revisional Bariatric Surgery for Weight Regain
5
such as meat, bread, or pasta. We often have to remind the patient of the
sensation of fullness they experienced in the immediate post-operative period
and relate that to what they are feeling now. Many realize that it is the exact
same feeling and that they have been trying to avoid that feeling by eating
"slider foods" and foods that will bypass the restrictive nature of their surgery.
ANATOMIC EVALUATION
At their initial evaluation appointment, patients are scheduled for three
specific tests which are usually performed within the following 2-3 weeks.
These consist of an endoscopic evaluation of the gastric anatomy, barium
upper GI, and nutritional laboratory evaluation. If nutritional intake concerns
were noted in the patient interview, nutritional evaluation with the dietician is
required. For those patients with laparoscopic adjustable bands, an upper GI,
to evaluate for band slippage, hiatal hernia, or esophageal dilation, and
nutritional lab work is performed. Occasionally endoscopy is used to evaluate
for band erosion, but that is often not necessary [3].
The endoscopy is performed by the bariatric surgeon to evaluate the
patient‟s gastric anatomy. Precise measurement of the various key anatomic
aspects of bariatric anatomy has been a challenge as we do not have adequate
measuring tools such as stick/ruler that can be inserted and used to make
measurements during the procedure. One such instrument was previously sold
commercially but is no longer available. Currently, measurements are
specifically taken during the endoscopy as to the distance from the patient‟s
incisors to the level of the z-line and to the level of the gastrojejunostomy in
order to estimate gastric pouch length. We attempt to determine if the pouch is
long and narrow (cylindrical) or wide (spherical) in order to make approximate
volume calculations. With narrow pouches we estimate pouch width to be the
same as gastrojejunostomy diameter and estimate volume in cm3 according to
the formula for the volume of a cylinder, i.e., r2l. We estimate the diameter of
the gastrojejunostomy, typically be retroflexing the scope in the Roux limb
and photographing the scope passing across the anatomosis. The scope
diameter is used as an internal standard to allow us to estimate the anastomotic
diameter, e.g., 2-fold, 3-fold, 4-fold, etc. versus scope diameter (10mm). The
surgeon also evaluates the pouch for evidence of hiatal hernia, ulcers, or a
gastrogastric fistula, and for potential afferent limb elongation.
A barium upper GI with air contrast is ordered with the additional request
of ingestion of a barium tablet and barium meal ingestion at the end of the
6
Eric J. DeMaria and Meredith A. Grzybowski
study. Patients are told to bring 6-8 ounces of cottage cheese with them to the
study for preparation of the barium meal. A standard barium upper GI is
performed followed by an evaluation using powdered barium mixed with the
cottage cheese at a 1:1 concentration that the patient is asked to ingest until
feeling full. While patients are often able to ingest between 4 and 6 ounces,
sometimes up to 12 total ounces of the barium cottage cheese mixture are
actually consumed. A final abdominal x-ray is performed to capture the
volume and possible dilation of the pouch with the barium meal. We have tried
chunky applesauce as an alternative for those patient that are unable to tolerate
cottage cheese due to allergy, lactose intolerance, or refusal due to
taste/texture, but the applesauce barium mixture appears to move too quickly
through the pouch into the efferent limb before volume estimation can be
obtained. There have also been several patients whose gastrojejunostomy was
dilated to an extent that the barium cottage cheese mixture emptied too rapidly
into the efferent limb and pouch volume estimation was inaccurate. Overall,
this test has been beneficial in providing information on GERD, presence of
hiatal hernia, ulcer, possible esophageal dysmotility issues, gastric pouch
enlargement and volume, gastrojejunostomy enlargement, and possible
afferent limb syndrome due to elongation of the blind end of the Roux limb
(candy cane) seen with side to side gastrojejunostomy anastomosis.
SURGICAL STRATEGIES
Patients are brought back into the office after the testing is completed to
review their results and determine what options are available to them. If their
anatomy is intact, then we refer them for nutritional counseling with our
dietician to get back on track with healthy eating habits and continue to follow
them on a regular basis for bariatric follow up [1-4].
Patients are treated on an individual basis and plans are made with each
patient depending on what was found during testing. Many patients are found
to have a sliding hiatal hernia, a dilated gastric pouch, or a dilated
gastrojejunostomy and frequently some combination of the 3 is found. At
times, additional testing is necessary to determine a course of action for the
patient. If significant GERD symptoms are found, esophageal manometry
testing may confirm that the lower esophageal sphincter is hypotensive. In that
case hiatal hernia repair and modified Dor, Toupet, or Nissen fundoplication
may be performed with the degree of fundoplication decided during surgery
depending on the technical issues found. Hiatal repair with fundoplication has
Revisional Bariatric Surgery for Weight Regain
7
also proved to be a valuable intervention in American patients whose
individual health insurance does not cover any further bariatric treatments as
the diagnosis being treated by this intervention is gastroesophageal reflux
disease. Patients presenting combination of a dilated gastric pouch and dilated
gastrojejunostomy usually continue with the evaluation process for the
potential of complete revision of their gastric bypass versus laparoscopic
adjustable band placement over their existing bypass. Those patients with
dilated gastrojejunostomy alone are considered for revision versus endoscopic
plication of the gastrojejunostomy. In laparoscopic band patients suffering
significant symptoms of excessive restriction with reflux and typical findings
on upper GI the band is often completely deflated in the office. Mostly these
patients choose to continue with evaluation for conversion to sleeve
gastrectomy or roux-en-y gastric bypass.
BEHAVIOR MODIFICATION
As most patients have regained some amount of weight, whether it be due
to maladaptive eating, hypoglycemia, or old habits returning, we require all
patients to go through a nutritional evaluation with our dietician. Even if the
patient‟s insurance company does not require a weight loss trial, we will often
require patients to complete a minimum of 3 months in a weight loss class to
relearn healthy eating habits and behaviors. We have come to require that a
patient desiring surgical intervention for weight regain in the absence of a
surgical complication must demonstrate a 10% total body weight loss during
this time to confirm compliance and behavior change. Healthy eating habits
and behaviors are essential for a successful revisional bariatric surgery, and
patients are informed that their compliance with diet and exercise is essential
in order to achieve positive results.
SUMMARY
Overall weight loss is less with revisional bariatric surgery and requires
more effort on the patient‟s behalf. Patient selection for bariatric revisional
surgery is key for both patient and programmatic success. With a
multidisciplinary team and good communication between the patient and that
team, success is possible.
8
Eric J. DeMaria and Meredith A. Grzybowski
REFERENCES
[1]
[2]
[3]
[4]
Brethauer SA, Kothari S, Sudan R, Williams B, English WJ, Brengman
M, Kurian M et al. Systematic review on reoperative bariatric surgery:
American Society for Metabolic and Bariatric Surgery Revision Task
Force. Surg. Obes. Relat. Dis. 2014;10:952-72.
Johnson WH, Fernanadez AZ, Farrell TM, Macdonald KG, Grant JP,
McMahon RL, Pryor AD, Wolfe LG, DeMaria EJ. Surgical revision of
loop ("mini") gastric bypass procedure: multicenter review of
complications and conversions to Roux-en-Y gastric bypass. Surg. Obes.
Relat. Dis. 2007;3:37-41.
Kellogg TA. Revisional bariatric surgery. Surg. Clin. North Am.
2011;91:1353-71.
Zundel N, Hernandez JD. Revisional surgery after restrictive procedures
for morbid obesity. Surg. Laparosc. Endosc. Percutan. Tech.
2010;20:338-43.
In: Management for Failed Bariatric Procedures
ISBN: 978-1-63483-753-8
Editors: J. Himpens and R. Vilallonga © 2015 Nova Science Publishers, Inc.
Chapter 2
METABOLIC FAILURES AND
BARIATRIC PROCEDURES
Pedro Paulo Caravatto, Tarissa Zanata Petry
and Ricardo Cohen
Center for Obesity and Diabetes,
Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
ABSTRACT
There is an increasing body of evidence that bariatric surgery leads to
higher remission rates of type 2 diabetes mellitus (T2DM) than any other
medical treatment or lifestyle intervention. Several trials published so far
comparing the effect of bariatric surgery and best medical treatment on
diabetic obese patients have shown that T2DM reached up to 75-80% at
the end of the study in the surgical group, although most studies have
shown a relatively short period of follow-up.
There is no doubt that bariatric procedures, primarily Roux-en-Y
gastric bypass, are more effective at inducing T2DM remission. However,
there is a lack of information regarding long-term results for disease
control. In this chapter, the authors present long-term results of bariatric
surgery over metabolic diseases remission.

Email: [email protected].
10
Pedro Paulo Caravatto, Tarissa Zanata Petry and Ricardo Cohen
INTRODUCTION
During the past decades, the number of individuals with type 2 diabetes
(T2DM) in the United States (U.S.) has more than doubled, showing that we
are in the midst of an epidemic. Approximately 25.8 million Americans were
diagnosed with diabetes (nearly 8.3% of the population), and by 2050 as many
as one in three U.S. adults could have diabetes [1-2]. Furthermore, T2DM is
the leading cause of kidney failure, non-traumatic lower-limb amputations,
coronary heart disease, stroke, and visual impairments among adults in the
U.S. [3].
Aside from high morbidity and premature mortality, T2DM imposes a
substantial burden on the economy because of its significant medical costs and
indirect costs that are the result of work absenteeism, reduced productivity and
unemployment from chronic disability. In 2012, the American Diabetes
Association (ADA) estimated that the total national cost of diabetes in the U.S.
was $245 billion, of which more than 70% represented direct health
expenditures [1]. This represents a 41% increase when compared to a previous
estimate published in 2008 [4]. In addition, there has been a significant
increase in health resources usage by people with diabetes. For example,
diabetics incur approximately 25% of all U.S. hospital inpatient days, almost
one third of all nursing/residential facilities days, and around half of all
physician office, emergency department, and hospital outpatient visits. An
even worse scenario is reported when analyzing data for a specific age, in
particular the elderly [1]. For these reasons, it is estimated that health
expenditures for diabetics are 2.3 times higher than they would be in the
absence of T2DM.
Prospective longitudinal studies have shown that bariatric surgery is the
most effective intervention for obesity and its associated diseases, in particular
T2DM, reducing the long-term mortality rate of morbidly obese patients when
compared to clinical treatment [5-6].
The improvement of metabolic control in bariatric patients was observed
as early as days or weeks after surgical procedure, long before considerable
weight loss occurred, indicating a direct anti-diabetic effect of the procedure.
Consequently, some operations began to be considered as an option to treat
less obese patients with uncontrolled T2DM [7]. As expected, good results
regarding metabolic control were obtained in this patient group without
significant weight loss, particularly after Roux-en-Y gastric bypass (RYGB)
[8-9]. Treatment goals are outlined in Table 1. Nonetheless, only limited
information is available regarding long-term effects, recurrence or worsening
Metabolic Failures and Bariatric Procedures
11
of metabolic diseases years after surgery, and factors associated with their reemergence.
Table 1. Treatment goals for T2DM patients
Partial remission
Complete remission
At least 1 year‟s duration
At least 1 year‟s duration
No active pharmacologic therapy or
No active pharmacologic therapy or ongoing
ongoing procedures
procedures
HbA1c < 6.5%
HbA1c 4.5 – 6%
FPG 100 – 125 mg/dL
FPG < 100 mg/dL
Secondary goals include: LDL < 100 mg/dL and blood pressure < 130x80 mmHg
*HbA1c – glycated hemoglobin.
FPG – fasting plasma glucose.
LDL – low-density lipoprotein.
EFFECTS IN TERMS OF GLYCEMIC CONTROL
We recently published the largest and longest-term study to date to
examine the safety and efficacy of RYGB in T2DM patients with BMI
between 30 and 35 kg/m2. All patients were followed from 1 to 6 years
(median 5 years). Main outcomes were safety and T2DM remission, defined as
glycated hemoglobin (HbA1c) < 6.5% without medication. All patients had
uncontrolled T2DM, despite appropriate lifestyle modifications and use of
antidiabetic medications including or not insulin for at least 1 year. Mean preop HbA1c was 9.7% and mean duration of disease was 12.5 years.
T2DM remission was observed in 88% of patients, with a significant
reduction of HbA1c (9.7 to 5.9%), despite diabetes medication cessation in the
majority of cases.
Improvement of diabetes (HbA1c < 7% with lower doses of oral diabetes
medications and no insulin) was achieved in 11% of patients. Only one patient
in the entire cohort had no changes in diabetes evolution. All patients
experienced significant weight loss at 5 years, however there was no
correlation between the amount of weight loss and levels of fasting plasma
glucose or HbA1c for the first 5 years.
Beta cell function significantly improved as measured by C-peptide
response to glucose load. No mortality, major surgical complication or
massive weight loss were reported [9].
12
Pedro Paulo Caravatto, Tarissa Zanata Petry and Ricardo Cohen
At 8 years follow-up, 11 (16.5%) patients with previous T2DM remission
were back on antidiabetic drugs, 10 were using metformin alone and 1 patient
was using a combination of vildagliptin and metformin. There was no
correlation between T2DM recurrence and weight regain. Excess weight loss
at 8 years was 69% for this series.
During hospital admission and after discharge, all patients had their
T2DM managed according to the following protocols adopted by our
institution (Tables 2, 3 and 4).
Table 2. Management of T2DM in the perioperative care (NPO status)
BLOOD
GLUCOSE
(mg/dL)
FROM
0
BLOOD
GLUCOSE
(mg/dL)
TO
69
INSULIN
(UI)
IV
GLUCOSE
(g)
ACTION
10
IV glucose G50% 20mL
70
99
0
Capillary blood glucose:
6am, 12pm, 6pm and 12am
Long-acting insulin once a
day
Fast-acting insulin
100
149
0
Fast-acting insulin
150
199
1
Fast-acting insulin
200
249
3
Fast-acting insulin
250
299
5
Fast-acting insulin
300
349
7
Fast-acting insulin
8
Fast-acting insulin
180
350
9
A retrospective analysis by Di Giorgi et al. reporting on 42 post RYGB
diabetic patients with a medium follow-up of 3 years showed resolution of
diabetes in 64% at 6 months, while all patients had their diabetes improved.
Pre-operative data showed that mean BMI was 51.4 kg/m2 and 34% of the
participants were using insulin. At 3 years diabetes recurrence was
experienced by 26% of patients with initial resolution and by 20% of patients
with initial improvement. This group had lower preoperative BMI compared to
those who did not recur. Such findings were not observed in our series, where
correlation to weight regain was not observed [10].
Metabolic Failures and Bariatric Procedures
13
Table 3. In-hospital management of T2DM in postoperative care (patients
on liquid diet)
1. Metformin 2 g per day (optimized)
2. DPP4 inhibitors
BLOOD
GLUCOSE
(mg/dL)
FROM
0
BLOOD
GLUCOSE
(mg/dL)
TO
69
INSULIN
(UI)
IV GLUCOSE
(g)
IV glucose G50%
20mL
Capillary blood glucose
before breakfast, lunch,
dinner and before 10
pm
180
*
Long-acting insulin
once a day (bed-time)
70
99
5
Fast-acting insulin
before breakfast, lunch
and dinner
100
149
6
Fast-acting insulin
before breakfast, lunch
and dinner
150
199
7
Fast-acting insulin
before breakfast, lunch
and dinner
200
249
9
Fast-acting insulin
before breakfast, lunch
and dinner
250
299
11
Fast-acting insulin
before breakfast, lunch
and dinner
300
349
13
Fast-acting insulin
before breakfast, lunch
and dinner
350
14
Fast-acting insulin
before breakfast, lunch
and dinner
(*) If patient is under insulin treatment prior to surgery, reintroduce 50-70% usual dose
of insulin and titrate according to fasting capillary blood glucose (target < 120 mg/dL)
and postprandial capillary blood glucose (target < 180 mg/dL)
* DPP4 - dipeptidyl peptidase 4.
10
ACTION
14
Pedro Paulo Caravatto, Tarissa Zanata Petry and Ricardo Cohen
Table 4. Outpatient T2DM management (long-term follow-up)
1. Metformin 2 g per day (optimized)
2. DPP4 inhibitors
3. Insulin
If patient is under insulin treatment prior to surgery, maintain same dose used at
hospital discharge and titrate according to fasting capillary blood glucose (target < 120
mg/dl) and postprandial capillary blood glucose (target < 180 mg/dl). Clinical practice
shows that it usually takes 21 days to withdraw insulin therapy in patients with
preserved beta cell function.
* DPP4 - dipeptidyl peptidase 4.
Chikunguwo et al. retrospectively studied 177 patients with T2DM who
had undergone RYGB. Patients were followed-up from 5 to 16 years (mean
8.6 years). Complete T2DM remission was observed in 88.7% patients, but
43.3% recurred. In this study, T2DM recurrence was correlated with weight
regain. The authors found that percentage of weight loss, gender, age and
severity of T2DM were independent predictors of recurrence. Strongest
predictors were insulin therapy and gender [11].
EFFECTS IN TERMS OF LIPIDS CONTROL
AND CARDIOVASCULAR OUTCOMES
Metabolic surgery benefits that go beyond glucose control include a
positive effect on lipid profile. Increases in high-density lipoprotein (HDL)
cholesterol have already been reported one year after RYGB [12, 13], however
data are still limited to non-controlled studies in morbidly obese patients.
Although the actual role played by HDL in the reduction of cardiovascular risk
is still unclear [14], there is some evidence that increase in HDL is associated
with a reduced progression of atherosclerosis and hence better cardiovascular
outcomes, which constitutes a major benefit from metabolic surgery [15, 16].
We examined other cardiovascular risk factors in diabetic patients with
low BMI submitted to RYGB and found that hypertension resolved in 58%,
hypercholesterolemia in 64%, and hypertriglyceridemia in 58%. For the entire
cohort, mean blood pressure progressively decreased over the course of six
years [9]. There was also a significant improvement over the six years in lipid
parameters, with progressive reductions in total cholesterol, LDL cholesterol
Metabolic Failures and Bariatric Procedures
15
and triglycerides, and increase in HDL cholesterol. These changes led to a 10year decrease in fatal and non-fatal stroke and myocardial infarction numbers.
Other studies have shown beneficial effects of gastric bypass on diabetes
and reduced mortality from heart disease in morbidly obese subjects [16, 17].
A recent report from the Swedish Obese Subjects (SOS) study [18]
demonstrated the reduction of myocardial infarction incidence in obese
diabetic patients following bariatric surgery. We reported the favorable
outcomes of metabolic surgery in low BMI patients that go beyond glycemic
control, as indicated by the substantial reductions in hypertension and
dyslipidemia, yielding major improvements in predicted CV risk. Our results
are similar to small, observational studies from India, China and South
America [19, 20, 21], although follow-up in these studies was relatively short.
WHAT IS THE ROLE OF WEIGHT LOSS IN THE INCIDENCE
OF CARDIOVASCULAR EVENTS?
Lifestyle interventions to prevent T2DM have not avoided cardiovascular
events, including in long-term follow up [22, 23]. Sjostrom et al. [15], in the
Swedish Obese Subjects study, a non-randomized prospective study,
concluded that, compared to usual care, bariatric surgery leads to a reduced
number of cardiovascular events and deaths. One of the most important
findings in the Swedish study was the lack of correlation between BMI and
cardiovascular mortality and/or events. And, conversely, a positive correlation
with fasting plasma insulin levels. The Look AHEAD study [24] showed that
intensive lifestyle modification may induce significant improvements in
intermediate health indicators, such as body weight, fitness, blood pressure,
glycemic control, and lipids. These improved risk factor profiles, however, did
not translate into lower rates of non-fatal myocardial infarction, non-fatal
stroke, hospitalization for angina, or death compared with conventional
diabetes treatment [25]. Look AHEAD found that people who are obese and
suffer from T2DM can lose weight and maintain weight loss with a lifestyle
intervention. Although the study found that weight loss had many positive
health benefits for patients with T2DM, it did not reduce the number of
cardiovascular events. Evidence is increasing that metabolic surgery is more
effective than medical or lifestyle interventions for weight loss and diabetes
remission. In a recent analysis by Arterburn et al. [26] of severely obese
patients with diabetes, the adjusted probability of initial remission was 12 to
16
Pedro Paulo Caravatto, Tarissa Zanata Petry and Ricardo Cohen
24 times greater for the 1395 patients who had bariatric surgery than for the
62322 who received usual medical care alone.
In a recent editorial, the same author [27] stated that the benefits of
intensive lifestyle treatment for T2DM were more prominent in patients with
early stage diabetes, similar to what was reported in bariatric surgery, showing
better results in milder, earlier stage disease. Consequently, a strong argument
can be made for considering earlier surgical intervention in moderately obese
patients (BMI <30 kg/m2) with early stage diabetes, in particular in those with
severe insulin resistance, higher cardiovascular risk and uncontrolled disease.
This argument backs up the 2011 International Diabetes Federation (IDF)
statement on new perspectives on surgical treatment of uncontrolled T2DM in
patients with BMIs between 30 and 35 kg/m2 [28].
Timing of metabolic surgery is of the utmost importance for T2DM
remission. In a retrospective study, Arterburn et al. [27] found that almost 35%
of the patients who went into remission following RYGB redeveloped T2DM
within five years of surgery. Predictor factors were poor preoperative glycemic
control, insulin use and longer diabetes duration, indicating that the earlier the
intervention takes place the better [26]. From the above, one may conclude
that the Look AHEAD study fundamentally shows that weight loss does not
appear to reduce T2DM-associated cardiovascular disease, but rather enhances
the benefit of interventions aimed at improving diabetes (diet, surgery etc.).
IS THERE A SURGICAL TREATMENT OPTION
FOR PATIENTS WITH TYPE 2 DIABETES RECURRENCE?
Over recent years, the aim of metabolic/bariatric surgery has changed
from weight loss only to metabolic control. So far, there is no recognized
definition of what constitutes failure of metabolic surgery, much less an
accepted standard of care for patients who fall into this category.
Table 5. Definitions for T2DM recurrence
Partial recurrence
HbA1c 6.5-7%, but higher than lowest
level reported after surgery
Addition of 1 oral antidiabetic agent
*HbA1c – glycated hemoglobin.
Complete recurrence
HbA1c > 7% and higher than lowest level
reported after surgery
Addition of 2 or more oral antidiabetic
agents and/or insulin
Metabolic Failures and Bariatric Procedures
Figure 1. T2DM recurrence after laparoscopic adjustable gastric band (LAGB).
Figure 2. T2DM recurrence after sleeve gastrectomy.
17
18
Pedro Paulo Caravatto, Tarissa Zanata Petry and Ricardo Cohen
Arterburn et al. proposed the following criteria for T2DM relapse after
bariatric/metabolic surgery. One or more of the following conditions should be
fulfilled: (a) restarting diabetes medication; (b) one or more HbA1c readings ≥
6.5%; and/or (c) one or more fasting glucose values ≥ 126 mg/dl [26].
Interestingly, the authors examined the T2DM relapse rate only among
subjects who initially experienced a diabetes remission after surgery (partial or
complete).
In this chapter, we propose new criteria for patients who do not fall into
the remission category but who had their metabolic conditions improved after
surgery and, for unknown reasons, later experienced worsening of their
metabolic status. These patients should be considered as suffering from T2DM
recurrence (and not relapse), and may be divided into two categories (Table 5).
Patients with T2DM recurrence may be candidates for revisional surgery
after optimized clinical treatment (Figures 1, 2, 3).
Figure 3. T2DM recurrence after gastric bypass.
Metabolic Failures and Bariatric Procedures
19
CONCLUSION
When offering surgical treatment aiming at durable diabetes remission,
patient selection and counseling are of the utmost importance. We found that
patients with a longer history of diabetes and those under insulin treatment
were more likely to relapse than those who were not using insulin or who had
diabetes for less than 10 years. However, not all patients receiving insulin
failed to achieve diabetes remission. An earlier surgical intervention clearly
appears to be preferable. However, more severely affected and insulindependent diabetic patients may benefit from surgery as well, since these
patients, although unable to interrupt diabetic medication, may experience
improvement in retinopathy, nephropathy, and other diabetes-related
conditions. Furthermore, these patients may benefit from a significant
improvement in quality of life and experience remission of other metabolic
diseases. It is also believed that an aggressive glycemic control may induce
beneficial “metabolic memory” – be it transiently – as reported in the UKPDS
study, and reduce the incidence of microvascular complications [29].
Therefore, patients with T2DM recurrence after metabolic surgery may still
continue to experience reduced microvascular and macrovascular
complications in the long-term when compared to those who never had their
disease controlled.
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Kim S, Richards WO. Long-term follow-up of the metabolic profiles in
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Sjöström L, Peltonen M, Jacobson P, et al. Bariatric surgery and longterm cardiovascular events. JAMA 2012; 307: 56–65.
Adams TD, Gress RE, Smith SC et al. Long-term mortality after gastric
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[19] Shah SS, Todkar JS, Shah PS, et al. Diabetes remission and reduced
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[26] Arterburn D, Bogart A, Coleman KJ et al. Comparative effectiveness of
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[28] Dixon JB, Zimmet P, Alberti KG, Rubino F. Bariatric surgery: an IDF
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In: Management for Failed Bariatric Procedures
ISBN: 978-1-63483-753-8
Editors: J. Himpens and R. Vilallonga © 2015 Nova Science Publishers, Inc.
Chapter 3
DIAGNOSTIC TOOLS IN FAILED
BARIATRIC PROCEDURES
Rudolf Weiner1,*, MD, PhD, Islam A. El-Sayes1,†, MD,
and Sylvia Weiner2,‡, MD
1
Center for Surgery for Obesity and Metabolic Disorders
(Center of Excellence)
Sana Klinikum Offenbach,
Offenbach am Main, Germany
2
General Surgery Department, Faculty of Medicine,
Alexandria University, Egypt
ABSTRACT
Worldwide, there is an evident increase in the incidence and
accordingly in the prevalence of obesity. Current estimates postulate that
the incidence of obesity will reach about 40% of the adult population by
the year 2030. Importantly, developing countries do not seem to be
immune against this epidemic. Accordingly, the worldwide performance
*
Corrsponding author: Rudolf Weiner (Weiner R), MD, PhD. Center for Surgery for Obesity and
Metabolic Diseases (Center of Excellence). Universitary Hospital Sana Klinikum
Offenbach.Clinic for Obesity and Metabolic Surgery. Starkenburgring 66. Offenbach am
Main. Germany. [email protected].
†
[email protected].
‡
[email protected].
24
Rudolf Weiner, Islam A. El-Sayes and Sylvia Weiner
of bariatric procedures is showing a corresponding yearly increase.
Recent procedures such as sleeve gastrectomy are currently replacing old
standard techniques. The increase in bariatric surgery numbers is
unfortunately associated with complications that cannot be under
estimated and that have been reported with all procedures. That is why
timely diagnosis and management of these complications is an integral
part of bariatric practice. Complications or (failures) can be broadly
divided in early and late complications. Although readily reported, failure
does not have a standardized definition. Gastric band has a special foreign
body-associated nature and will therefore be separately discussed.
Acute failures or complications can be detected through reliable
clinical symptoms and signs summarized in this chapter. Radiological
studies and diagnostic laparoscopy are essential diagnostic and
therapeutic tools.
Late complications or failures will be thoroughly discussed.
Standardized techniques play the main role in the diagnosis of failure
after bariatric intervention. These techniques can be implemented in all
procedures. All these techniques will be discussed with their possible
pros and cons. Diagnostic techniques include: radiological studies,
endoscopy and diagnostic laparoscopy. Radiological studies include for
example contrast-enhanced upper GI series, computed tomography and
three-dimensional tomographic reconstructions. The role of endoscopy
and diagnostic laparoscopy will also be highlighted.
INTRODUCTION
In 2005, 23.2% (937 million) of the world‟s adult population was
overweight, and 9.8% (396 million) was obese. According to current
projections, from 2005 to 2030 the number of overweight individuals will
increase by 44%, to reach a total of 2.16 billion, corresponding to 38% of the
world‟s adult population [1]. During the same interval, the number of obese
individuals will increase by 45% to reach a total of 1.12 billion (20% of the
world‟s adult population). In 2005, the prevalence of overweight was higher in
economically developed countries compared to developing countries (35.2 vs
19.6%). Similarly, the prevalence of obesity was higher in developed countries
compared to developing ones (20.3 vs 6.7%). However, growth in population
size, aging, and urbanization of lifestyle will all contribute to an epidemic of
overweight and obesity in developing regions in the next few decades [1]. This
overwhelming increase in the prevalence of morbid obesity with its associated
comorbidities pushed institutions worldwide to search for new minimally
invasive modalities to face this epidemic. Over the past years, standard
Diagnostic Tools in Failed Bariatric Procedures
25
procedures like biliopancreatic diversion (BPD), duodenal switch (DS), gastric
banding (LAGB), and Roux-en-Y gastric bypass (RYGB) established their
position in the armamentarium of bariatric procedures. Other procedures such
as sleeve gastrectomy and mini-gastric bypass are also partially replacing old
standard procedures. More recently, newer surgical as well as endoscopic
bariatric procedures started to compete with these standard procedures.
However, this increasing number of performed bariatric interventions does
not come without complications, either acute early complications or late
complications (failures) [2]. Unsatisfactory gastrointestinal manifestations
were reported in 16.9% of patients who underwent RYGB, 7.8% of LAGB and
37.7% of BPD patients [2]. Reflux was reported by 10.9% of RYGB, and
4.7% of LASGB patients. Stomal stenosis was present in 4.6% of RYBG
patients. Even sleeve gastrectomy, although one of the most recent procedures,
suffers failures and complications as reported in many reviews [3, 4]. These
complications attributed to bariatric interventions may be indications for
operative revisions. In addition to these (anatomical) failures, another very
important cause of failure indicating revision is weight gain after bariatric
intervention. Some reports postulated that the most common cause for revision
after a bariatric intervention is weight regain or insufficient primary weight
loss after the intervention [5, 6]. Gagner reported that weight regain was the
main cause of re-operation in about 90% of patients in his series [6]. The
consideration of an intervention as failing needs an adequate definition and a
standardized diagnostic approach in order to correctly diagnose and then treat
a failure when it occurs.
DEFINITION OF A FAILED BARIATRIC PROCEDURE
Controversy exists regarding the definition of a failed bariatric procedure.
The wide spectrum of bariatric procedures performed worldwide and the lack
of standardized criteria to define success or satisfactory outcome following a
procedure plays a role. Another factor is the variation in the expected weight
loss results following each procedure. Baltasar in a recent meta-analysis
proposed that sleeve gastrectomy achieves the greatest mean BMI reduction
(12-17 units) while gastric banding produces the least satisfactory outcome in
terms of weight loss [7].
Another factor leading to the lack of definition of failure is the indication
for revision after a (possibly) failed procedure. Failure or revision after most
procedures is mainly due to inadequate weight loss. In the specific field of
26
Rudolf Weiner, Islam A. El-Sayes and Sylvia Weiner
LAGB migration or slippage are important indications contributing to the
consideration of gastric band as a (failed) procedure. This issue has been
addressed in a recent systematic review by Mann and his colleagues [8].
Although Body Mass Index Loss is the most accurate interpretation tool for a
successful or a failed procedure, still other indices are being used by other
authors, for example percentage of total body weight, or change in BMI [8, 9].
The most frequent cited definition for failure after bariatric surgery as
reported by Mann et al. was: <50% of excess weight lost (EWL), with or
without residual BMI of greater than 35 kg/m2, at 18 months post-operation.
The second most frequently cited definition was: <25% of excess weight
lost (without a time-frame specified). However, in all the reviewed studies,
there was surprisingly no comment on the effect of the primary procedure on
the associated metabolic status of the patient. Consequently, remission or
persistence of the associated primary metabolic impairment (diabetes and
hypertension in the first place) was not listed as factor in assessing whether
this procedure was successful or failed.
Additionally, most of the reviewed studies failed to report the selection
criteria for failure. In our opinion, factors such as patient dissatisfaction with
the procedure, food intolerance, and impairment of a healthy life style should
also be part of the consideration of the procedure as a failed procedure.
In summary, a consensus for standardization of the definition of failure
after bariatric procedure is still lacking.
SPECTRUM OF FAILURE OF A BARIATRIC PROCEDURE
A pitfall in most currently implemented definitions for a failed procedure
is, in our opinion, the concentration on a long-term failure, and ignoring the
acute or short-term failure. A failed procedure is also a procedure which can,
in the early post-operative course, be associated with complications.
Accordingly, early leakage or bleeding should also be counted as acute failures
and should be timely and thoroughly diagnosed and accordingly managed.
Hence, we would like to classify failures broadly as: acute failures (can
also be referred to as: acute complications) and long-term failures.
Diagnostic Tools in Failed Bariatric Procedures
27
ACUTE FAILURE, DIAGNOSIS AND POSTULATED
ALGORITHM (FOR ALL PROCEDURES OTHER THAN
GASTRIC BANDING)
To be considered successful a bariatric intervention requires thorough
understanding of the associated anatomical and physiological changes.
Consequently it is preferably performed by a highly experienced team, that can
diagnose and timely manage any deviation from the normal postoperative
course. Otherwise, potentially devastating outcomes may occur. Recent data
from the USA have reported postoperative complication rates ranging between
2.2-10.8 percent [10-12]. Retrospective analysis of our unit‟s data revealed an
early postoperative morbidity rate of 7.1 percent [13].
Early postoperative failure includes, primarily, leakage and bleeding. In
order to prevent and timely manage these events, a triad of adequate
preoperative preparation, adoption of standardized operative technique and
meticulous postoperative care is strongly recommended. During the early
postoperative phase, persistent unexplained tachycardia of more than 100
beats/min, fever (≥38.5°C), abdominal pain, tachypnea (>20 breaths/min) or
decreased urinary output despite good hydration must induce a high index of
suspicion. Laboratory findings of C-reactive protein (CRP) >150 mg/L,
leukocytosis >11,000 cells/ml or a drop in plasma hemoglobin of more than 2
gram/dl also suggest the development of complications.
We recommend CRP level and complete blood count to be routinely
checked on the first and fifth postoperative day. Diagnostic radiological and
endoscopic tools should also be readily available but they are not routinely
used in uncomplicated cases. In our center, all patients are discharged on the
fifth postoperative day, as long as the postoperative course is smooth. Our
experience suggests that postoperative hospital stay of up to five days ensures
adequate perioperative patient assessment, unless postoperative complications
necessitating a prolonged hospital stay are encountered.
Accurate diagnosis and timely management of acute failure of a bariatric
intervention can be highly challenging. Particular care must be given to this
high-risk patient group, where results of laboratory parameters may be
misleading. Reliable clinical evaluation and interpretation of radiological
studies pose another challenge. Thus, diagnosis and management of postoperative complications require an integrated teamwork approach that
analyzes the triad of clinical suspicion, altered laboratory profile and abnormal
28
Rudolf Weiner, Islam A. El-Sayes and Sylvia Weiner
radiological studies. More importantly, to date, we lack a consensus for sound
management of those complications.
HOW TO DIAGNOSE A POSSIBLE EARLY COMPLICATION?
1. Laboratory Parameters
Routine postoperative check of patient‟s laboratory profile (full blood
count and CRP) should be a standard practice. Any deviation from the normal
values should be strictly monitored. CRP and leukocyte count play a major
role in the early detection of postoperative complications, especially staple line
disruption and leakage [14] Analysis of our data showed that elevated CRP
and leukocytosis were detected in 18 patients (36.5 percent) out of 49 patients
and 31 patients (47%) out of 66 patients with early complications after RYGB
and sleeve gastrectomy respectively, including 19 patients (86.3%) and 12
patients (100 percent) who developed early postoperative leakage after those
procedures [13].
Postoperative check of hemoglobin level is also mandatory. A drop of
more than two grams/dl should warrant further work up, especially if
combined with tachycardia, evidence of gastrointestinal bleeding or excessive
bloody drain effluent.
2. Clinical Symptoms and Signs
Abdominal pain, nausea and vomiting requiring excessive analgesic or
antiemetic treatment should raise the suspicion of possible complications.
Hypotension, tachycardia, fever, tachypnea, dyspnea, low urinary output and
abnormal color or increased volume of drain effluent should also be handled
with a high index of suspicion [15]. Additionally, hematemesis or melena raise
the suspicion of staple line bleeding. To date, the sensitivity and specificity of
these parameters have not been well studied. Tachycardia seems to be
correlated with the highest sensitivity and specificity amongst the other
parameters [16, 17]. In our center, tachycardia was found in five patients
(42%) and seven patients (37%) who developed early post-operative leakage
and bleeding respectively [13].
Diagnostic Tools in Failed Bariatric Procedures
29
3. Radiological Studies
Extravasation of gastrointestinal contents can be diagnosed radiologically
by contrast-enhanced computed tomography (CT) scans with oral contrast
(Figure 1) or by gastrograffin swallow studies (Figure 2).
Figure 1 and Figure 2. Extravasation of gastrointestinal contents can be diagnosed
radiologically by contrast-enhanced computed tomography (CT) scans with oral
contrast (Figure 1) or gastrografin swallow studies (Figure 2).
30
Rudolf Weiner, Islam A. El-Sayes and Sylvia Weiner
The presence of an abscess cavity, air foci (Figure 1) in the vicinity of the
operative field or stranding in the mesentery on CT scans raise the possibility
of leakage. Pleural effusion or pneumonia may also be suggestive of an
underlying leak [18]. Intra- as well as extra-luminal bleeding can be diagnosed
by CT scans. [19, 20]. The same applies to abdominal wall bleeding and
intraoperatively inflicted solid organ injury.
Some authors perform routine postoperative gastrograffin upper GI series
for all their patients due to simplicity and relatively low cost of the procedure
[21]. Negative studies should however not mislead the surgeon in the presence
of a strong clinical suspicion [15]. Mittermair et al. [22] reported complete
inadequacy of gastrograffin series to detect leakages in their patients. Such
data together with the radiation exposure accompanying these diagnostic
modalities questions the necessity of their routine postoperative use.
4. Diagnostic Laparoscopy (DL)
DL is the most reliable tool to confirm or rule out serious early
postoperative issues including leakage and extra-luminal bleeding in patients
with suspicious clinical, laboratory or radiological findings.
In our personal series, we have observed a 100% specificity for DL in 23
patients with complicated sleeve gastrectomy: DL confirmed complicated
post-LSG course (13 patients with bleeding, nine with leakage and one with
trocar-site hernia). This observation should be compared with the findings
with RYGB: a specificity of only 70 percent in 33 patients with suspected
complications. DL confirmed complications suspected by routine
postoperative check in only 23 patients (12 patients with leakage, seven with
bleeding, three with trocar site hernia, and one with small bowel obstruction)
whereas it was negative in 10 patients (Table 1).
The discrepancy between RYGB and sleeve gastrectomy may be
attributed to the fact that DL can miss some complications such as transient
internal herniation, twisted gastro-jejunal or entero-enteral anastomotic
reconstruction, intussusception or anastomotic ulcer post-RYGB. These
factors that can lead to transient deviation from normal post-RYGB course are
not encountered after LSG. The results are currently under further analysis for
future publication.
The incidence of bleeding after obesity surgery ranges from 0.6 to 4
percent [23, 24]. Stapling through highly vascular tissues can be followed by
considerable amount of intra- as well as extra-luminal (intra-peritoneal)
31
Diagnostic Tools in Failed Bariatric Procedures
bleeding. Bleeding should be controlled by surgical intervention (hematoma
evacuation, over-sewing, and drainage) when patients are hemodynamically
unstable. In hemodynamically stable patients, we usually resort to
conservative methods with fluid resuscitation, blood transfusion (if necessary)
and careful observation.
Table 1. Value of diagnostic laparoscopy (DL) in patients with a
suspicious (*) post-operative course after LSG vs. LRYGB
First detected
indication for DL
Elevated CRP
LSG
N = 23
Diagnosis
confirmed by
positive DL
Leakage: 7
Negative
DL
LRYGB
N = 33
Diagnosis confirmed
by positive DL
Negative
DL
0
Leakage: 9
Trocar site hernia: 2
4
Tachycardia
Bleeding: 9
Leakage: 1
0
Bleeding: 6
Leakage: 3
4
Abdominal pain
Bleeding: 3
Trocar site
hernia: 1
0
Bleeding: 1
Trocar site hernia: 1
2
Suspicious CT
scan
Bleeding: 1
0
SBO: 1
0
Leakage: 1
Total number (%)
23 (100%)
(p<0.05)
0 (0%)
23 (70%)
10
(30%)
LRYGB: laparoscopic Roux-en-Y gastric bypass, SBO: small bowel obstruction.
Values refer to number of patients in whom DL was done and confirmed or excluded a
suspected acute post-LSG complication.
* Suspicious means: Persistent unexplained tachycardia of more than 100 beats/min,
fever (≥38.5 C), a more than routinely-encountered post-operative abdominal
pain, tachypnea (>20 breaths/min), or decreased urinary output despite good
hydration, C-reactive protein (CRP) >150 mg/l, leukocytosis >11,000 cells/μl or a
suspicious CT scan.
We propose the following algorithm (Algorithm 1) for possible diagnosis
and management of acute failures after bariatric intervention.
32
Rudolf Weiner, Islam A. El-Sayes and Sylvia Weiner
Algorithm 1. Management of patients with suspected acute leakage after bariatric
intervention.
LATE FAILURE AFTER BARIATRIC INTERVENTION;
SPECTRUM OF DIAGNOSTIC MODALITIES
After briefly discussing the acute failure of a bariatric procedure, we
would like to address the long-term failure of a bariatric procedure, which is a
failure occurring after an uneventful early post-operative phase. All bariatric
procedures can be subjected to long-term failure.
In our opinion LAGB should be separately discussed because of the
specific nature of this foreign body-associated procedure. In addition to the
common causes of long-term failures encountered with other procedures
(weight regain, reflux, hiatal herniation, ulceration,…..) and urgent bandrelated conditions (gastric perforation, volvulus, abscess formation,….),
Diagnostic Tools in Failed Bariatric Procedures
33
LAGB can cause two special conditions or causes of failure, namely: band
slippage and band migration.
Diagnosis of Band Slippage
Band slippage is encountered in 4-13% of patients [25]. Patients with
slipped band usually present with manifest upper abdominal pain and acute
upper obstructive manifestation. If neglected these can progress to gastric
gangrene by strangulation of the blood supply of the pouch. Band slippage is
usually an acute condition, and should be timely diagnosed and properly
managed. Band slippage is often recognized on gastrografin upper abdominal
series. The slipped band tends to be more horizontally placed [26]. Through
the weight of the herniated stomach, the anterior and posterior band margins
are no longer opposed and give the so called O sign [27]. Because of the
progressive obstruction and strangulation, an air-fluid level may appear in the
proximal gastric pouch.
Diagnosis of Band Erosion
Band erosion is usually a gradual process that can progress from
incomplete to complete intra luminal band migration. Band migration usually
presents with vague manifestations, including loss of restriction (with possible
weight gain), upper abdominal pain and port site pain or port site infection.
Band erosion is typically detected by gastroscopy. A systematic review of
band erosion in 15,775 patients revealed 231 cases of erosion (1.46%) in
15,775 all detected by gastroscopy [28]. This experience should not understate
the role of radiological interventions in the diagnosis of this event. In
fluoroscopic series, a leak of contrast around the eroding location of the band
can be detected. CT scans can also detect a completely migrating band, with
more certainty than incomplete erosion [29].
Port-Related Complications
Two important port-related complications are port inversion and tubing
defect or disconnection. Port displacement can be readily detected in
abdominal radiographs. Tubing system defect or disconnection can be
34
Rudolf Weiner, Islam A. El-Sayes and Sylvia Weiner
diagnosed by water soluble contrast material injection in the port system.
We propose an algorithm for rapid assessment and diagnosis of gastric band
failures (algorithm 2)
Algorithm 2. How to manage a failed band.
RADIOLOGICAL DIAGNOSTIC TOOLS FOR A FAILED
BARIATRIC INTERVENTION
Fluoroscopy (Upper GI Series)
Water-soluble contrast upper GI series have commonly been used to show
the pathway constructed by a bariatric procedure, be it restrictive or
Diagnostic Tools in Failed Bariatric Procedures
35
malabsorptive. In sleeve gastrectomy, the currently most commonly performed
restrictive procedure, different patterns of the residual stomach have been
described by Werquin et al. [30]: a tubular pattern (66%) with a uniform
caliber, the superior pouch pattern (26%, with a wide superior component of
the retained fundus that gradually fills), the inferior pouch pattern (8%, with a
wide residual distal component), the superior-inferior pouch pattern (both
proximal and distal pouches), the pseudodiverticular pattern with a diverticular
dilatation of the lesser curve. Other rare patterns, such as the corkscrew have
also been reported [31].
Long-term failure of sleeve gastrectomy can be seen in fluoroscopic upper
GI series, where gastric dilatation or stenosis can be diagnosed. Gastric
dilatation is usually suspected in fluoroscopy by loss of the normal tubular
pattern of the sleeve and pouch enlargement. Stenosis can be readily seen by
impaired distal contrast flow, and may be associated with proximal gastric
dilatation (Figure 3), gastro-oesophageal reflux and hiatal herniation.
Figure 3. Stenosis can be associated with proximal gastric dilatation.
Upper GI series play also a significant role in failed malabsorptive
procedures. Assessment of the proximal pouch, the alimentary limb and the
site of the gastro-eneterostomy can be accomplished by fluoroscopic series.
Gastric pouch size can be readily assessed by upper GI series, especially if
36
Rudolf Weiner, Islam A. El-Sayes and Sylvia Weiner
compared with immediate post-operative series. Shah et al. [32] described that
the size of the gastric pouch after RYGB should be the same as that of lower
thoracic or lumbar vertebral body. Upper GI series by their dynamic nature
allow to demonstrate stenosis of the gastroenterostomy. Pouch distension and
delayed passage of contrast through a smooth narrowing are highly suggestive
for this condition [32].
Although not typically diagnosed in upper GI series, a stenosis of the
entero-enteral (JJ) anastomosis can also be shown on these series. If stenosis is
associated with significant stasis at the pancreaticobiliary limb, symptoms may
include pancreatitis and biliary stasis. The stasis may be severe enough to
induce gastrogastric fistulation or rupture (blow out) in acute cases. This
situation may be diagnosed on dynamic series by stasis of contrast flow,
retrograde passage in the biliopancreatic limb or reflux in the alimentary limb.
Plain abdominal films may also show fluid level formation.
In malabsorptive procedures a specific cause of failure is blind loop
formation. This formed sac acts as a reservoir or a second stomach, which
overtime may lead to loss of the restrictive element of the procedure. Late
evacuation of its contents is in our opinion another cause for late dumping
symptoms. Additionally, recurrent abdominal colics and bacterial overgrowth
may be associated with blind loop sac formation.
Marginal ulcers developing at the gastroenerostomy site are an important
cause of failure after bariatric procedures, usually presenting with vague upper
abdominal complaints (Pain, nausea, vomiting, etc). Smoking and chronic acid
exposure are possible precipitating factors. In upper GI series these ulcers can
be seen as ulcer niches at the anastomosis site or in the proximal part of the
alimentary limb [33].
Another condition that may occur after bypass procedures is internal
herniation, a situation linked tot the creation of peritoneal defects. This
condition can also be detected in GI series when small bowel limbs containing
contrast in their lumens are seen within the hernia space [34, 35].
Dynamic upper GI series may also help in the diagnosis of gastro-gastric
fistulation, when contrast flows in the distal pouch.
Despite the value of fluoroscopy in obesity practice, practical difficulty in
performing the study may influence interpretation [36]. Practical difficulties
include for example fluoroscopy table weight limit. Most currently used static
tables tolerate not more than 550 pounds (400 pounds for movable tables).
However, larger capacity systems are now available with weight limits up to
600 pounds for static tables and 500 pounds for movable tables. The problem
of poor interpretation can be overcome by performing the study in supine
Diagnostic Tools in Failed Bariatric Procedures
37
position with lateral spread of weight, leading to decreased thickness of
abdominal wall tissues and accordingly better interpretation of the study with a
lower dose of radiation. Another issue is the distance between the table and the
radiation source, which typically ranges from 45 to 49 cm, and reaches in
recent devices up to 60 cm. Performing the study in supine position may allow
a better accommodation of the patient in the device. A third problem is the
width of the table, which if insufficiently wide, may lead to patient instability
during the examination. A fourth problem is the need for a higher dose of
radiation to penetrate through a relatively thicker abdominal wall.
In fluoroscopic diagnostic studies we prefer to use water soluble contrast
(Gastrograffin). This avoids the risk of barium induced peritonitis and at the
risk of impaction at any stenotic site. An important precaution point is to allow
for a reasonable period of fasting after gastrografin intake in cases where an
operation is indicated. Alternatively, gastric decompression should be tried.
Several reports documented the irritating hypertonic effect of gastrografin on
bronchial epithelium, and the occurrence of marked pulmonary oedema and
even death in case of aspiration [37].
Apart from 3D gastric pouchography, which is of utmost importance in
follow-up of all bariatric interventions, conventional abdominal CT scans
(enhanced by oral and intravenous contrast) are also of value in assessing
failure or complications after bariatric interventions. Because we are focusing
in this chapter on long-term failures after bariatric interventions we will not
discuss the major role of CT scans in assessing acute complications after
surgical interventions. Instead, we will mention some possible causes of
failure, that can be diagnosed on routine CT scans.
Recurrent weight gain or insufficient weight loss can result from
enlargement of the constructed pouch and/or the alimentary limb. This can be
easily detected on abdominal CT scans. After sleeve gastrectomy, loss of the
normal tubular shape of the constructed pouch denotes a possible cause of
insufficient weight loss. After malabsorptive procedures, pouch enlargement,
distension of the alimentary limb, or widening of the anastomosis play a
similar role.
Measuring the diameter of the gastroenterostomy during examination
should be a routine part of interpretation of CT scans in patients who
underwent malabsorptive bariatric interventions. In these scans, administration
of an oral contrast material just prior to the examination helps to diffentiate the
gastric pouch, gastroenterostomy and alimentary limb (which are opacified)
from the biliopnacreatic limb and enteroenterostomy (non opacified). This is
essential for adequate interpretation of the cause of failure and also for
38
Rudolf Weiner, Islam A. El-Sayes and Sylvia Weiner
detecting potential events like internal herniation. Distention of the gastric
pouch and collapse of the distal pouch are also important features. The normal
peristaltic movements of the biliopancreatic limb protects from retrograde
passage of contrast material or gases in this limb [29, 38].
Through oral contrast intake, conditions such as gastrogastric fistulation
can be detected by abnormal flow of contrast in the distal gastric pouch.
Similarly, with adequate localization of the gastric pouch and alimentary limb,
blind loop formation (also at the site of the enteroenterostomy) may be seen.
Although not typically diagnosed, marginal ulcerations have been reported to
be detected on CT abdominal scans [39].
THREE DIMENSIONAL CT ASSESSMENT
A corner stone in accurate assessment of failure after bariatric intervention
is the proper outlining of anatomical changes in the gastro-intestinal tract,
which allows to choose the best management or revisional modality. Previous
studies reported that accurate assessment of pouch size enables the surgeon to
design the best strategy and perform the best available intervention [40]. Here,
we think that 3D pouch construction provides the best aid to the treating team.
Despite reports that endoscopy, upper GI series and CT scans are the most
commonly used assessment modalities [41-45], we believe that they don‟t
offer sufficient data. Endoscopy is to some extent operator-dependent and
routine CT is of a higher value in the evaluation of acute complications.
Endoscopy is more invasive and is not free of complications. Moreover,
insufflation of air during endoscopy may lead to over-distension of the gastric
pouch [40]. The classical upper GI series can be useful in providing
approximative data for pouch volumes. Langer and his colleagues postulated
that a sleeve wider than 4 cm is considered to be dilated, but they did not
estimate the sleeve volumes [46].
Three dimensional CT gastric reconstruction (together with alimentary
limb reconstruction) represents in our opinion the best investigative modality
for pouch and alimentary limb. Based on our experience, we affirm that this
modality of investigation gives the most accurate reconstruction of the actual
intra-abdominal anatomy. Sets required for this investigative modality should
be an integral part of any center practicing obesity surgery.
Although there were reports [47] comparing the accuracy of pouch
measurements after gastric bypass using gastroscopic assessment versus those
using 3D pouchography did not find statistically significant difference
Diagnostic Tools in Failed Bariatric Procedures
39
between both measurements, we still stress on the superior value of 3D
pouchography. As mentioned, interpretation of endoscopic findings can be
operator dependent. Many authors support our opinion regarding the value of
3D gastric pouchography [48]. Technically, 3D pouchography entails drinking
a powder or effervescent granules diluted with water after overnight fasting.
Ingestion allows stomach distension with air. This distension helps in
obtaining an actual picture for the current gastric (and alimentary limb)
anatomy. Addition of a spasmolytic agent is indicated. Some authors prefer
glucagon [47], others tend to use Buscopan® [40]. Thin slice scans (1 mm) are
taken and three dimensional volume-rendering images created in a 3D
workstation. The modality is described in different techniques using different
contrast agents. [40, 47, 48] Some authors tend to use iodine containing
contrast agents [40], others prefer effervescent granules without the use of
iodine-containing oral contrast agents [47].
Some authors [47] resort to 3D pouchography to obtain base line data for
future comparison in patients with non-satisfactory results after bariatric
intervention. Through this modality a large and sufficient deal of information
can be available which, if properly analyzed, usually allows for the best
intervention to overcome the encountered failure after a bariatric intervention.
A large pouch can be easily assessed (Figure 4).
Figure 4. A large pouch after sleeve gastrectomy seen on CT pouchography.
40
Rudolf Weiner, Islam A. El-Sayes and Sylvia Weiner
Other abnormalities such as loop formation, a wide gastroenterostomy and
a twisted pouch (Figure 5) can be readily diagnosed [40]. In addition, hiatal
herniation, a common cause for complaints after bariatric intervention can be
adequately diagnosed (Figure 6).
Figure 5. A twisted pouch after sleeve gastrectomy.
Other less readily detected pathologies, e.g., gastro-gastric fistulation are
also readily seen in 3D pouchographies. Reports from different centers on
cases of fistulation that failed to be diagnosed despite several gastroscopies
and upper GI series have been published [40].
Moreover, computed tomography with 3D imaging has been shown to be
of reasonable value in patients with previous gastric banding, because it allows
to delineate the entire band, location and orientation, as well as related
complications such as erosion, slippage and infection. Port-related
complications may also be detected [49].
A possible limitation of this modality is ist inherent radiation exposure
[50], although low dose exposure with a highly preserved quality can be
achieved in recent stations [48, 51]. Some assume that the radiation dose used
Diagnostic Tools in Failed Bariatric Procedures
41
in 3D CT imaging does not exceed the radiation dose in conventional CT
scans [48].
Blanchet et al. mentioned additional limitations of this technique [48] i.e.,
the need for a recently equipped station, and the learning curve required for
performing the study and interpreting its findings (although the latter usually
does not exceed 10 minutes after achieving an adequate learning curve).
Inadequate fasting or failure of adequate oral intake of the contrast agent [40],
leads to incomplete distension of the pouch and inadequate interpretation of
the results.
Figure 6. Hiatal herniation, a common cause for complaints after bariatric intervention
can be adequately diagnosed on CT pouchography.
ROLE OF ENDOSCOPY IN FOLLOW-UP AND DETECTION
OF FAILURES OR COMPLICATIONS AFTER BARIATRIC
INTERVENTIONS
Endoscopy plays a major role in the bariatric field in that it allows
evaluation of symptoms attributed to complications or failures after surgery. In
42
Rudolf Weiner, Islam A. El-Sayes and Sylvia Weiner
an analysis of more than 7,000 restrictive and malabsorptive procedures 4
main complications were reported after restrictive prrocedures; pouch or stoma
dilatation (2.4%), stomal stenosis (2.2%), staple line failure (1.5%) and
stomach erosions (1.2%). These complications were also reported after
malabsorptive procedures with incidences of 0.47%, 2.7%, 5.9% and 1.2%
respectively. These figures denote the importance of follow-up endoscopy in
assessing failures and complications after bariatric interventions [52]. That is
why we recommend a scheduled follow-up endoscopy regimen after bariatric
interventions. The diagnostic spectrum of gastroscopy in patients with failed
bariatric surgery is very broad and better to be illustrated based upon which
procedure is performed and its possible causes of failure or complications.
Follow-Up Endoscopy after Roux-En-Y Gastric Bypass
Patients with nausea, vomiting or dysphagia after RYGB should have a
gastroscopic evaluation to rule out conditions like marginal ulceration in 2752% of patients followed by stomal stenosis in 4 -39% [53, 54, 55].
Stomal Stenosis
An anastomosis is considered stenotic if the normal 9.5 mm endoscope
cannot readily bypass it [56]. Stenosis has a reported incidence of 5-12% after
LRYGB [57, 58]. Possible underlying factors for a stenotic gastrojejunostomy
include local ischemia, the use of a circular stapler and local inflammation (by
smoking for example) [56].
In case of stenosis in the presence of active marginal ulceration ulcer
treatment should be initiated prior to dilatation of the stenosis to avoid
inadvertent perforation during the dilatation sessions [56]. An intended
diameter of dilatation to avoid symptomatic recurrence is 15 mm [59]. An
important point to be considered here is to adequately assess the proximal part
of the alimentary limb to rule out any associated pathology or active
ulceration.
Endoscopic dilatation can be safely started 4 weeks post-operatively [59,
60] and is usually performed using balloon dilatation through a bougie passed
over a guide wire. Guide wire guidance is essential when a bougie cannot be
readily passed through a stenotic stoma [56]. Torsion, angulation of the stoma
and marginal ulceration are all underlying factor for failed dilatation.
Diagnostic Tools in Failed Bariatric Procedures
43
Marginal Ulceration
This condition is reported to vary in incidence from 0.6-16% [45].
Marginal ulcers are asymptomatic in more than 20% of cases [58]. Ulcer
development is limited to the intestinal side of the anastomosis [56].
An important predisposing factor for marginal ulceration and pouch
inflammation is H.Pylori infection. Although not highly sensitive, mucosal
biopsies should be taken prior to and during every follow-up endoscopic
session after RYGB, and the same applies to all bariatric interventions. A
proved infection should be thoroughly treated and follow-up endoscopy after
eradication is a routine practice in our patients.
Other factors than H. Pylori infection have been strongly linked to
marginal ulceration. These factors may be either intrinsic or extrinsic. The
former include pouch acid production, pouch ischemia and gastrogastric fistula
due to retrograde passage of acid produced from the distal pouch into the
constructed pouch and subsequently over the site of the anastomosis. The latter
include smoking and alcohol consumption.
Pouch and Stomal Dilatation and Blind Loop Formation
This triad represents an important cause of failure after RYGB. In this
case failure is determined by insufficient weight loss or weight gain. Through
any of those three causes, an abnormally large amount of food will be ingested
and rapidly dumped distally. This can simply be explained by loss of
restriction. During endoscopy, length of the pouch (distance between the
gastro-oesophageal junction and the stoma) can be readily measured. Despite
the fact that the diameter of the stoma can be assessed by experience of the
endoscopist, it cannot be actually measured.
Thanks to the advances in interventional endoscopic techniques, the
spectrum of endoscopic applications exceeds the diagnostic level and reaches
the therapeutic level. Techniques as the endoscopic overstitch are currently
practiced in our clinic, but results are still in the evaluation phase.
Gastro Gastric Fistulation
An important cause of failure after RYGB is the formation of a
gastrogastric fistula. A channel is gradually formed between the proximal and
distal gastric pouches. This condition has two effects. First, the restrictive
effect of RYGB is lost due to the passage of food stuffs from the proximal
pouch into the distal pouch which causes the patients to tolerate larger
44
Rudolf Weiner, Islam A. El-Sayes and Sylvia Weiner
volumes of meals. Second, the retrograde passage of acid from the distal into
the proximal pouch results in exaggerated effect of gastric acid on the
constructed stoma, with consequent oedema, ulceration and stenosis. This
event is not easily found during routine endoscopy performed by nonexperienced personnel. As previously mentioned, pouchography plays a major
role here. Still, besides its possible therapeutic role, endoscopy can assess this
situation, and get access to the distal stomach pouch.
Follow-Up Endoscopy after Sleeve Gastrectomy: (Figure 7)
Stenosis of the Sleeve
Although uncommon, stenosis is a serious complication after sleeve
construction. We experienced cases with severe nutritional impairment due to
sleeve stenosis, up to Beri Beri and Wernicke‟s encephalopathy. Stenosis is
most common at the incisura angularis. In our opinion, gastroscopy can help in
evaluation of a stenotic sleeve. It is noteworthy that the stenotic segment can
be overlooked when the endoscope, when it crosses the stenosis thanks to its
mere weight. This is why we recommend pouchography for the accurate
assessment of the stenotic segment before ruling out sleeve stenosis (Figures 8,
9, 10)
Figure 7. Follow-up endoscopy after sleeve gastrectomy showing a gastric fistula.
Diagnostic Tools in Failed Bariatric Procedures
Figure 8.
Figure 9.
Figures 8, 9, 10. (Continued).
45
46
Rudolf Weiner, Islam A. El-Sayes and Sylvia Weiner
Figure 10.
Figures 8, 9, 10. Sleeve stenosis as seen on CT pouchography.
Sleeve Dilatation
Long-term results after sleeve gastrectomy are not universally satisfactory
in terms of weight loss and weight regain has been reported in 75% of the
cases [61]. This finding has been correlated with increased sleeve volume.
Consequently assesment of the sleeve volume in late follow-up sessions is of
utmost importance. Patients presenting for evaluation of weight regain or nonsatisfactory weight loss undergo a standardized assessment that mainly
includes endoscopic assessment followed by pouchography.
During endoscopy, a wide sleeve, allowing swift retroflexion or inversion
of the gastroscope, usually indicates an increased sleeve volume. Accurate
measurement of the sleeve volume and shape however cannot be accomplished
by endoscopy. The full assessment usually proceeds to pouchography to
delineate the new sleeve shape.
Diagnostic Tools in Failed Bariatric Procedures
47
Follow-Up Procedures After Malabsorptive Procedures
(Biliopancreatic Diversion, BPD)
As for RYGB, pouch assessment (whether a large pouch of 200-500 ml
size in BDP Scopinaro or a tubular sleeve in duodenal switch) and stomal
inspection can be endoscopically performed. Biopsies from a marginal ulcer or
for detection of H. Pylori gastritis, or from ileal mucosa can be easily
achieved. Conditions involving stomal stenosis, pouch dilatation or blind loop
formation are very amenable.
Follow-Up Procedures After Vertical Banded Gastroplasty
Vertical banded gastroplasty is no longer a common bariatric practice.
This procedure remains interesting because of the common presentation of
patients with history of vertical banded gastroplasty who suffer from problems
related to the functional failure of this procedure. A high pressure created by a
stenotic distally applied ring or mesh is cranially propagated. This leads to a
common triad of presentations; gastro-oesophageal reflux, pouch enlargement
(new stomach) and gastro-gastric fistula. The latter two phenomena are
associated with loss of restriction with resultant weight gain. All these changes
can be detected endoscopically. Again, the accurate volumetric assessment is
better achieved by pouchography.
Follow-Up Procedures After Gastric Banding
At endoscopy a normally functioning non-complicated band in
retroflexion appears as a belt surrounding the gastroscope. However, two
important conditions have to be carefully assessed after gastric banding; band
erosion and band slippage. We discussed before band slippage, a condition
that as mentioned before is better assessed by upper GI series. Band erosion is
also diagnosed by upper GI series, but endoscopy here seems tob e a better
diagnostic tool.
Band erosion has been reported in rates ranging up to 2.8%. [62] Band
erosion is a gradual process involving penetration of the tight band into the
gastric wall. The blackish discoloration of the eroding segment is
pathognomonic and is possibly due to the burning effect of gastric acid on this
segment.
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Rudolf Weiner, Islam A. El-Sayes and Sylvia Weiner
Patients suffering from band erosion usually present with a gradual loss of
the restricting effect of the gastric band. Sometimes the first manifestation of
erosion is tenderness or infection of the port of the migrating band, due to
ascending infection along the tubing system. Endoscopy can be both
diagnostic and therapeutic in these cases, as band extraction can be completed
endoscopically provided more than 50% of the band circumference is eroding
inside the stomach lumen [56].
Endoscopy and Hiatal Hernia After Bariatric Intervention
A commonly encountered event after bariatric intervention is hiatal
herniation. Either this herniation was already present at the time of the primary
intervention, or it developed by disappearance of the fat pad surrounding the
cardia as a part of weight loss after bariatric surgery. This leads to the classical
symptoms of hiatal herniation presenting as epigastric discomfort, dysphagia
or reflux manifestations.
Endoscopy has been broadly used in the diagnosis of this type of sliding
hiatal herniation. Herniation can be assessed by one of two methods [63]:
either by measuring the distance between the squamocolumnar transition and
the diaphragmatic impression (usually considered when more than 3 cm), or
by inspecting the impression of a patulous diaphragmatic sphincter by a
retroflexed endoscope).
Endoscopy and Reflux Disease After Bariatric Intervention
Another important cause of failure or dissatisfaction after bariatric
intervention is the development of gastrooesophageal reflux disease. Patients
usually present with typical manifestations including dull aching upper
abdominal pain, heart burn, vomiting and dysphagia with in extreme cases
reflux of gastric juice through the nose. We saw many cases presenting with
intolerable reflux manifestations, mainly after sleeve gastrectomy. That is why
diagnosis of gastro-esophageal reflux disease should be a routine part of
follow-up after bariatric intervention. Differential diagnostic points include
other medically-treatable causes (e.g.: H. Pylori induced gastritis and marginal
ulceration, etc.). After ruling out all medical causes, and after failure of
medical management of reflux, a surgical approach may be required, for
example conversion of a sleeve into RYGB. The role of endoscopy in this
Diagnostic Tools in Failed Bariatric Procedures
49
condition should be respected. The presentation with the typical findings of
reflux on endoscopy is diagnostic with a specificity of about 95% [64, 65].
Role of Diagnostic Laparoscopy in Assessment of Failure After
Bariatric Intervention: (Figures 11, 12)
Laparoscopy constitutes one of the best diagnostic (and at the same time
therapeutic) modalities.
Some patients are presented with failures or complications after bariatric
interventions that remain unexplined despite a full diagnostic work-up.
Conditions such as extensive adhesions, blind loop formation, twisted
pouches or sleeves, hernitations (whether internal or hiatal) may escape
diagnosis by the routinely available techniques. This is a frequent event. In
these patients, diagnostic laparoscopy gives the highest level of accuracy and
offers at the same time a simultaneous therapeutic option. (See before also, the
role of diagnostic laparoscopy in the assessment of acute failures after bariatric
interventions)
Figure 11.
Figures 11 and 12. (Continued).
50
Rudolf Weiner, Islam A. El-Sayes and Sylvia Weiner
Figure 12.
Figures 11 and 12. Diagnostic laparoscopy offers the best sensitivity for complications
or failures after bariatric intervention. See the hiatal herniation (Figure 11) and the
extensive adhesions (Figure 12) which may cause failure after bariatric interventions.
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In: Management for Failed Bariatric Procedures
ISBN: 978-1-63483-753-8
Editors: J. Himpens and R. Vilallonga © 2015 Nova Science Publishers, Inc.
Chapter 4
ADJUSTABLE GASTRIC BAND FAILURES
J. W. M. Greve
Bariatric and gastrointestinal surgeon,
Medical director Dutch Obesity Clinic South
Department of Surgery, Zuyderland Medical Center Heerlen
and Orbis Medical Center Sittard, Heerlen, the Netherlands
ABSTRACT
The adjustable gastric band is a good treatment option but requires a
strict follow up and good compliance of the patient. Despite good results
failures do occur either due to technical failures or patient noncompliance. Failure can also be a result of band complications.
In many cases surgical revision is possible either by repositioning of
the band or replacement of the band. A back on track program and band
adjustments can also result inrecovering an initial good result.
In case of band failure conversion to another technique is shown to
be safe and effective. A good treatment strategy is based on the
conclusions of a mandatory multidisciplinary team.
Failure of an initially successful band is rather a phase in a life long
obesity treatment program and not a disqualification of the band as valid
treatment option.

E-mail address: [email protected].
58
J. W. M. Greve
1. INTRODUCTION
In search for a safe and effective surgical treatment for morbid obesity the
idea of an adjustable band was developed. As early as 1982 a first paper on
adjustable gastric banding was published and mid eighties of the past century a
workable device was constructed and used clinically [1, 2]. Laparoscopic
placement made it a very successful and frequently used device (Cadiere,
Belachew) [3, 4]. Many types of the adjustable silicone gastric band (ASGB)
have been developed over the years. The most important improvement was a
change from low volume high-pressure bands to high volume low-pressure
bands, which reduced the risk of erosion significantly. Placement of the band
in the early days was peri-gastric creating the retro gastric tunnel by dissecting
at the lesser curve of the stomach. This technique had a significant erosion rate
probably due to micro lesions of the stomach wall. Moreover due to placement
through the lesser sac with a relatively large pouch slippage and pouch dilation
were a frequent problem. These problems were significantly reduced by
introduction of the pars flaccida technique [5].
Over the years it has been shown that follow up is crucial in a successful
treatment program in patients with an adjustable gastric band. There is a
significant correlation between frequency of follow up and weight loss as was
shown by Ren and colleagues [6]. Several algorithms have been proposed to
improve outcome, in particular on when and how to adjust the band. The green
zone concept by O‟Brien based on clinical parameters is the most effective,
but other options are available such as adjustments based on balloon pressure
as proposed by Fried [7]. When all criteria are fulfilled (correct placement,
correct type of band and an optimal follow up program) good long term results
(>5 years) can be achieved that are comparable to the gastric bypass [8, 9].
Currently however, most bariatric surgeons no longer consider the
adjustable band as a viable treatment option. Long term results from early
series with inferior band types and poor follow up programs show very poor
results with a high percentage of revisions and band removals and few patients
with sufficient long-term weight loss. Poor results and the introduction of
“easy, no worry, procedures” such as the gastric sleeve resection has resulted
in dramatic reduction of band placements, partly under pressure of the public
opinion. Nevertheless with a good patient selection and a good follow up
program the adjustable band is still a very valid treatment option.
As all bariatric procedures the adjustable band is not flawless. Even in
good programs problems may occur that need correction. Moreover more than
800,000 bands have been placed worldwide which means that, even with low
Adjustable Gastric Band Failures
59
failure rates, there will be a significant number of patients that may need a
revision or conversion of the procedure.
2. BAND FAILURES
Failures of the band can be divided in several categories. Primary failures
pertain to patients who never reach a desired weight loss, which can be due to
a technical problem (high band position, large size of the band, malposition of
the band, mechanical defect of the band etc.) or due to non-compliance of the
patient (poor diet habits, failure to adhere to the follow program). A second
category consists of the patients who had a successful weight loss but then
regained weight. This can be due to a mechanical failure (band leakage, tubing
or port disconnection, tubing breakage), slippage of the band or pouch dilation
or changed dietary habits of the patient while some patients develop band
intolerance. A third category consists of the patients with a band complication,
a condition that often needs acute intervention. Examples are acute herniation
of the stomach through the band, acute obstruction, erosion of the band,
internal herniation of bowel around the tubing but also severe reflux and/or
esophagus dilatation.
3. GENERAL CONSIDERATIONS IN REVISION
OR CONVERSION
When a surgical procedure is required to improve the outcome of the
patient this can either be a revision/correction of the current procedure (e.g.,
band reposition, band replacement, port revision etc.) or a conversion to a
different type of procedure [10]. Reversal is in itself an easy procedure but
should only be considered on explicit patient request or under rare
circumstances. Just removing the band will without exception result in weight
regain and loss of the positive effect on the co-morbidities. If a band is
removed it is advisable to take down the entire plication (gastro-gastric
sutures) in case the patient reconsiders and comes back for a new bariatric
procedure.
In all patients careful evaluation by a multidisciplinary team including a
dietician, psychologist and bariatric surgeon is mandatory. This may help to
identify patients who have a deteriorated eating pattern or inappropriate life
60
J. W. M. Greve
style changes. In these patients a “back on track” program and careful
adjustment of the band may be sufficient. However multidisciplinary team
evaluation can also assist in the decision on which strategy to follow when a
revisional procedure or a conversion to another technique is required. Next to
evaluation of patient behavior upper gastrointestinal X-ray and or endoscopy
are required to detect technical failures or band complications. The final
decision for an intervention should always be based on evaluation of all results
by the multidisciplinary team.
4. PRIMARY FAILURE
Primary failure as a result of a technical failure should be evaluated
carefully. In all patients dietary counseling is mandatory as well as evaluation
of filling volume of the band. Life style modifications need to be recorded as
well. Diagnosis based on these results is a multidisciplinary team effort. X-ray
and or endoscopy are required to exclude a technical problem. If there is a
band malfunction (leakage, band not closed) or malposition of the band (band
not around the stomach) a revision of the band is required by either
replacement of the band or repositioning. In case of a high band position (no
stomach above the band, Figure 1C) successful reposition of the band is
unlikely and conversion to another procedure is required.
Available options are Roux en Y gastric bypass (RYGB), sleeve
gastrectomy (SG), biliopancreatic diversion (BPD), duodenal switch (DS) or
omega loop gastric bypass. More recently some surgeons have added a gastric
plication to the band but long term results are not available yet [11].
Conversion of a failed restrictive procedure to a new type of restrictive
procedure is less likely to be successful. However, several authors have
reported good outcomes of conversion to a SG. Nevertheless, in most series
conversion to a RYGB is considered the gold standard and good outcomes are
reported [10, 12]. Optionally conversion to RYGB can be done while leaving
the band in place for future adjustments (adjustable banded RYGB) [13].
Although BPD and DS are feasible not many surgeons are in favor of this
options [14, 15]. This is also true for the so called “Bandinaro” in which the
band is left in place [9].
Adjustable Gastric Band Failures
61
Figure 1. Upper GI X-ray of band related complications. A: posterior slippage with
vertical band position. B: anterior slippage with horizontal band position. C: primary
failure with high band position (no gastric pouch). D: acute herniation of the stomach
through the band.
4.1. Conversion to Sleeve Gastrectomy
Since its introduction the nowadays very popular SG procedure is being
used as rescue operation for the ASGB. It has been shown to be feasible and
relatively safe although severe complications have been reported with a
significant percentage of leaks and fistulas that are difficult to treat [16]. The
62
J. W. M. Greve
procedure can be done in 1 or 2 stages with a lower reported complication rate
in the latter strategy [17, 18]. Successful weight loss is reported ranging
between 31-60%EWL however there is an increased complication rate with
leaks in up to 6% [10]. In a paper by the group of Rosenthal et al. comparing
RYGB with SG after band it was found that in non-responders (primary
failure) conversion to RYGB was more successful than SG [19].
4.2. Conversion to RYGB
Most reported series on treatment of a failing ASGB treat conversion to
RYGB. In particular, in primary failures (non-responders) successful treatment
is more likely with a bypass [19]. Similar to conversion to a SG a 2-stage
procedure may be more safe but a large number of publications have shown
the efficacy and safety of conversion to a RYGB in 1 stage [12]. Outcome
after conversion to RYGB is comparable to the results of a primary RYGB
with similar or slightly higher complication rates [12, 20].
4.3. Conversion to Adjustable Banded RYGB
Restriction is an important part of the working mechanism of a RYGB.
Several studies have shown a benefit for a non-adjustable band placed around
the pouch of the RYGB as reported by Fobi in open RYGB and more recently
by Bessler in laparoscopic procedures [21, 22].
Furthermore, placement of an adjustable band around the gastric pouch of
RYGB patients with weight regain was shown to be a valid option [23]. In
patients with banded pouch after SAGB, all studies reported further weight
loss, varying from 55.9%–94.2% excess body mass index loss (EBMIL) after
12–42 months of follow-up (Figure 2). With these considerations in mind a
logical step was to leave the band in place when conversion to a RYGB was
indicated, to prevent pouch dilation and to add the option for adjustments.
Feasibility of this strategy has been demonstrated but larger studies with long
term follow up are needed [13]. Potential problem with this treatment mode is
that the band may add complications to a regular gastric bypass such as
slippage, infection and erosion of the band. Most important is to protect the
band from contact with the small bowel as was shown in the past with the
adjustable RYGB.
Adjustable Gastric Band Failures
63
Figure 2. Salvage of failing RYGB with an adjustable band on the pouch. Excess body
mass index loss (%EBMIL) after revision. Values shown for follow-up (in months)
after revisional surgery (t _ 0) [23].
Figure 3. Functional or adjustable gastric bypass. A procedure with a high risk of band
erosion to the small bowel [24].
64
J. W. M. Greve
This was a procedure in which the pouch above the band (allowing access
to the remnant stomach by opening the band) was used to anastomose the
jejunum to (Figure 3). This resulted in a high erosion rate into the small bowel
and the procedure was abandoned after careful evaluation [24].
In conversion of a band to adjustable band RYGB the excluded stomach
can be used to create a Nissen like plication distal to the band (Greve
plication) to prevent slippage and avoid contact of the SAGB with the small
bowel (Figure 4).
Figure 4. In conversion of a band to adjustable RYGB the excluded stomach can be
used to create a Nissen like plication distal to the band (Greve plication) to prevent
slippage and contact of the SAGB with the small bowel.
Adjustable Gastric Band Failures
65
5. SECONDARY FAILURE
Secondary failure is defined when patients who had an initial good weight
loss and resolution of co-morbidities experience significant weight regain.
Causes can be patient related (diet, life style) or due to a technical problem.
Minor problems such as port dislocation or port disconnection are not
discussed here, as the solution is simple. The majority of secondary failures
are related to pouch dilation or band slippage. In early series pouch dilation or
slippage was a frequent problem in up to 40% of the patients [25]. Introduction
of the pars flaccida technique has significantly reduced the incidence of
slippage to 6.5% and less [8, 25].
5.1. Failure Due to Patient Compliance or Due to Band
Intolerance
In patients with insufficient follow up or incorrect band adjustments (too
tight or not tight enough) a “back on track” program and proper adjustment of
the band may be an option. In particular a too tight band will result in wrong
eating habits.
These patients can develop reflux like symptoms and often are
permanently hungry due to lack of satiety. Opening the band and re-education
of the patient may work. However most patients will need a conversion to a
different procedure. Options are discussed in subsection 4.
5.2. Mechanical Failure of the Band
Although the adjustable bands are made of durable silicone, technical
failures can occur. Breakage or unlocking of the band will result in loss of
restriction and weight regain. Another cause of loss of restriction is breakage
of the tubing, which is often due to material fatigue. Inserting a connecting
piece can fix breakage of the tubing but it is probably better to replace the
band as is the case with a broken band. Leakage of the balloon can also occur.
In particular in some of the older band types (Swedish band) a fold in the
balloon could cause a perforation of the balloon at inflation.
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J. W. M. Greve
5.3. Pouch Slippage or Dilation
Definition of slippage versus pouch dilation is difficult and not relevant
for the treatment. After counseling by the multidisciplinary team and proper
diagnosis by radiology initial treatment can be band deflation. If there is a
spontaneous reposition gradual insufflation of the band can be attempted [26].
Failure of reposition after deflation or recurrence of slippage is an indication
for band reposition in patients with good weight loss. Good results have been
reported also on the long term with this policy [27, 28]. In the early days
posterior slippage (band in a vertical position, Figure 1A) was a frequently
encountered problem with the perigastric technique. Replacing the band using
the pars flaccida approach can solve this issue. In the more common anterior
slippage (band in a horizontal position, Figure 1B) laparoscopic repositioning
is in general successful. An important technical aspect is the release of all
gastro-gastric sutures and the gastric plication all the way to His‟ angle. In
most cases the band can be opened and re-used. After correction of the
position, fixation of the band by plication of the fundus to the pouch with a
minimum of 4 non-absorbable sutures is required. Symmetrical pouch dilation
probably requires conversion to RYGB because successful repositioning is
less likely [26].
5.4. Gastro-Esophageal Reflux (GERD)
Secondary GERD is usually a result of a too tight band with stasis and
regurgitation of food into the esophagus. Opening the band may resolve this
condition. In some patients a hiatal hernia may have developed de novo or was
missed during band placement. Correction by closing the hiatus and
repositioning of the pouch is an option [29]. However, in general in patients
with severe reflux symptoms conversion to a RYGB with, if applicable, repair
of the hiatal hernia is considered to be the best option [30].
6. BAND COMPLICATIONS AND TECHNICAL FAILURES
6.1. Revision After Band Erosion
Band erosion can be early or late. Early erosion is most likely due to a
lesion of the stomach wall at insertion or a secondary infection of the band.
Adjustable Gastric Band Failures
67
Late erosion can be due to over-inflation of the band but often no clear
explanation is found. Symptoms are upper abdominal pain, loss of restriction
and sometimes the opposite, food intolerance. Fever may occur and
inflammation around the port of the band is often a first symptom of band
erosion. Diagnosis is confirmed by gastroscopy, followed by CT scan that can
be helpful to identify a large inflammatory mass. Treatment strategy is
manifold. Once the diagnosis is confirmed the band can be removed
(endoscopically or surgically). Endoscopic band cutting tools can be used for
endoscopic removal but in that situation the port of the band needs to be
removed first [31].
Port removal is in general advised to prevent complications due to the
tubing when the band migrates in total to the stomach with the port still
attached. Surgical removal is the most used option, the laparoscopic approach
being the preferred one. It is possible to immediately convert to another
procedure such as repair of the gastric wall defect and placement of a new
band or conversion to gastric bypass [32, 33]. Alternatively after removal of
the band and closure of the defect a biliopancreatic diversion can be
constructed in the same session, avoiding an anastomosis in an infected and
inflamed area. However, in most cases band removal and revision some 3-6
month later is preferred.
When the patient benefited from successful weight loss with the band, rebanding may be attempted. After band erosion, conversion to RYGB is
nevertheless preferred and, as mentioned before, long-term results are good. In
fact a 2-stage procedure allows conversion to any type of bariatric procedure
later on. A 1-stage conversion to SG or RYGB is not advised because of the
high complication risk, in particular leakage.
6.2. Band Obstruction
Obstruction of the band may be due to a large food particle, a bezoar or
may be due to acute herniation of the stomach (see below). Symptoms are food
intolerance, inability to drink and regurgitation of saliva. Occlusion of the
outlet can be solved by deflation of the band or by endoscopic removal of the
foreign body or food particle. Bezoar is rare but can be more problematic and,
if large, may even need surgical removal. Prevention by avoiding the ingestion
of indigestible fibers (asparagus, oranges etc) is key.
68
J. W. M. Greve
6.3. Acute Herniation of the Stomach
When a patient after ASGB develops sudden food intolerance and
epigastric pain he/she should be considered an emergency. When a significant
part of the stomach herniates through the band incarceration of the stomach
can occur with high risk of necrosis and perforation. An upper GI contrast
study or even a plain abdominal X-ray is diagnostic (Figure 1D). Immediate
deflation of the band followed by emergency laparoscopy is needed. At
laparoscopy the band can be opened and the stomach, when ischemic but not
necrotic, can be left in place for a re-laparoscopy and repositioning of the band
several days later. Alternatively the band can be removed and the patient
planned for elective conversion to another procedure.
CONCLUSION
There is a distinct group of patients that can effectively be treated with an
adjustable silicone gastric band, which remains a safe and effective operation.
However, as there is not one single surgical procedure that will be
permanently effective in any patient, revisions and conversions will be
required.
Patients who had a good result with the SAGB but who have either a
mechanical failure or a secondary pouch problem can be treated effectively by
surgical correction. It is also shown that when a band fails conversion to
another technique is safe and effective. It is obvious that revisions and
conversions need to be done in centers of excellence and by experienced
surgeons as these procedures can be complex and do carry a slightly higher
risk.
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In: Management for Failed Bariatric Procedures
ISBN: 978-1-63483-753-8
Editors: J. Himpens and R. Vilallonga © 2015 Nova Science Publishers, Inc.
Chapter 5
FAILED SLEEVE GASTRECTOMY
Ricard Corcelles, MD, PhD,
and Antonio Lacy1, MD, PhD
Insititute of Digestive and Metabolic Diseases. Gastrointestinal
Surgery Department, Hospital Clinic Barcelona, Barcelona, Spain
ABSTRACT
In the last 15 years, LSG has become increasingly popular as a
primary procedure because of its simplicity, relative safety, and
effectiveness to achieve sustained weight loss over time. LSG has
demonstrated its effectiveness in achieving weight loss and resolution of
obesity related co-morbidities. Despite good success rates, it may
occasionally be associated with failure. LSG failure is defined by
insufficient weight loss, weight regain, surgical complications, and poor
control of comorbidities such as gastro-esophageal reflux disease
(GERD). As demand for LSG increases, so will the need for revisional
surgeries. The incidence of revision varies according to the studies
analyzed but revision rate following primary LSG is reported to be
between 5-30%. Revisional surgery is technically more demanding, and
associated with higher complications and mortalities compared to primary

Ricard Corcelles: Insititute of Digestive and Metabolic Diseases. Gastrointestinal Surgery
Department, Hospital Clinic Barcelona, Barcelona, Spain. E-mail: [email protected].
1
Corresponding author: Antonio Lacy, MD, PhD. Insititute of Digestive and Metabolic Diseases.
Gastrointestinal Surgery Department, Hospital Clinic Barcelona, Barcelona, Spain. E-mail:
[email protected].
74
Ricard Corcelles and Antonio Lacy
bariatric procedures. Complication rates between 0 and 46% have been
reported after these reoperations. In this chapter, we will analyze the
potential causes of LSG failure as well as the suggested revision
surgeries.
1. INTRODUCTION
Sleeve Gastrectomy was first created by Hess and Marceau in 1998 as the
first part of the duodenal switch (DS) operation [1, 2]. In high risk and supersuper obese patients, the gastric sleeve part of the DS operation was often
performed alone in an attempt to reduce morbidity and mortality, and to
facilitate the laparoscopic approach [3]. Owing to the relative technical ease,
low complications rates and good weight loss results, it was found that
laparoscopic sleeve gastrectomy (LSG) could be performed in many cases as a
stand-alone bariatric operation [4]. Technical details of LSG vary, but the
ultimate goal of the procedure is to remove the vast majority of the stomach,
especially the fundus, leaving only a thin gastric tube from the esophagus to
the duodenum. The absence of gastro-intestinal anastomosis during the
operation, and leaving patients with an intact gastrointestinal (GI) tract are
other potential benefits of this relatively new technique.
In the last 15 years, LSG has become increasingly popular as a primary
procedure because of its simplicity, relative safety, and effectiveness to
achieve sustained weight loss over time. A recent meta-analysis data by
Buchwald and colleagues suggests LSG is the second leading bariatric
operation in the world, only surpassed by laparoscopic Roux-en-Y gastric
bypass (LRYGB) [5]. As demand for LSG increases, so will the need for
revisional surgeries. In this chapter, we will analyze the potential causes of
LSG failure as well as the suggested revision surgeries.
2. LAPAROSCOPIC SLEEVE
GASTRECTOMY (LSG) FAILURE
LSG has demonstrated its effectiveness in achieving weight loss and
resolution of obesity related co-morbidities [6]. Despite good success rates, it
may occasionally be associated with failure. LSG failure is defined by
insufficient weight loss, weight regain, surgical complications, and poor
control of comorbidities such as gastro-esophageal reflux disease (GERD) [7,
Failed Sleeve Gastrectomy
75
8]. LSG patients appear to be subjected to weight regain after more than 3
years. Himpens et al., noted that more than 30% of the LSG patients had
inadequate weight loss or weight regain, requiring an additional procedure [9].
This is similar to what has been reported with other restrictive weight loss
operations such as the adjustable gastric band (AGB), or the vertical banded
gastroplasty (VBG) [10, 11]. Several factors may be responsible for late
weight regain after sleeve gastrectomy. These factors include dietary factors,
and changing eating habits to high caloric meals. Long term anatomic changes
with the sleeved stomach dilatation might allow the patient to consume larger
amounts of food, thus contributing to weight regain as well [12]. Furthermore,
loss of patient follow-up and counseling, may also play an important role in
weight regain. Surgical complications after LSG can lead to procedural failure
[8]. A recent systematic review of the literature on LSG including a total of 15
studies (n = 940 patients) revealed overall complication rates of 12.1%.
Reported complications include bleeding or leakage from the staple line,
strictures, delayed gastric emptying, gastric dilation, and vomiting [13]. LSG
failure is however multifactorial and finds a feeding ground in patient‟s poor
adherence, procedure failure, and surgeon error.
3. REVISIONAL SURGERY AFTER LSG FAILURE
The prevalence of revisional surgery increases as the number of LSG
procedures rises. The incidence of revision varies according to the studies
analyzed but revision rate following primary LSG is reported to be between
5% and 30% [9]. Revisional surgery is technically more demanding, and
associated with higher complications and mortality compared to primary
bariatric procedures. Complication rates between 0 and 46% have been
reported after these procedures [7]. Revision of previous bariatric operations
carries a higher overall risk of leakage. A review of revisional bariatric
surgeries conducted by Jones et al., (n = 838 patients) reported a 14% (n =
118) major complication rate and 0.8% (n = 7) mortality rate. The study also
noted that complication rates were lower in the laparoscopic patients with no
mortalities in this group [14]. This challenging scenario obligates bariatric
surgeons to have solid options in revisional surgery after LSG failure [15-19].
Revisions are technically demanding due to the increased tissue fibrosis and
the altered anatomy following the primary procedure [20]. The currently
accepted alternatives for the patients who require revisional surgery for failed
LSG are detailed as follows.
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Ricard Corcelles and Antonio Lacy
3.1. Laparoscopic Re-Sleeve Gastrectomy (LRSG)
Laparoscopic re-sleeve gastrectomy (LRSG) was initially reported in 2003
as revision for poor weight loss after DS [21]. Since its first description by
Gagner et al., several case series have been published [13]. Baltasar et al.,
showed feasibility of LRSG in the super-super obese patients, when the
resulting gastric pouch is too large or dilated after the original LSG [12].
Another retrospective study included 13 patients with ineffective weight loss
(%EWL < 50%) or weight regain who underwent LRSG. All patients
underwent a preoperative upper GI series showing persistent fundus at the
time of revision. Weighted mean preoperative body mass index (BMI) and
excess weight were 44.6 kg/m2 and 61.8 kg, respectively. After 12 months
follow-up, mean BMI, percent of EWL, and percent of BMI loss decreased to
27.5 kg/m2, 71.4%, and 82.8%, respectively. There was no morbidity reported
[16]. However, LRSG results are far from being complications free, and
complications at time may be severe in nature [22]. Within a smaller case
series study (n = 7) of patients undergoing LRSG Dapri et al., reported one
leak at the angle of His, and less successful weight loss than for primary cases
[15]. Interestingly, Rebibo et al., retrospectively evaluated outcomes in 15
patients having LRSG after failure of LSG [18]. These patients were matched
(age, gender, BMI, and co-morbidities) 1:2 with patients undergoing first line
LSG. The mean operating time was longer in the LRSG (116 vs. 86 min; p ≤
0.01), and postoperative complications were higher in the re-sleeved patients.
Two patients experienced leakage and one died. At 12 months the EWL was
66% for the LRSG and 77% for the primary LSG group (p = 0.05) [18].
The results of the above mentioned studies suggest that LRSG can achieve
significant short-term weight loss at 24 months follow-up but at the cost of
substantial peri-operative complications.
3.2. Laparoscopic Gastric Bypass (LRYGBP) or Omega Loop
Mini Gastric Bypass (LMGB)
The conversion of a failed LSG to laparoscopic gastric bypass (LGB),
considered by many the “gold standard” bariatric procedure, has been accepted
as a revisional option because of the reasonable balance between weight loss
and complications. A recently published systematic review of revisional
surgery following failed primary LSG reported weight loss improvement in
more than 100 patients (6 studies) with laparoscopic gastric bypass (LGB)
Failed Sleeve Gastrectomy
77
(laparoscopic Roux en Y gastric bypass (LRYGB) or omega loop mini gastric
bypass (LMGB)) as a revisional procedure [23]. Mean preoperative BMI was
41.9 kg/m2, which decreased after conversion to 38.9 kg/m2 at 3 months, 36.5
kg/m2 at 6 months, 33.7 kg/m2 at 12 months, and 35.7 kg/m2 at 24 or more
months of follow-up. Percentage of EWL was 48% over the last follow-up
period (i.e., 24 months). Similar trends in weight loss results have been
recently published with 21 patients undergoing LMGB; a single gastro-jejunal
bypass anastomosis connecting the gastric sleeve to a jejunal loop (200 cm
downstream from the ligament of Treitz). Mean BMI at 12 and 24 months
after LMGB was 34.6 kg/m2 and 35.7 kg/m2, respectively [24].
The Fourth International Consensus Summit on Sleeve Gastrectomy [25],
a recent survey of 88 bariatric surgeons experienced in LSG (average of 295
operations per surgeon), reported that LRYGB was the preferred option if a
second operation is required for weight regain after LSG [25]. Twenty %
consider LRSG, 46% conversion to LRYGB and 24% conversion to BPDDS.
However, strong evidence suggests weight loss outcomes after LGB are
similar to those after LRSG. Cheung et al., [23], reported short-term weight
loss outcomes after failed LSG. At 24 months, mean BMI and percentage
EWL were 35.7 kg/m2 and 48%, for the LGB group (n = 114) vs. 35.3 kg/m2
and 44%, for the LRSG group (n = 45). The article review concludes there are
no significant differences in weight loss improvement between both
procedures. Langer et al., reported satisfactory results of 8 patients converted
to LGB because of insufficient weight loss and severe reflux disease [17].
Interestingly, the authors emphasized that patients undergoing conversion to
LGB after LSG could be more prone to regain weight.
Perioperative complications after LGB as revisional procedure have also
been reported. Moszkowicz et al., described a morbidity rate of 9.5% after
LMGB [24]. A prospective case series study from the Netherlands (n = 18
patients) reported successful results within the LGB as a revision procedure in
terms of weight loss, GERD, and dysphagia [19].
However, associated peri-operative complications were significantly high
and included anastomotic leakage (n = 2), intra-abdominal bleeding (n = 2),
splenectomy, wound infection, and cardiac decompensation.
LSG has been reported to carry a risk of GERD. A retrospective study (n
= 30) evaluated long term side effects after LSG. More than 20% of patients in
the study reported severe GERD or vomiting at 6 years after the procedure [9].
Weiner et al., reports a 15% incidence of GERD in a cohort of 76 subjects,
which was improved by conversion to LGB [26].
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Ricard Corcelles and Antonio Lacy
In this clinical situation, conversion to LGB is a consistent option for
management of GERD related complications after LSG (Figures 1-4).
Figure 1. Conversion from LSG to LGB.
Figure 2. Conversion from LSG to LGB; gastric sleeve dissection.
Failed Sleeve Gastrectomy
79
Figure 3. Conversion from LSG to LGB; gastric pouch transaction.
Figure 4. Conversion from LSG to LGB; gastrojejunal anastomosis.
3.3. Laparoscopic Biliopancreatic Diversion with Duodenal
Switch (BPDDS)
Sleeve gastrectomy was primarily planned as the first stage of a two stage
duodenal switch, hence making the BPDDS a logical candidate for revisional
surgery after SG.
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Ricard Corcelles and Antonio Lacy
However, patients who underwent LSG, as a premeditated and planned
strategy for eventually performing BPDDS should not be considered as
benefiting from a “true revisional procedure” for failure and are not analyzed
in this chapter. LSG conversion to BPDDS has some potential advantages.
There is no need to dissect and manipulate the stomach, which may ultimately
decrease gastric leak rates, and other peri-operative complications compared to
those observed in a primary BPDDS procedure.
Single-stage BPDDS has been reported to have higher complications rates
[27]. Iannelli et al., retrospectively compared 110 super-obese patients (BMI ≥
50 kg/m2) undergoing the two staged DS with 110 patients (matched for age,
gender and BMI) undergoing the single-stage DS [28].
The postoperative complication rate was 8.2% in the staged approach and
15.5% in the single-stage DS group. Multivariate analysis showed that singlestage DS was the only predictive factor of complications (odds ratio 2.36; 95%
confidence interval 1.001-5.61) [28]. A small study evaluated outcomes in 9
patients with failed LSG converted to DS [15].
There were no conversions in the study but operative time was
considerably long (mean 152.6 ± 54.3 minutes). Complications included one
patient with bleeding, one patient with a duodenoileostomy leak, and one with
a duodenoileostomy stenosis. Weight loss at 25 months follow-up was
successful; mean 25 month BMI and percent EWL was 27.3 ± 5.2 kg/m2 and
73.7 ± 27.7%.
During follow-up, 2 patients required revision due to hypoproteinemia and
diarrhea (feeding jejunostomy tube) [15]. Thus, BPDDS as revisional surgery
after LSG failure, promotes substantial weight loss improvement but at the
cost of relatively high complication rates.
3.4. Miscellanea of Revisional Procedures
After failed sleeve gastrectomy, some alternative procedures have been
described in an attempt to minimize surgical complications and improve
weight loss outcomes.
Among these, single anastomosis duodenoileal bypass [29], plication of
the sleeve [30], banded sleeve [31], butterfly gastroplasty (micro funnel
shaped pouch) [32], and side to side jejunoileal anastomosis, are the most
important.
Results however continue to remain limited to case reports, and very small
case series, hence no conclusions can be drawn.
81
Failed Sleeve Gastrectomy
Figure 5. Proposed algorithm of treatment after LSG failure.
Table 1. Failed Primary Laparoscopic Sleeve Gastrectomy Studies
Author
AbdelGalil*
Chevallier
Dapri
Dapri
Gautier
Iannelli
Langer
Lech*
Nienhuijs
Year of
Type of
publication study
n (size)
Age
(years)
2013
Case series
40
32
2013
2011
2011
2013
2011
2010
2013
Case series
Case control
Case control
Case series
Case series
Case series
Case series
38
7
19
15
13
8
10
49.5
44
47.2
39.7
40.3
35.8
n/a
2011
Case series
29
n/
Case series
Case series
n/a
15
18
6
47
46.5
42
2012
Rebibo
Van Rutte 2012
Wadhawan 2013
*
Only abstract available.
Pre-op
Revisional
BMI
Procedure
(kg/m2)
Butterfly
48
gastroplasty
44
LMGB
38.9
LRSG
36.9
BPDDS
40.9
LRYGB
34.9
LRSG
47
LRYGB
n/a
LRSG
LRYGB and
45
open
41.5
LRSG
32.3
LRYGB
38
LRYGB
82
Ricard Corcelles and Antonio Lacy
CONCLUSION
In general, revisional surgery is technically more demanding than primary
bariatric procedures, and must be performed with extreme care. Such
operations should be carried out in tertiary centers with experienced bariatric
surgery programs that can limit the incidence and severity of peri-operative
complications. Furthermore, the selected type of revisional procedure should
take three different considerations into account: the individual patient history
and cause of failure, the difficulty of the revisional procedure, and the bariatric
surgeon‟s experience.
After thorough revision of the available literature, it appears that
revisional surgery for LSG failure overall offers weight loss improvement at
24 months. In summary: while LRSG, and LGB appear to be reasonable
options with well-adjusted results and complication rates, the conversion to a
BPDDS appears to create an increased weight loss but at the cost of major
morbidity. LGB can effectively manage intractable GERD after LSG.
Unfortunately, the data in revisional sleeve gastrectomy is limited, and long
term randomized controlled studies are required to compare weight loss
outcomes and complication rates.
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Gugenheim, J. Laparoscopic sleeve gastrectomy followed by duodenal
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In: Management for Failed Bariatric Procedures
ISBN: 978-1-63483-753-8
Editors: J. Himpens and R. Vilallonga © 2015 Nova Science Publishers, Inc.
Chapter 6
REOPERATIONS FOR ROUX-EN-Y GASTRIC
BYPASS FAILURES
Jacques M. Himpens1,, MD, PhD,
and Ramon Vilallonga†, MD, PhD
1
Division of Bariatric Surgery, Chief of Department
AZ St-Blasius, Division of Bariatric Surgery,
Dendermonde, Belgium
2
Endocrine, bariatric and metabolic Unit,
General Surgery and robotic Department, Consultant surgeon
Universitary Hospital Vall Hebron, Universitat Autònoma de Barcelona,
Endocrine, bariatric and metabolic Unit, General Surgery Department,
Barcelona, Spain
ABSTRACT
The Roux-en-Y gastric bypass procedure is considered by many the
“state of the art” bariatric intervention. Nevertheless, as any other weight
loss/ metabolic operation it requires a strict follow up and good patient
compliance to avoid the development of poor dietary habits. The most
dreaded dietary flaw is without doubt sweets eating, which constitutes the

Corresponding author: Division of Bariatric Surgery. Chief of Department. AZ St-Blasius.
Division of Bariatric Surgery. Kroonveldlaan 52, 9200 Dendermonde. Belgium. Email:
[email protected].
†
Email: [email protected].
88
Jacques M. Himpens and Ramon Vilallonga
ruin for all bariatric procedures. Poor weight loss outcomes may however
be the consequence of anatomical aberrations of the bypass construction
as well. In addition, surgical complications may arise all along the
postoperative course of the bypass patients. Complications and
anatomical flaws may warrant surgical intervention to correct the
anatomy, or, in some occasions, to radicalize the bypass or to convert the
bypass to another type of bariatric/metabolic procedure.
The decision to surgically re-intervene must be backed up by the
conclusions of a multidisciplinary consultation.
INTRODUCTION
The Roux-en-Y gastric bypass (RYGB) is considered the gold standard for
bariatric (“metabolic”) surgery. The procedure existed long before the
laparoscopic infatuation and survived the rise of several upcoming fashionable
operations such as the adjustable band (AGB) and the previously abandoned
vertical banded gastroplasty (VBG) (the latter witnessed a revival because of
the laparoscopic approach [1])
RYGB has undergone a substantial evolution over the years, both with the
open, “classic” or the minimally invasive approach. In its initial embodiment
RYGB as proposed by Mason [2] involved the creation of a horizontal
stomach pouch, which, consequently, comprised a significant portion of the
stomach fundus. With time, it became clear that the construction with
horizontal stomach pouch was quite sensitive to dilation and subsequent
failure. Newer versions of the RYGB, involving the use of the lesser curvature
part of the cardia for pouch creation were popularized by surgeons such as
Griffen [3]. With the advent of laparoscopy the technically quite complex
RYGB procedure experienced a drop in popularity to the benefit of LAGB. In
1994 however Allan Wittgrove [4] and colleagues succeeded in performing a
full- laparoscopic RYGB (LRYGB). Nevertheless, it took several years before
the laparoscopic procedure benefited from general acceptance by the surgical
community. Recently, the laparoscopic version of RYGB regained the pole
position in terms of most popular and most performed bariatric operation [5].
Presently LRYGB is usually performed according to a few technical
variations. Whereas initially the alimentary limb (AL) (Figure 1) was
constructed some 150 cm long and the biliopancreatic limb (BPL) was kept
rather short (which would allow endoscopic access to the excluded duodenum,
stomach and biliary tree), more recently there is a tendency to reduce the
length of the AL and to lengthen the BPL [6].
Reoperations for Roux-en-Y Gastric Bypass Failures
89
Figure 1. The typical “old fashioned” Roux-en-Y gastric bypass with relatively short
biliopancreatic limb (BPL). The small gastric pouch (GP) is anastomosed to the
alimentary limb (AL) that lies anterior to the stomach remnant (REMN) and the colon.
The junction of AL and BPL results in the common limb (CL).
This new modification allegedly increases weight loss and enhances the
metabolic impact of the construction.
In terms of anastomotic technique in RYGB, some surgeons prefer the
handsewn technique [7], in contrast with others who choose the circular
stapled technique [8] or the linear stapled technique [9]. Most surgeons by
now close the potential hernia defects (Figure 2), but others claim that closure
is not necessary [10].
90
Jacques M. Himpens and Ramon Vilallonga
Figure 2. The 2 most important defects created by the Roux construction: Petersen‟s
defect (P) between the mesentery of the alimentary limb (AL) and the transverse
mesocolon and the mesenteric gap situated between the mesenteries of the
biliopancreatic (BPL) and the common limb (CL).
Despite the popularity of LRYGB, many surgical teams recently made the
switch to supposedly simpler procedures including the sleeve gastrectomy
(LSG) and the mini gastric bypass (MGB), often called the omega loop or
single anastomosis gastric bypass (OLGB, respectively SAGB). Of note, the
“newer” procedures have not yet sustained the test of time and little is known
about the long-term outcomes.
Reoperations for Roux-en-Y Gastric Bypass Failures
91
Over the years it has been shown that follow-up is crucial for a successful
gastric bypass. Adequate follow-up with periodical blood analysis is
necessary, not only to dietary flaws (especially the abuse of carbohydrates and
simple sugars), but also to detect the development of vitamin, mineral and
protein deficiencies [11].
As all bariatric procedures LRYGB has some drawbacks. Even with good
follow-up, problems may occur that need correction. Consequently,
considering the high number of patients who have undergone LRYGB, it is
inevitable that some individuals will need correction of the bypass
construction for different reasons. It is the aim of this chapter first to analyze
possible complications or unwanted side effects (such as insufficient weight
loss and weight regain) that will need correction, and, second, to provide
solutions to address this issue.
1. Types of Failures
Failures of gastric bypass can be divided into several categories:



Some patients never reach sufficient weight loss, which may be due to
anatomical reasons or to lack of discipline of the patient (poor diet
habits, failure to adhere to the follow-up program). These failures are
considered primary failures.
Some patients initially did experience successful weight loss but
subsequently suffered weight regain. This evolution may be due to
anatomical reasons (such as pouch dilation or gastrogastric fistula),
but is most often caused by changed dietary habits of the patient.
These failures are called secondary failures.
Some patients suffer a complication that demands surgical correction.
Examples of complication are intractable gastro-esophageal reflux
(GERD), with or without hiatal hernia (HH), herniation of the gastric
remnant through the hiatus, food intolerance because of long-term
anastomotic stenotic problems, ulceration of the anastomosis,
ulceration in the gastric remnant, blind loop symptoms at the level of
the gastro-enteral or the entero-enteral (jejunojejunal or JJ)
anastomosis, internal herniation with obstruction of the AL, the BPL
or the common limb (CL), intussusception at the level of the
alimentary-biliopancreatic confluent, trocar incision herniation, and
problems concerning glucose metabolism, such as neuroglycopenia.
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Jacques M. Himpens and Ramon Vilallonga
2. General Considerations in Revision or Conversion
As in every bariatric-metabolic procedure it is essential to analyze the
cause of failure of LRYGB,. Analysis must involve thorough evaluation of the
anatomical integrity of the bypass construction. Anatomical alterations often
may remain silent and not interfere with the clinical outcome. In face of poor
clinical results, however, anatomical alterations should be addressed.
Alterations may be situated in any of the components (i.e., the gastric pouch,
shape or volume, the diaphragmatic hiatus, the length of the limbs). In some
occasions the aberrant anatomy may be deemed too complicated and
conversion to a different type of procedure (e.g., conversion to a distal RYGB)
while keeping the gastric pouch and anastomosis as they are may be preferred.
The most radical conversion procedure consists of reversal but should only be
considered under rare circumstances. Simple reversal will most likely result in
weight regain and resurgence of co-morbidities. Consequently, reversal
procedures will most often be combined with conversion to a restrictive
construction such as SG.
Whenever a substantial change in anatomical construction is anticipated, a
multidisciplinary team should be consulted to address all the aspects of the
required therapeutic change. In our practice, the multidisciplinary team
consists of a dietitian, a psychologist, a gastroenterologist, an endocrinologist,
and, last but not least, the bariatric surgeon. Multidisciplinary evaluation is
organized by the bariatric coordinating nurse, who because she personally
knows the patients can best evaluate the capacity of the patient to deal with
newly induced dietary restrictions, lifestyle changes, compliance with
supplementation and medication and acceptance of a proposed new operation.
The psychologist‟s task is to evaluate how the patient has progressed since the
preoperative assessment. In some instances the patient will demonstrate a
psychological incapacity or refusal to deal with the characteristics of the
bypass. In contrast, sometimes the patient may have developed unrealistic
expectations and must be taught to accept the actual outcome of the LRYGB
in terms of weight loss, even when the outcome does not match his/her
expectations. The patient must also be educated about the impact of a new
surgical procedure that may, for example, significantly impair the capacity of
ingesting food. This impairment may in some occasions surpass the
psychological capacities of the individual. The dietitian analyzes the patient‟s
dietary response to the bypass itself. When restriction is still active, some
patients overcome the imposed small size of meals by increasing the frequency
of meals (polyphagia). When restriction has weaned off, patients often
Reoperations for Roux-en-Y Gastric Bypass Failures
93
experience the tendency to increase the size of their meals (hyperphagia) [12].
Alternatively, some subjects no longer observe the strict dietary restrictions
such as the abstinence from sugars that were imposed at the time of surgery.
Typically, some patients will preferably choose carbohydrates, especially
liquid ones, because they no longer experience any dumping sensation - the
alleged primary deterrent from ingesting sweets [13]. Typically, sweets eating
will not warrant a surgical solution, because, as demonstrated by Scopinaro,
this evolution is resistant to all bariatric constructions [14]. Consequently, the
dietitian‟s main task consists of putting the patient back on the “right track.”
The gastroenterologist and the radiologist evaluate the shape and volume
of the different bypass components and will in addition check for possible
significant changes such as marginal ulcers, HH, or gastrogastric fistula.
Besides confirming the diagnosis made by the radiologist, the endoscopist may
attempt to correct some of the detected anatomical aberrations and proceed to
reducing the size of the pouch or trying to close a gastrogastric fistula.
Interventional endoscopy has recently gained an important position in the
correction of bypass failures but because of the novelty of the technique and
lack of mid- to long-term outcome reports this aspect will not be further
addressed in the present chapter.
The endocrinologist investigates the possible insufficient improvement or
resurgence of comorbidities, and, depending on the severity of the findings,
may orient towards a surgical solution to address this issue. Conditions
amenable to improvement with operative treatment include dyslipidemia,
arterial hypertension (AHT) and type 2 diabetes (T2DM). When the
aforementioned diseases have not substantially improved, or have re-emerged
after initial remission or improvement either the patient‟s dietary compliance
or the team‟s choice for the bypass procedure itself may be questioned.
The bariatric surgeon must evaluate the safety of an anticipated reintervention, taking the specific history of the patient into account. Patients
who postoperatively suffered a leak at the gastro-enterostomy for instance may
not be ideal candidates for undergoing procedures involving the pouch part of
the RYGB construction. Depending on the indication, the surgeon may decide
to opt for a procedure that will influence the length of the limbs rather than to
alter the volume of the pouch.
The final decision for any bariatric reintervention should always be based
on evaluation of all results by the multidisciplinary team.
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Jacques M. Himpens and Ramon Vilallonga
3. Primary Failure
Primary failures are rare after RYGB. Except for the cases where the
patient displays an outrageous lack of dietary discipline, primary failures
should always raise the suspicion of anatomical causes. In primary failures the
most obvious culprit for poor weight loss is a poorly designed gastric pouch,
that may have been constructed too large, or that has been made of parts of the
stomach that are too distensible. Several strategies have been described to
address this issue.
3.1. Reshaping the Pouch
A poorly constructed gastric pouch (i.e., too large a pouch, or a pouch
including the fundus) may be found, usually in patients who previously
underwent another bariatric procedure such as LAGB or LSG, and in whom
poor dissection of the apical part of the stomach results in the keeping of a
large pouch, usually located posteriorly. Another possible anatomical cause for
poor weight loss is the presence of a gastrogastric fistula, a condition that
results in the abolition of the bypass physiology. The gastrogastric fistula may
sometimes be the result of an imperfect transection of the stomach, usually
located at the uppermost part of the staple line [15], but is most often caused
by a perforating marginal ulcer, that connects the staple line of the
anastomosis with the horizontal staple line on the remnant stomach [16].
Diagnosis and treatment strategy are based on a multidisciplinary approach. It
is however noteworthy that in some occasions a gastrogastric fistula will only
be discovered at surgical re-exploration. Correction of too large a pouch
consists of extensive dissection of the gastric pouch, but only on the left sided
part of the latter to avoid ischemic problems, because the blood supply
essentially is provided by the vessels at the lesser curvature side of the
stomach pouch. Usually the anastomosis itself can be kept as is. After
complete dissection of the gastric pouch a re-resection can be performed under
safe conditions, guided by a large bore gastric tube introduced by the
anesthesiologist and kept in close contact with the lesser curvature of the
stomach pouch. The resection of the pouch is best performed with a linear
stapler with green or black load because the tissues invariably will be
thickened. Alternatively, the fully dissected lateral aspect of the gastric pouch
can be imbricated (or plicated), which has the advantage of being cheaper and
possibly reduces the risk of fistula caused by staple line dehiscence. During
reshaping of the pouch we usually perform dissection and resection of the
fundic part of the remnant as well, in an effort to rule out all possible hidden
Reoperations for Roux-en-Y Gastric Bypass Failures
95
gastrogastric fistula [17]. Typically, resection of the remnant will be carried
out from the top down to the level of the antrum, i.e., to the right of the
alimentary limb, because as mentioned above, a gastrogastric fistula of the
posterior aspect of the gastro-enteral anastomosis (GEA) is always possible.
Dissection of the part of the remnant lying across the anastomosis is obscured
by the mesentery of the alimentary limb and must be performed, at the risk of
devascularizing that part of the remnant, which is another reason why we do
not hesitate to perform resection of its fundic part.
3.2. Banding the Pouch
RYGB is commonly seen as a mixed procedure (mixed restrictive and
malabsorptive). Even with a correctly constructed pouch and gastroenterostomy (GEA) the restrictive aspect may not suffice in some instances
and may find benefit from additional measures. These measures include the
placement of a non-adjustable band around the bypass pouch as reported by
Fobi in open RYGB [18], and more recently by Bessler in laparoscopic
procedures [19]). In our [20] (and in others‟) experience the secondary
placement of a band is however fraught with a high erosion rate (in our
experience up to 20%). Another, perhaps better option for addressing poor
weight loss after RYGB consists of the placement of an adjustable band
(AGB) around the gastric pouch as described by Bessler [21].
After banding the pouch with an AGB, further weight loss, varying from
55.9%–94.2% excess body mass index loss (EBMIL) has been documented
after respectively 12–42 months of follow-up [22]. While theoretically the
incidence of erosion after placement of an adjustable band should be lower
than with a non-adjustable (Fobi) ring, adjustable band-specific complications
such as slippage, infection and erosion of the band may appear. In case of one
of the aforementioned mishaps it is better to remove the band (= foreign
object), if at all possible by endoscopic technique, and to trim the pouch over a
large bore tube.
3.3. Longitudinal Partial Resection of Pouch and Alimentary Limb
(Gagner technique)
Michel Gagner‟s team developed an interesting technique to influence the
volumes involved in the bypass in an effort to resume weight loss without
using a foreign object [23]. The technique consisted of reducing the gastric
pouch together with the proximal part of the antimesenteric edge of the AL
with a linear stapler. Long-term weight loss outcomes of this ingenious
technique were however disappointing, both in Gagner‟s and in our
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experience. Rather than resecting the pouch and the AL longitudinally, we also
attempted to reduce both by plication around a 34 Fr orogastric tube, quite
similarly to the newly described technique that mimicks SG [24].
Unfortunately, here as well, midterm outcomes concerning weight loss were
rather poor.
3.4. Endoscopic Trimming of Pouch and Gastro-Enteral Anastomosis
Recently, several techniques have been described to reduce the size and/or
the compliance of the gastric pouch and to reduce the size of the GEA. As
previously mentioned, these techniques are beyond the scope of this chapter.
3.5. Reversal and Conversion to Sleeve Gastrectomy
When all possible correctible causes for primary failure of the RYGB have
been ruled out the multidisciplinary team may conclude that the choice for
RYGB was not the correct one and may decide to reverse the bypass. See
below (4.2)
4. Secondary Failure
Secondary failure occurs when patients who initially experienced good
weight loss and resolution of co-morbidities suffer a significant weight regain
and resurgence of the comorbidities. This evolution indicates that the
procedure most likely was indeed correctly chosen and well carried out (as
demonstrated by the initial success), but that some unwanted evolution did
interfere with continued weight loss. Causes of weight regain may well be
patient related (diet, life style) or may be linked with anatomical changes that
have developed over the years. There are conflicting data in the literature
concerning the importance of the secondary dilation of the pouch, and of the
dilation of the GEA [25, 26]. Based on the (poor) experience gathered with
pouch trimming and anastomotic reshaping performed for primary failure, we
cannot recommend a surgical re-intervention that limits itself to these
objectives. In secondary failures the pouch can be banded (by adjustable or
non-adjustable band) as well, but, as mentioned before, this strategy does carry
its own complications. In addition, patients who got used to the quite
comfortable eating conditions secondary to the RYGB more often than not
will only reluctantly accept a new significant reduction.
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4.1. Distalization of RY Gastric Bypass
The RYGB being a mixed restrictive-malabsorptive procedure, the
malabsorption may be enhanced as well. Malabsorption can be augmented by
increasing the length of the bypassed bowel. Consequently, the conventional
“proximal” bypass may be converted into a “distal bypass.” Because of the
substantial number of severe complications described in the literature,
distalization of the bypass is only performed in well-compliant individuals
who nevertheless developed weight regain after initial good weight loss. The
best candidates are the patients who did not dilate their gastric pouch (hence
cannot eat large volumes), but who developed a grazing (or polyphagic) eating
pattern.
Lengthening the AL to 200 or even 250 cm has proven useless on the long
term for patients who failed the RYGB [27]. Conversely, “true” distal gastric
bypass has been proposed several years ago as active remedial operation for
failed RYGB. While extremely effective in terms of weight loss, the side
effects of the distal construction however have proven too significant to allow
general acceptance of the procedure. In the initial description by Sugerman,
who used the distalization principle in patients who did poorly after (open)
proximal bypass, the metabolic consequences were considerable and some
patients died [28]. Brolin [29] found that only half of the patients had clear
benefits from the conversion of a regular to a distal RYGB. However, Brolin
described a particular type of distal bypass, with a very long alimentary
channel and a very short (75 cm) common channel. Our technique of bypass
distalization much more resembles the open operation described by Rawlins et
al. [30], who reported good results in compliant patients with a construction of
a 100 cm long CL and a 150 cm AL. We actually maintain a length of 150 cm
both for the AL and the CL, the BPL not being routinely measured [31].
This technique has the practical advantage that mostly the alimentary limb
had been constructed some 150 cm long, hence that all that needs to be done is
to transect the alimentary flush with the entero-enteral anastomosis and to
reimplant the alimentary limb on the common some 150 cm proximal to the
ileocecal valve. Thus, the sum of AL + CL is approximately 300 cm, the
minimum length to avoid protein malnutrition according to Scopinaro [14].
With our distalization strategy, besides inducing good additional weight loss in
a good number of individuals, we managed to “cure” a patient from
insulinodependent T2DM, despite a weight loss of approximately 50% EBMIL
obtained by the “regular” RYGB. It is clear however that after distalization
patients become at high risk to develop deficiencies including protein
malnutrition, hence the obligation to select the patients in terms of compliance
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(as demonstrated by their behavior after the initial RYGB) and the
commitment of both patient and multidisciplinary team to zealously follow-up
the patient at regular intervals.
4.2. Reversal (Figure 3-11) and Conversion to Sleeve Gastrectomy
(As First Step of a Duodenal Switch or DS)
For some individuals the RYGB induces dietary restrictions -such as the
interdiction of ingesting sugar- that proved too hard to keep. Non-compliance
to the diet however results in an array of undesired symptoms including
hypoglycemia and eventually weight regain.
Figure 3. The gastro-enteral anastomosis must be taken down, uniting the gastric pouch
(A) and the proximal part of the alimentary limb (AL) The gastro-enteral anastomosis
is being transected (separation of A and B). Transection is performed just distal to the
anastomosis to create ischemic discoloration of the most proximal part of the AL,
which facilitates identification of the gastric pouch part at the anastomosis. Thanks to
the ischemic discoloration of the most proximal part of the transected AL the trimming
of the gastric pouch can be kept minimal.
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99
For these patients, the RYGB appears to represent a “wrong choice” on
the long-term and it might consequently be better to change the metabolicsurgical strategy overall. Converting one procedure to another or even simple
reversal of a procedure nowadays is less of a challenge than in the open
surgery era, because laparoscopy causes far less adhesions. In order to allow
more than one final choice it is an acceptable policy to initially reconvert the
bypass anatomy to a normal situation. We described the technique in 2006
[32] and reported on our patients‟ outcomes a few years later [33].
Figure 4. A gastrotomy is performed in the remnant vis-à-vis the distal part of the
pouch, that is opened in its distal part at this time.
Obviously, reconversion to a normal anatomy will not likely improve
weight loss. However, starting from the newly re-obtained normal anatomy, a
LSG can be constructed, either immediately during the reversal or with some
delay to give the patient the occasion to accommodate to the new situation
[34]. A „„sleeve-like‟‟ gastrectomy can be performed over a 34-French bougie
to calibrate the new stomach (Figure 10), while imbricating (“plicating”) the
middle part of the sleeve proximal to the antrum of the stomach (Figure 11).
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Figure 5. Anastomosis is performed between the open pouch and the remnant
(Posterior layer). A manual anastomosis is preferred. Please note that the vertical part
of the pouch and the corresponding part of the remnant are not opened, but rather
sutured together to restore a fundus-like structure to avoid reflux.
Figure 6. Anastomosis is performed between the open pouch and the remnant (Anterior
layer). A manual anastomosis is preferred. Please note that the vertical part of the
pouch and the corresponding part of the remnant are not opened, but rather sutured
together to restore a true fundus to avoid reflux.
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Figure 7. The JJ anastomosis is being transected at C, separating the BPL from the ALCL confluent. Note that first the original mesenteric defect must be recreated and that
the linear stapler is placed slightly on the BPL side of the anastomosis to avoid
narrowing at the AL-CL junction. A rim of ischemic tissue may thus be left on the ALCL side of the anastomosis, but this has no clinical significance.
It appears that in some cases LSG is actually superior to RYGB, possibly
because of the preservation of the antrum and pyloric sphincter, with
subsequent enhanced gastric emptying [35] and inhibition of the orexogenic
Ghrelin hormone [36]. In addition, in cases in which the restriction created by
the sleeve does not suffice, the “natural complement” of the LSG, i.e., a DS
may be carried out. DS is a typical biliopancreatic diversion, and has been
shown to be the most active procedure in terms of T2DM remission rates [37].
In addition, because of the preservation of an acceptable stomach volume (i.e.,
the sleeved stomach), unlike with the distal gastric bypass, the DS might be
safer than the distal RYGB.
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Figures 8 and 9. Anastomosis between B (previously the proximal AL) and C
(previously the BPL), restoring the continuity of the small bowel. Care must be taken
not to twist the mesenteries of the 2 small bowel loops. With the technique usually
chosen for RYGB the mesenteric defect at this anastomosis should be quite small.
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Figure 10. A „„sleeve-like‟‟ gastrectomy can be performed by the use of a 34-French
bougie to calibrate the new stomach.. The technique starts by devascularizing and
resecting the fundus, ending a few cm proximal to the level of the newly fashioned
anastomosis.
Figure 11. Plication of the middle part of the sleeve proximal to the antrum of the
stomach.
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5. Revisional Procedures After RYGB for Complications
Interfering with the Outcome
5.1. Hiatal Hernia and Gastro-Esophageal Reflux (GERD)
Despite the recognized efficacy of the RYGB anatomy in abolishing
GERD, reflux symptoms may complicate even RYGB. Usually, reflux will be
alkaline, but acid reflux is possible as well, perhaps as a result of too large a
gastric pouch or too a short an AL, or, more frequently, as a result of an
abnormal communication between the bypassed gut and the pouch or the AL
as seen in gastrogastric fistula. Alternatively, an obstruction may be causing
acid reflux, as in cases with severe adhesions impacting on the CL or in trocar
orifice herniation.
In case of alkaline reflux, a Hiatal Hernia (HH) must be ruled out.
HH can be highly symptomatic after RYGB, not only in terms of GERD,
but in terms of dysphagia as well. The latter condition may induce excessive
weight loss, which may warrant reintervention. Rarely, HH involves herniation
of the excluded stomach, a situation that requires immediate reoperation
because of the risk of strangulation.
Figure 12. Our personal technique of crural repair. While the fully dissected distal
esophagus (ESO) is reclined anteriorly, the posterior closure of the hiatal crura is
performed by at least one Figure of 8 stitch of polypropylene material buttressed by
cellulose acetate pledgets.
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When performing hiatal exploration a thorough circular exploration of the
crura must be performed as well as dissection/liberation of the distal
esophagus, the latter being important to rule out epiphrenic diverticula and to
provide sufficient slack for the intra-abdominal esophagus, an essential
condition in avoiding recurrence [38]. In our experience, crural repair is best
performed by posterior placement of non-absorbable, deep stitches, that are
then tied over pledgets (we usually use cellulose acetate pledgets) [39] (Figure
12). The use of prosthetic mesh is best avoided because of the risk of erosion
in a previously dissected area.
5.2. Issues at the Gastro-Enteral Anastomosis
A dreaded problem at the GEA is the anastomotic or marginal ulcer, a
condition that occurs in up to 50% of the cases [40]. Causative factors include
excessive acid production as with a large pouch (but again, a gastrogastric
fistula must be ruled out), ischemia, and the persistence of foreign material
(staples or non-absorbable sutures). Marginal ulceration appears more
frequently in smokers. When conservative management including the use of
large doses of proton pump inhibitors (PPI) fails, surgical treatment may be
considered. In case of perforation, surgical treatment must be performed
immediately.
5.2.1. Elective Treatment of Marginal Ulceration
The first treatment of chronic marginal ulcer is the cessation of cigarette
smoking. Smoking is a leading cause of recurrent anastomotic ulceration.
Surgical exploration should aim at reducing the acid production, e.g., by
reducing the size of the pouch, by performing vagotomy, or, more radically, by
performing remnant gastrectomy to permanently reduce gastrin and
subsequent acid production. Even in the presence of small pouches, in case of
chronic marginal ulcer, we usually resect the GEA together with a chunk of
pouch, care being taken not to induce ischemia.
To avoid vascularity issues, dissection at the lesser curve is kept minimal
and transection (either stapled or preferably manual, with the coagulating
hook) performed at an angle, keeping the greater curvature part of the pouch
substantially shorter than the lesser curvature. Reanastomosis is preferably
performed manually to avoid ulcer-inducing staples. We usually perform
resection of the fundus as well, with the purpose to allow better visualization
of the greater curvature side of the pouch, and to reduce systemic acid
production overall.
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5.2.2. Emergency Treatment of Marginal Ulceration
When faced with perforated anastomotic ulceration, the surgical treatment
should be confined to dealing with the acute situation, i.e., the perforation
itself. Trimming of the edges of the ulcer and suture closure covered by an
omental patch is probably the best initial treatment. Because of the invariably
present concomitant peritonitis, it is preferable to delay more extensive
treatment such as described in 5.2.1. (the search for a gastro-gastric fistula,
trimming of the pouch and total reconstruction of the GEA ) to a later date,
when septic symptoms and acute inflammatory changes have subsided.
In exceptional cases the perforation involves the remnant part and a bulbar
ulcer may be found. Treatment should be as for any perforated duodenal ulcer.
5.3. Other Circumstances Amenable to Surgical Correction
5.3.1. Blind Loop Syndrome (Candy Cane Deformation at the GEA,
“cloaca” Formation at the JJ Anastomosis)
Not infrequently patients who underwent LRYGB several months to years
previously complain of abdominal pain confined to the left upper quadrant
together with severe nausea and sometimes dysphagia. This condition is
pathognomonic for blind loop syndrome. Diagnosis can be made by barium
swallow (to identify a “candy cane” deformation of the blind end of the AL)
and/or by CT scan (to diagnose a “cloaca” formation at the level of the Y
anastomosis).
Treatment is surgical (laparoscopic) and consists of stapled resection of
the redundant part (Figure 13). Care must be taken to avoid excessive
narrowing of the lumen, which especially at the GEA may result in increased
dysphagia. Stenosis may cause staple line leakage as well.
5.3.2. Intussusception at the JJ Anastomosis
An unusual cause of obstruction is the intussusception at the level of the JJ
anastomosis. Mostly the condition consists of the retrograde invagination of
the CL into itself and into the JJ anastomosis [41].
The cause is unclear, but one hypothesis is the existence of an active
pacemaker in the distal small bowel that sends impulses in a retrograde
fashion. Typically these patients will present a typical “target sign” at the
abdominal CT scan.
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Figure 13. The candy cane deformity of the blind end at the alimentary limb may
become highly symptomatic and demand resection. It is important to pull the
uppermost part of the “candy cane” cephalad and to the left rather than to pull on the
staple line. Note the presence of a large bore orogastric tube to prevent stenosis.
Treatment is surgical (laparoscopic) and quite urgent to avoid necrosis.
The best approach consists of plication, or, better, resection and redo of the JJ
anastomosis, because simple reduction and fixation is fraught with a high
incidence of recurrences.
5.3.3. Internal Hernia
Internal hernia (IH) is a common cause of chronic pain after RYGB.
Typically the patient suffers crampoid pain, comparable to contraction pains
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during labour, most often occurring after a meal. Some patients become
emaciated because of this condition.
It is noteworthy that previous closure of the mesenteric and Petersen
defect (Figure 2) does not provide fool-proof warranty for absence of IH. In a
recent retrospective study performed 9 years after the LRYGB [42], we found
that the incidence of small bowel occlusion including IH was a frightening
9%, despite our policy of systematically closing all the defects with nonabsorbable suture. Obviously, technical flaws may be responsible for this
finding, but it is possible as well that the sometimes massive weight loss
creates gaps in an initially well performed closure. Diagnosis in the acute
setting is merely clinical: a patient with excruciating pain should be taken to
the operating room for emergency laparoscopic exploration. When the cause
of the acute abdomen is indeed found to be an IH, some bowel loops will
appear dusky (or black!). Often a substantial quantity of intraperitoneal milkywhite fluid may be noted, corresponding to chyle, produced by the chronic
hyperpressure in the lymphatics of the small bowel.
When reduction of an IH is attempted it is wise to start exploration at the
ileo-cecal transition and to gently pull the bowel, passing it from the grasper in
one hand to the other, going cephalad, until a “snap” is felt which indicates the
reduction of the herniated part. Closure of the defect that caused the IH is
usually straightforward after adequate reduction and should be performed by a
running suture of non-resorbable suture material.
5.3.4. Excessive Weight Loss and Protein Malnutrition
This condition is quite rare after “regular” RYGB. However, malnutrition
is occasionally encountered in some patients who skipped the scheduled
follow-up visits, neglected their complaints (of nausea, e.g.) or developed
extremely poor eating habits consisting of exclusively ingesting carbohydrates
for example. These patients may lose excessive weight and/or develop
hypoproteinemia. These individuals invariably present a significantly impaired
healing capacity because of malnourishment and are therefore initially best
treated by the laparoscopic placement of gastrostomy in the excluded stomach
(food stuffs administered via this route will be fully absorbed). After recovery
of their metabolic balance these patients will require extensive counseling to
address their poor dietary habits, and sometimes will need to undergo
corrective surgery which may consist of reversal of their procedure.
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5.3.5. Hypoglycemia and Neuroglycopenia
The dramatic impact of RYGB on glucose metabolism, even in the
absence of T2DM is well documented. Recently, some attention has been paid
to the hypoglycemia syndrome, a condition appearing some 2 to 3 years after
the RYGB procedure and characterized by the apparition of hypoglycemia
some 90 minutes to 2 hours after a meal (especially after a meal rich in
carbohydrates). Hypoglycemia may be accompanied by vague symptoms of
light-headedness, fatigue, exhaustion and marked tremor, but syncopes and
epileptic insults are relatively common as well. When neurological symptoms
of hypoglycemia become apparent, the syndrome is referred to as
neuroglycopenia. This clinical condition is remarkably underestimated and is
often confused with “chronic fatigue,” fibromyalgia, or organic central
neurological aberrations.
5.3.4.1. Diagnosis
The diagnosis of the hypoglycemia syndrome is essential because this
condition may cause car accidents, accidents on the work floor, or in the
household. The clinical aspect differs from the dumping syndrome because
individuals suffering from hypoglycemia very rarely mention pain and/or
diarrhea. Also, the chronology of events differs, the symptoms with the
hypoglycemia syndrome occurring later after a meal than with dumping.
Initial diagnosis can be made by a tolerance test with a standard meal or
with oral glucose. It is important to record the clinical symptoms that go
together with the biochemical hypoglycemia during the test, because some
patients do not suffer any symptoms despite plasma glucose values as low as
30 mg/dl. Once the diagnosis of hypoglycemia, which is secondary to an
exaggerated insulin response to carbohydrates and sugars, has been made [43],
the possibility of an insulin producing pancreatic tumor must be ruled out. The
most accurate test available is the sampling of plasma insulin after selective
intra-arterial peripancreatic Calcium injections. Intra-arterial Calcium elicits a
pancreatic insulin response when a secreting tumor is present. The selectivity
of the test allows to detect the approximate location of the tumor in the
pancreas. Additional diagnostic tools are the Magnetic Resonance Scan and
the Octreotide inhibition test.
5.3.4.2. Treatment
The first treatment of the hypoglycemia syndrome is dietary: patients
should refrain from all intake of simple sugars and limit the ingestion of
carbohydrates. The requested change in eating behavior is a considerable task,
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because most patients go through an acute withdrawal phase when kept away
from carbohydrates and sugars.
Medical treatment consists of oral acarbose, diazoxide or parenteral
octreotide but these treatment modes are expensive and not very efficient [44]
Surgical treatment
The most effective treatment is surgery. Three types of operations have
been described:



the placement of a band or ring around the pouch to slow down gastric
emptying
pancreatectomy.
reversal of the procedure
1/ Placement of band around the stomach pouch
This treatment was proposed more specifically to address the problem of
postprandial dumping [45]. Despite quite good outcomes in terms of dumping
reduction, this technique faces the relatively high incidence of complications
we already mentioned. Moreover, the technique does not appear to be effective
in true postprandial hypoglycemia.
2/ Pancreatectomy
Theoretically, pancreatectomy makes sense because it removes the source
of insulin secretion. This strategy was first described by Service et al. [46].
Despite good short-term outcomes this very aggressive surgical procedure
however does not appear to keep its promises on the long term.
3/Reversal (as mentioned before)
Reversal of the bypass construction is logical because it addresses the
alleged cause of insulin hypersecretion, i.e., the bypass of the duodenum,
causing an imbalance in incretin production. Some reports however question
this approach [47].
There is quite a simple strategy to avoid reversing a bypass for
hypoglycemia syndrome in vain. This strategy consists of placing a
gastrostomy tube in the remnant stomach, either laparoscopically, or
percutaneously, under CT guidance. The patient hereafter is fed exclusively
through the gastrostomy. When hypoglycemia clearly regresses (which can be
documented by an oral tolerance test through the gastrostomy tube), reversal
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111
may safely be attempted. We try to perform full reversal rather than a
functional reversal, which may be obtained by gastro-gastrostomy uniting
pouch and remnant. Rather, we perform transection of the GEA and of the JJ
anastomosis at the level of the BPL ending. The blind end of the AL and of the
BPL are reanastomosed, hereby restoring small bowel continuity. Finally, the
pouch and remnant are reanastomosed as well, which concludes reversal to a
normal anatomy (and may be complemented by sleeve-like gastrectomy)
(Figures 3-11).
CONCLUSION
The laparoscopic Roux-en-Y gastric bypass has passed the test of time and
a number of patients have now undergone the procedure more than 10 years
ago. Even though the overall outcomes are excellent, not unexpectedly, some
late complications do arise, creating weight problems or other conditions that
may be significant in terms of patient comfort and even safety. This chapter
attempted at describing the most common problematic issues occurring
occasionally after (laparoscopic) Roux-en-Y gastric bypass and to come up
with an acceptable strategic approach (Figure 14).
Figure 14. Algorithm showing the surgical management for Roux-en-Y gastric bypass
failures.
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[27] Christou NV, Look D, Maclean LD. Weight gain after short- and longlimb gastric bypass in patients followed for longer than 10 years. Ann
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[28] Sugerman HJ, Kellum JM, DeMaria EJ. Conversion of proximal to distal
gastric bypass for failed gastric bypass for superobesity. J Gastrointest
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[29] Brolin RE, Cody RP. Adding malabsorption for weight loss failure after
gastric bypass. Surg Endosc 2007;21(11): 1924-6.
[30] Rawlins ML, Teel D 2nd, Hedgcorth K, Maguire JP Revision of Rouxen-Y gastric bypass to distal bypass for failed weight loss. Surg Obes
Relat Dis. 2011;7(1):45-9.
[31] Dapri G, Cadière GB, Himpens J. Laparoscopic conversion of Roux-enY gastric bypass to distal gastric bypass for weight regain. J
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[32] Himpens J, Dapri G, Cadière GB. Laparoscopic conversion of the gastric
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[33] Dapri G, Cadière GB, Himpens J. Laparoscopic reconversion of Rouxen-Y gastric bypass to original anatomy: technique and preliminary
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[34] Vilallonga R, van de Vrande S, Himpens J. Laparoscopic reversal of
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FG, Chouinard ML, Havel PJ. Vertical sleeve gastrectomy improves
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In: Management for Failed Bariatric Procedures
ISBN: 978-1-63483-753-8
Editors: J. Himpens and R. Vilallonga © 2015 Nova Science Publishers, Inc.
Chapter 7
FAILED MINIGASTRIC BYPASS:
SURGICAL STRATEGIES
Jean-Marc Chevallier
Department of Bariatric Surgery, Hôpital
Européen Georges Pompidou, Paris, France
ABSTRACT
Against morbid obesity MGB is an alternative to RYGB with less
morbidity and same long-term efficiency because it involves just one
anastomosis. But the presence of bile in the afferent limb and the 200 cm
long bypass imply that MGB failure reoperations must be approached
differently than after RYGB. Revision rate is between 0.8 and 4.7% in the
literature, 2% in our experience (20/1000). Revisions are performed for
complication (leaks, biliary reflux or marginal ulcer), inadequate weight
loss or malnutrition. Leaks after MGB can lead to biliary peritonitis and
must be treated quickly by conversion from MGB to RYGB. Intractable
bile reflux is rare (0.9%) and must be treated by conversion of the MGB
to RYGB, provided the common limb length down to the ileocecal valve
is longer than three meters. Insufficient weight loss or weight regain
(4.9%) require a multidisciplinary assessment to evaluate eating disorders
and to appreciate if there is a true pouch dilatation. If the patient remains
morbidly obese and the gastric pouch appears dilated a revision with

Corresponding author: Professor Jean-Marc Chevallier. Department of Bariatric Surgery,
Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France. E-mail: [email protected].
118
Jean-Marc Chevallier
pouch trimming might be efficient. If the pouch is not dilated a band can
be placed around the gastric tube in order to add more restriction.
MGB is more malabsorptive than RYGB but the rate of malnutrition
appears low (between 0.3 and 1.28% in the literature). In case of alarming
malnutrition a revision can be decided after preparation. Restoration of a
normal anatomy can easily be performed after MGB. The conversion of
the MGB to a sleeve gastrectomy has a substantial leakage rate but it
obviously allows the patient to keep thin.
With experience MGB appears to have a small reoperation rate, to be
easily converted or reversible if necessary. It should thus be considered in
the armamentarium of bariatric surgeons.
INTRODUCTION
Morbid obesity has become a public health problem in most countries. It
leads to a high incidence of complications that decrease life expectancy, even
in young adults. Medical treatment of obesity is known to bring disappointing
results; however, bariatric surgery has been proved to be efficient for the
treatment of morbid obesity, and for decreasing even mortality and
complication rates [1].
Our surgical team has 20 years of experience in laparoscopic bariatric
surgery. We used to perform the Laparoscopic Roux-en-Y gastric bypass
(RYGB) using the Lonröth technique, which consists of an omega loop raised
up to the gastric pouch, in which both anastomoses are created and then
separated by a section converting the omega into a Roux-en Y gastric bypass
[2]. The Laparoscopic Minigastric Bypass or One Anastomosis Gastric bypass
(MGB) is a modification of this omega loop bypass, with only one
anastomosis, namely the gastrojejunostomy.
In 2005, a prospective randomized trial compared MGB to RYGB and
showed better outcomes for MGB at 2 years [3]. However MGB has raised
criticism and controversy, especially regarding its potential risk of biliary
reflux [4]. More recently, some long-term series on MGB have shown
promising results in terms of security and efficiency [5-9].
After having published the outcomes of our first 100 MGB procedures
[10], we have recently reported on our first 1000 MGB procedures over a 7year period [11]. We compared these results to the literature and focused in
this chapter on surgical strategies in case of MGB failure.
Failed Minigastric Bypass: Surgical Strategies
119
1. THE MGB PROCEDURE (FIGURE 1-2)
All surgical procedures were carried out by six different surgeons using
the same standardized technique (Figure 1). Details of the surgical procedure
have been published previously [10], and are similar to those described by
Rutledge [12]. A long and narrow gastric tube was created by applying one
horizontal 45-mm roticulator Endo-GIA® stapler (Covidien, Cincinnati, OH,
US) at the angle of lesser curvature, just above the left branch of the crow‟s
foot, and then four to five vertical 60-mm roticulator Endo-GIA® staple
cartridges upward to the angle of His, calibrated along a 32-Fr bougie, similar
to the vertical part of a sleeve gastrectomy. No reinforcement was done on the
staple line. Section of the greater omentum in bivalve was performed. The
jejunum was mounted antecolically at 200 cm down from the ligament of
Treitz, and a side-to-end anastomosis (Figure 2) was performed with the
gastric tube using a posterior 45-mm Endo-GIA® stapler and an anterior
running suture. A nasogastric tube was passed into the efferent loop, and a
closed vacuum drain was placed behind the anastomosis. The anastomosis was
finally checked using an intraoperative methylene blue test.
Figure 1. One anastomosis Gastric Bypass.
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Jean-Marc Chevallier
Figure 2. Linear stapled gastrojejunal anastomosis.
2. DEFINITION OF FAILURE; REVISION OF AN MGB
In most series weight loss was determined as changes in mean BMI and
mean percent Excess Body-Mass Index loss (%EBMIL), with BMI 25 as the
upper limit of normal according to the actually adopted standard measure [13].
Failure can be due to complication (marginal ulcer or intractable bile
reflux), insufficient weight loss (defined by a %EBMIL of < 25%) or on the
opposite, excessive weight loss with malnutrition (%EBMIL > 100% with
albuminemia < 30 g/L).
Table 1 summarizes late revisions after MGB in four long-term studies.
Revision rate was between 0,8 and 4.7%. Lee published in 2011 a revision rate
of 1.7% on 1322 MGB at 9 years follow up [14]; these data have been updated
in 2012 in comparison to RYGB [7].
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Failed Minigastric Bypass: Surgical Strategies
Table 1. Late revisions after MGB in the literature
Lee 2012 [14]
Musella [8]
Inadequate WL
Bile reflux
malnutrition
Obstruction
Internal hernia
Marginal ulcer
stricture
10 (0.9%)
4 (0.3%)
10 (0.9%)
1
0
7
1
1
TOTAL
33/1322 (2.8%)
1
1
0
4
0
7/818
(0.8%)
Noun [6]
4
4
33 (open)
0
6
0
47/1000
(4.7%)
Chevallier
[11]
4
7
2
5
0
2
0
20/1000 (2%)
WL = weight loss.
In this latter paper the two most common reasons for revision were
malnutrition and inadequate weight loss in 10 (30,3%), marginal ulcer in 7
(21,2%) and intractable bile reflux in 4 (12,1%) patients. Revisional surgery
performed was RYGB in 11 (47.8%), Sleeve Gastrectomy in 10 (43.5%) and
conversion to a normal anatomy in 2 (8.6%) patients. In our recently published
experience [11] we had to revise 20 patients (2%): 7 for intractable reflux
(35%), 5 for intestinal obstruction, 4 for inadequate weight loss, 2 for marginal
ulcer, and 2 for malnutrition.
The chapter will be divided in three parts: revision for complication,
inadequate weight loss and malnutrition.
3. REVISION FOR COMPLICATION
The early complication rate was 6% in the meta analysis [15], 51 leaks
(1%), 2.8% marginal ulcers, 4.2% anemia. Late complications leading to
revision are collected in Table 1.
3.1. Leaks
Our 0.6% rate of leakage is low, and is similar to other series [5-9]: this
may be because a good blood supply was preserved in the thinner gastric tube
and jejunal loop without mesenteric interruption.
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Jean-Marc Chevallier
After MGB leak at the gastrojejunostomy leads to a biliary peritonitis. As
for every bariatric procedure in case of leakage the reoperation must be
decided as soon as possible, but in the case of MGB it is even more important
because of the presence of bile. If the reoperation has been decided soon
enough the treatment of the leak can actually be a simple suture, but it has to
be accompanied by the conversion of the MGB to a RYGB in order to move
the bile away from the gastrojejunostomy (see below).
3.2. Biliary Reflux
Critics of the MGB procedure compare it to the first bypasses performed
by Mason in 1969 [16], which consisted of horizontal sectioning of the
proximal part of the stomach and then raising the bowel loop to form an
omega shape. The proximity of the anastomosis to the esophagus caused
incapacitating biliary reflux, which led the author to abandon the omega
procedure for the Roux-en-Y procedure.
Symptomatic biliary reflux is not frequent after MGB and most of the time
can be cured medically. In a recent publication [17] we compared
postoperative GIQLI (GastroIntestinal Quality of Life Index) 5 years after
MGB with preoperative GIQLI. Interestingly we found no significant
differences in the GERD symptoms (Regurgitation, heartburn, nausea,
belching) between the two groups. Lee reported intractable bile reflux in four
cases [7]. In our experience 11 cases of biliary reflux so far necessitated us to
convert to a RYGB at ~2 years post-MGB in patients who had lost all their
excess weight. The conversion had a spectacular effect on biliary reflux, and
patients also maintained their weight loss.
However, GERD is rarely a problem in MGB because the anastomosis is
placed low in the stomach. Although it is common to find bile around the
anastomosis in the medium- and long-term, it is rarely seen as far up as the
esophagus. MGB actually creates an anatomy where reflux is intuitively
promoted, as opposed to the standard RYGB. This is one of the major
criticisms raised against the MGB: unfortunately, our data were insufficient to
determine if this criticism is unfounded. We can only mention that among the
post-operative gastroscopic biopsies conducted, we found foveolar
hyperplasia, a sign of biliary reflux, in only 13/76 (17.1%) cases at 2 years and
in 2/43 (4.6%) cases at 4 years, with no dysplasia or metaplasia [18].
We have no experience of the anti-reflux technique, as described by others
[19]. In our technique the gastric pouch must be long and narrow. Stapling
Failed Minigastric Bypass: Surgical Strategies
123
must be vertical, perpendicular to the incision in the pouch, and above the
posterior surface of the stomach so that the afferent loop comes from the back,
and is higher than the efferent loop. If biliary reflux ever becomes intractable,
conversion to RYGB is still a valid and effective straightforward option.
3.3. Marginal Ulcer
One of the classic concerns with a gastrojejunal bypass is the occurrence
of marginal ulcers at the edge of the gastrojejunal anastomosis, a condition
that is caused by the small gastric pouch continuing to secrete acid. In a recent
meta-analysis collecting 5095 cases operated between 1997 and 2011 in seven
different centers [15] the marginal ulcer rate was 2.8%. Most of the marginal
ulcers appear to be curable medically.
In our experience two ulcers were revealed by symptoms of peritonitis late
in follow-up. Both patients were heavy smokers; they had lost all their excess
weight, and had stopped taking proton-pump inhibitors. Overall, the number of
marginal ulcers (2%) was however low and equivalent to that found after
RYGB [20]. The rate of ulcers was probably low because of our policy of
preoperatively screening for Helicobacter Pylori and eradicating whenever
present. The small size of gastric pouches with our technique, and the routine
prescription of proton-pump inhibitors most likely helped keeping the
incidence as low as well. A larger gastric pouch in MGB (likely producing
more acid) might increase the incidence of ulcers; a pouch must be long and
narrow to keep the acid secreting volume low. The bile in contact with the
anastomosis may actually buffer the ulcerogenic effect of acid on the
anastomosis [21]. As for RYGB smoking was a risk factor for marginal ulcers
throughout this series We think that patients who continue smoking after an
omega-loop bypass need to keep taking proton-pump inhibitors.
3.4. Conversion of MGB to RYGB (Figure 3)
In case of leak or intractable bile reflux MGB can be converted to RYGB.
Two techniques are available to convert MGB to RYGB:
3.4.1.

to perform a latero-lateral jejunojejunostomy 70 cm distal to the
gastrojejunostomy (Figure 3 A)
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Jean-Marc Chevallier


to staple the afferent loop just between both anastomosis (Figure 3B)
to close the mesenteric defect (Figure 3C)
This technique was proposed by Lee [14] but might be dangerous: because
the bypass is already 200 cm long, adding 70 cm results in a 270 cm, which
could be too long and lead to malnutrition (see below).
The best approach is to measure the total limb length down from the
gastrojejunostomy. If it is more than 3 meters long, Lee‟s technique may be
performed with security. If limb length is less, the following second option
should be used.
3.4.2.



Resection of the anastomosis
restoration of the digestive tract by a linear side-to-side
enteroenterostomy
then performing a regular RYGB by transecting the gastric pouch
more proximally and constructing a 1.5-meter long alimentary limb
(Figure 4).
Figure 3. Conversion MGB to RYGB: easy way (1: jejunojejunostomy, 2: section
between both anastomosis).
Failed Minigastric Bypass: Surgical Strategies
Figure 3A. Jejuno-jejunostomy (70 cm distal from Gastrojejunal anastomosis).
Figure 3B. Section between both anastomosis.
Figure 3C. Closure of mesenteric defect.
125
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Jean-Marc Chevallier
Figure 4. Conversion MGB to RYGB: regular RYGB. 1: resection of GJ anastomosis.
2: enteroenterostomy. 3: regular RYGB.
4. REVISION FOR INADEQUATE WEIGHT-LOSS
Five percent (n = 49) of patients had a ≤ 25% EBMIL and had to be
considered weight-loss failures [11]. In this population, the mean preoperative
BMI was 42.5 ± 6.4 kg/m2 and the %EBMIL was 13.8 ± 12.6% at 5 years.
Noteworthy, 40% of these patients previously had had a gastric banding
(LAGB).
Dilatation of the gastric pouch occurred in four patients, which caused
excessive weight regain by 24 months post MGB. The dilatation was assessed
by an upper GI series. Redo surgery was done by pouch trimming using a
calibration tube for all patients, at ~4 years post MGB, when patients had a
mean BMI of 39.3 kg/m2 and a mean %EBMIL of 40.3%. There was no peror post-operative morbidity.
Failed Minigastric Bypass: Surgical Strategies
127
At 5 years, these patients' mean BMI was 35.9 kg/m2 and %EBMIL was
55.7%. Three of these four patients had had LAGB before MGB.
In front of inadequate weight loss the first question is: is it primary weight
loss or weight regain? A psychological and dietetical assessment is mandatory.
The multidisciplinary team has to be consulted for an unanimous decision
before considering reoperation.
The discussion about weight regain after MGB is not very different from
the one after RYGB. Revisional procedures can be either endoscopic or
laparoscopic. Considering the potential risk of redo surgery, an endoscopic
procedure should be the first choice to improve weight loss. Unfortunately
these advanced endoscopic procedures are still under evaluation and not
significantly efficient so far [22].
Consequently most of the cases actually are treated by redo surgery.
The choice of the type of surgery should be guided by different factors to
limit complications. It has actually been proven that the risk of leakage is more
important after redo surgery than after the primary bypass [23].
The local anatomical conditions might influence the decision: previously
dissected tissues, sclerosis caused by postoperative leakage can lead the
surgeon to avoid stapling or resection. Diabetes resurgence may invite for a
more malabsorptive radical solution, such as a distal bypass or a duodenal
switch. Conversely, patients who regain weight after initial good weight loss
have, most of the time, lost the restrictive part of the bypass.
A regular upper GI series or a 3-D CT-scan volumetry will then assess a
pouch dilatation. A pouch over 200 cm3 is considered the threshold to
reoperate [24].
Two options are available: pouch trimming or banding.
4.1. Pouch Trimming After MGB Failure (Figure 5)
The restrictive action of MGB is due to a long and narrow gastric pouch,
which recently has been considered as the most efficient form of pouch even
in RYGB [25]. As with RYGB, pouch trimming may be considered when
there is an actual pouch dilatation. If pouch dilatation was due to a technical
mishap in the previous operation (incomplete section of the upper fundus too
far away from the EG junction) (primary dilatation) trimming the pouch is
worthwhile. If dilatation occurred after the operation (secondary dilatation),
because of inadequate eating behavior the decision to reoperate is highly
dependent on the psycho-dietetical evaluation.
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Jean-Marc Chevallier
Figure 5. Pouch trimming for weight regain.
Outcomes of reoperation have been reported as good with a primary
dilatation, but moderately good after a secondary dilatation.
Reoperation begins by complete adhesiolysis with clear identification of
the anastomosis, the biliary and alimentary limbs. The gastric pouch must be
dissected off the remnant stomach with freeing of all adhesions of the greater
omentum. This usually allows to appreciate the magnitude of the pouch
dilatation. The gastric tube has then to be separated from the excluded stomach
and the omentum up to the left diaphragmatic crus. This exposes the pouch
that can now be resected upwards by a linear Stapler exactly like a "re-sleeve."
As in every redo gastric resection it could be advisable to use higher staples
(especially in the higher fundus) and/or reinforcement material. A methylene
blue test can also be performed to check the staple line.
4.2. To Band a MGB (Figure 6)
If a bypass failure is due to a failure of the restrictive part it is also
possible to add some restriction by putting a band around the gastric pouch.
This has been reported for RYGB failures and led also Mal Fobi to propose a
non-adjustable banded bypass, which led to prolonged weight loss [26].
Some series have shown that putting an adjustable band around the gastric
pouch after a RYGB can lead to better weight loss afterwards [27]. Even
though this has not been published yet it seems particularly suitable to put a
band around the tube of a MGB because this tube is long and even in case of
Failed Minigastric Bypass: Surgical Strategies
129
dilated tube there is always room enough to put the band around the stomach
above the anastomosis.
The technique is exactly the same as putting a primary band through the
pars flaccida. After having opened the pars flaccid of the little omentum, the
peritoneal sheet is cut along the edge of the right crus and a retrogastric tunnel
is dissected. The posterior dissection reaches the left crus and the band is
placed at the upper part of the gastric tube far away from the anastomosis. As
there is no longer a lesser sac, the band is not fixed posteriorly. It is then
advisable to fix the band to the excluded stomach by three stitches: one above
and two beneath the band.
5. REVISION FOR MALNUTRITION
Excessive weight loss can be considered as %EBMIL > 100% and
albuminemia < 30 g/l.
Rutledge observed malnutrition in 31/2401 patients [12], Noun in 4/1000
[6] and Lee in 9/1322 [14].
Figure 6. Band on MGB.
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Jean-Marc Chevallier
In our experience malnutrition occurred in three patients [11]. Their mean
BMI at 5 years was 19 kg/m2 and %EBMIL was 124% and 122%. After
treatment in a specialized medical unit with parenteral alimentation and
psychiatric support, they recently had a reversion of the SAGB into a normal
anatomy. The potential risk of malnutrition after MGB occurs because of the
long bypassed biliary limb, with consequences depending on the length of the
common limb.
5.1. Considerations on “Normal” Limb Length
The "normal" efferent limb length is 592 cm (extremes: 380-790). This
means that the length of the intestine can be very variable [28]. It is usually
considered that an effective and safe bypass must bypass 1/3 of the total limb
length. The regular MGB bypasses 200 cm.
This is adapted if the total limb length is 600 cm. If the efferent limb is
only 380 cm long (lowest extreme), this means that the remaining common
limb will only be 180 cm long (less than 50% of the efferent limb) which
could lead to protein deficiency or malnutrition. If the limb is 790 cm long
(highest limit), the bypass will be around ¼, which could be not enough and
may lead to insufficient weight loss. These considerations highlight the fact
that it is important, when performing a malabsorptive procedure like MGB, to
measure the whole intestinal length from the ileocaecal valve upwards or at
least to check that there are still three more meters down from the anastomosis.
This also explains why a regular RYGB (which bypasses 150 cm) can lead to
failure if the total limb length is 790 cm.
All theses considerations do not take into account the villi‟s surface for
each cm2 that could be different from one patient to another and decreases
with age.
5.2. MGB 'S Risk of Malnutrition
Too short a common limb can lead to protein deficiency and malnutrition
whatever the patient eats. One of the criticisms about MGB is that patients
may complain of frequent stools, bowel urgency or diarrhea.
Lee [7] reported that, when compared with RYGB, MGB patients had a
similar QOL at five years and experienced less abdominal pain but higher
stool frequency.
Failed Minigastric Bypass: Surgical Strategies
131
In our experience [17], patients usually have 3 to 4 stools per day during
the first 3 months after MGB, and then the rhythm slows down to one or 2
unless when patients continue to consume fats. We compared postoperative
GIQLI five years after MGB with preoperative GIQLI.
Interestingly, as demonstrated by Lee, we found no significant differences
in diarrhea symptoms between the preoperative and the 5-year's groups.
According to the literature the rate of malnutrition after MGB could be
between 0.3 and 1.3% (Table 2).
5.3. When to Reoperate?
After a period of incapacitating diarrhea, the albuminemia level falls under
30 g/L. It is important to check the serum prealbumin, showing the lack of
protein pooling. The patient has to be hospitalized in a medical unit to check
the whole gut and use parenteral nutrition. Most of the time this period of
parenteral nutrition improves the nutritional status but when the patient comes
back home there may be further deterioration. The recurrence of protein
deficiency is an indication to reoperate, especially because parenteral feeding
often leads to venous catheter infection.
5.4. Which Revision?
In case of malnutrition after MGB the patient's situation becomes
dangerous. The debate is whether it is better to restore the normal anatomy
(exposing the patient to return to morbid obesity) or if it is possible to let a
secure part of a bariatric procedure (convert the MGB to a Sleeve
gastrectomy).
5.4.1. Restoration to a Normal Anatomy (Figure 7)
The MGB can be considered as easily reversible. The restoration of a
normal anatomy can be performed by the following consecutive steps:
1. Section of the stomach above the anastomosis (Figure 7 A)
2. Creation of a vertical gastro-gastrostomy (Figure 7B)
3. Restoration of the digestive tract by a linear enteroenterostomy
(Figure 7C)
4. Resection of the anastomosis (Figure 7D)
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Jean-Marc Chevallier
Table 2. risk of malnutrition after MGB according to literature
N
%
Rutledge [12]
31/2401
1.28%
Noun [6]
4/1000
0,4%
Lee [7]
9/1322
0.6%
Chevallier [11]
3/1000
0.3%
Figure 7. Restoration of a normal anatomy. (1: section above the gastrjejunostomy, 2:
gastrogastric anastomosis, 3: jejunojejunostomy, 4: resection of GJ anastomosis)
Figure 7A. Section above the gastrojejunostomy.
Failed Minigastric Bypass: Surgical Strategies
Figure 7B. Gastrogastric anastomosis.
Figure 7C. Jejuno-jejunostomy.
Figure 7D. Resection of gastrojejunal anastomosis.
133
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Jean-Marc Chevallier
5.4.2. Conversion of a MGB to a Sleeve Gastrectomy
This conversion has been described by Himpens et al., for a RYGB [29].
The difference is that with RYGB a handsewn gastrogastric anastomosis must
be performed between the pouch and the part of the stomach just distal to the
horizontal stapling line. This leaves a stomach volume that can be resected at
the end of the procedure aided by the use of a 32 or 32-Fch bougie to calibrate
the new stomach.
CONCLUSION
MGB is an alternative to RYGB with less morbidity and same long-term
efficiency because it involves only one anastomosis. Nevertheless, the
presence of bile in the afferent limb and the 200 cm long bypass imply that
MGB failure reoperations must be discussed somehow differently than after
RYGB. Leaks can lead to biliary peritonitis and must be treated by conversion
from MGB to RYGB. Intractable bile reflux is rare and must be treated by
conversion of the MGB to RYGB, but the common limb length must be longer
than 3 meters down to the ileocecal valve. Insufficient weight loss or weight
regain may happen. A multidisciplinary assessment must be evaluated if there
is pouch dilatation. If the patient remains morbidly obese and the gastric pouch
appears dilated, a revision with pouch trimming might be efficient. If the
pouch is not dilated, a band can be placed around the gastric tube to add more
restriction.
MGB is more malabsorptive than RYGB, but the risk of malnutrition is
less than 4%. If the patient is at danger, a revision can be decided after
preparation. Restoration of a normal anatomy can easily be performed after
MGB. The conversion of the MGB to a sleeve gastrectomy allows the patient
to keep thin but has a higher leakage rate. See algorithm Figure 8.
With experience, MGB actually appears to have a small reoperation rate to
be easily converted or reversible. It should then be considered in the
armamentarium of bariatric surgeons.
*
After ressuscitation, SG = sleeve gastrectomy, PPI: proton pomp inhibitors.
Figure 8. Algorithm for revisional surgery after failed MGB.
136
Jean-Marc Chevallier
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[6] Noun, R., Skaff, J., Riachi, E., Daher, R., Antoun, N. A., Nasr, M. One
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[8] Musella, M., Susa, A., Greco, F., De Luca, M., Manno, E., Di Stefano,
C., et al., The laparoscopic mini-gastric bypass: the Italian experience:
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Endos. 2014; 28(1):156-63.
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[11] Chevallier, J. M., Arman, G. A., Guenzi, M., et al., One thousand single
anastomosis (omega loop) gastric bypasses to treat morbid obesity in a
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Deitel, M., Gawdat, K., Melissas, J. Reporting weight loss 2007. Obes.
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Mason, E. E., Ito, C. Gastric bypass in obesity. Surg. Clin. North Am.
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Billroth II anastomosis for peptic ulcer. A prospective comparative
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reoperative bariatric surgery for failed and complicated procedures.
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relevance of Roux-en-Y gastric bypass volumetry using 3-dimensional
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Fobi, M. Banded gastric bypass: combining two principles. 2004 ASBS
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Irani, K., Youn, H. A., Ren-Fielding, G. A., et al., Mid-term results for
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(2):219-24.
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gastric bypass into a normal anatomy. Obes. Surg. 2006 Jul; 16(7): 90812.
In: Management for Failed Bariatric Procedures
ISBN: 978-1-63483-753-8
Editors: J. Himpens and R. Vilallonga © 2015 Nova Science Publishers, Inc.
Chapter 8
SURGICAL PROCEDURES FOR FAILURE
OF BILIOPANCREATIC DIVERSION
WITH DUODENAL SWITCH (BPD-DS)
Simon Marceau, MD, FRCS (c), Simon Biron, MD,
MSc, FRCS (c), Frédéric-Simon Hould†, MD. FRCS (c),
Stefane Lebel‡, MD, FRCS (c), Odette Lescelleur§, MD,
FRCS (c), Laurent Biertho#, MD, FRCS (c)
and Picard Marceau, MD, PhD, FACS, FRCS (c)
Bariatric Surgeon, IUCPQ,
Laval University
Québec (Québec), Canada

Corresponding author: Simon Marceau, MD, FRCS (c). Department Head. Bariatric Surgeon.
IUCPQ, Laval University. 2725, chemin Ste-Foy. Québec (Québec) G1V 4G5. Tél.: (418)
656-4810. Fax.: (418) 656-4825. Email: [email protected].

Email: [email protected].
†
Email: [email protected].
‡
Email: [email protected].
§
[email protected].
#
[email protected].

Email: [email protected].
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Simon Marceau, Simon Biron, Frédéric-Simon Hould et al.
ABSTRACT
We are presenting our experience in dealing with patients on whom
BPD-DS has caused either excessive malabsorption or insufficient weight
loss.
We discuss the decision making to proceed with changing the
architecture of the intestinal bypass and what procedure was used to
resolve the problem. Suggestions are given on how each procedure was
performed and the results obtained from each of these.
In conclusion failure after BPD-DS is relatively rare and revision for
denutrition is usually simple and efficient. A complete reversal of the
procedure is also feasible.
INTRODUCTION
BPD-DS is a safe and very efficient procedure when follow-up is
appropriate. It can but rarely fail by causing either excessive malabsorption or
not enough weight loss and will require revisional surgery.
Recently we reported a review of 2615 consecutive patients submitted to a
BPD-DS between 1992 and 2010. 95% of these patients were followed up
with a visit or blood work within the last 2 years with a mean follow-up of 9.6
years (range 2 to 20 years) [Ref].
We reported that 2.9% (n:78) of these patients required the intestinal
diversion be restored either for excessive malabsorption (n:37) or for
insufficient weight loss (n:41).
In the present chapter we will focus on these patients and will discuss the
type of procedure used. We will first present the possible revisions for
malabsorption and then the revisions for insufficient weight loss.
Revision for Malabsorption
BPD-DS by decreasing bile contact with food permanently compromises
absorption of fat, liposoluble vitamins and calcium. This is usually easily
compensated with appropriate supplements. However by shortening the
functional intestine by about half, it temporarily compromises protein
absorption in about 20% of the patients for the first year. This is followed by
spontaneous recovery for the great majority of patients particularly with
appropriate treatment. In a few patients, protein absorption remains under
Surgical Procedures for Failure of Biliopancreatic Diversion …
141
normal levels, and resists to medical treatment. A decision needs to be taken to
modify the architecture of the bypass. Circumstances dictate the timing to do
so. There is not one perfect timing for reoperation, since it depends on
patients‟ collaboration, easiness of follow-up and severity of patients‟
symptoms. One needs to keep in mind the risk of hypoalbuminemia on the
liver, which may be life threatening when hypoalbuminemia reaches levels
below 25g/l. We report our own experience hereunder.
Patient Characteristics
During our 20-years of experience with BPD-DS, a decision was made to
modify the bypass in 28 patients and to completely reverse the bypass in 9 (for
a prevalence of revision for malabsorption of 1.4%). The reasons that forced
the decision to modify the bypass were complex but the dominant factor was
recurrent protein deficiency in 15; diarrhea in 8; abdominal pain in 4;
persistent anorexia in 7 and persistent asthenia in 3. There were also
aggravating factors complicating the situation.
Nine patients were drug addicts, 5 presenting with psychiatric problems, 4
with excessive use of alcohol and in 4 the situation was aggravated by the
appearance of concomitant diseases (2 cancers, 1 lupus and 1 cirrhosis). The
bypass was almost completely dismantled in 9 patients. This group was
younger (38 vs 51 years old) and the decision was delayed (8 vs 4 yrs)
compared to the group whose bypass was only lengthened.
Surgical Approach
In 80% of patients measures of the intestinal segments before revision
were found to be within 10% the expected length: Total Alimentary Channel
(TAC) 250 cm and Common Channel (CC) 100 cm. In 20% it was found to be
longer, with variation in the 50 to 100% range for the TAC and between 100
and 175% for the CC. None of the patients were found with channels shorter
than expected.
Isolated lengthening of the CC (which is rarely done for diarrhea), can be
realized by moving the the ileo-ileal anastomosis upward at the desired level
on the TAC channel (Figure 1).
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Figure 1. Lengthening only the Common channel. To lengthen only the common
channel for controlling diarrhea, the ileo-ileostomy can be displaced more proximally
on the total alimentary channel. It implies a mesenteric closure and a new end to side
ileo-ileostomy. TAC: Total alimentary channel; CC: Common Channel; BC: Biliary
Channel.
For lengthening both the TAC and the CC one can either move the distal
end of the strict alimentary channel to an appropriate level on the biliary
channel (BC) requiring one closure and one anastomosis (Figure 2) or use a
"kissing anastomosis method" (side to side) without any closure, between TAC
and BC. This technique is easier but leaves a loop in place (Figure 3). In our
experience, the lengthening varied from 50 to 300cm for a mean of 100 cm.
On the other hand, 3 different techniques are available to completely or
almost completely reverse the intestinal bypass. For complete reversal it is
possible to take down the duodeno-ileostomy and to do a new duodenoduodenal anastomosis with the duodenal-stump, and complete the procedure
by replacing the previous latero lateral anastomosis for a new end to end ileoileostomy.
It requires a closure of the mesenteric window, and 2 new anastomosis
(Figure 4). To avoid dissecting the duodenal area and to do an almost complete
reversal is possible through two methods.
Surgical Procedures for Failure of Biliopancreatic Diversion …
143
Figure 2. Lengthening both the total alimentary and common channels. The total
alimentary channel (TAC) is transected with a mechanical device above the ileoileostomy and reanastomosed at an appropriate level on the biliary channel (BC). Both
TAC and Common Channel (CC) are lengthened for an equivalent length. The same
method can be used for a "nearly complete reversal" if the reanastomosis between the
proximal TAC and the proximal jejunum is done as close as possible to the ligament of
Treizt.
Figure 3. Kissing anastomoses for lengthening both TAC and CC. A kissing
anastomosis (side to side) between TAC and BC forming a loop will lengthen both
TAC and BC for an equivalent length. This is the simplest technique and requires only
one anastomosis. TAC: Total alimentary channel; CC: Common Channel; BC: biliary
Channel.
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Simon Marceau, Simon Biron, Frédéric-Simon Hould et al.
Figure 4. Complete reversal. The duodeno-ileal anastomosis is taken down and a new
duodeno-duodenal anastomosis is done with the duodenal stump. The end of the
previous biliary channel is then connected to the origin of the previous total alimentary
channel. It requires a mesenteric closure and 2 anastomosis. TAC: Total alimentary
channel; CC: common channel; BC: biliary channel.
One technique is to do an end to side ileo-jejunostomy as close as possible
from both the duodenal area and the Angle of Treitz at ±20 cm from each one
and replace the initial ileo-ileostomy by a new end to end ileo-ileostomy. It
requires a closure of the mesenteric window and 2 anastomosis.
The other technique consists of using the same approach as for
lengthening both the TAC and CC (Figure 2) and to do the reconnection as
high as possible to the proximal jejunum close to the angle of Treitz. This
requires only one mesenteric window closure and a single anastomosis. With
these 3 different methods patients end up with a sleeve gastrectomy with either
a normal intestinal tract; or with about 40 to 150 cm biliary bypass. This last
method is obviously easier and requires only one small bowel anastomosis.
The long-term risk of peptic ulcer is considered negligible.
Results
The lengthening of the intestinal segments was efficient to correct the
malabsorption in 80% of the patients. The remaining 20% of patients required
Surgical Procedures for Failure of Biliopancreatic Diversion …
145
re-lengthening or complete reversal of the duodenal switch. In terms of weight
gain there was none in one third of the patients, and the other two-third gained
8 to 45 kg. There was one operative death in this group of 37 patients. The
mean follow-up after revision was 5.5 years. Late unrelated death was not
different than for the whole group. There were 2 suicides (1 and 8 years after
revision) and 2 deaths from pulmonary insufficiency (2 and 4 years after
revision).
After complete or nearly complete reversal malabsorption ceased and a
mean 32 kg weight regain occurred (range: 18 to 74 kg). When the decision
for reversal was triggered by the presence of chronic abdominal pain (n:4) this
symptomology persisted despite complete revision. There was no major
complication following reversal.
Conclusion in Regard to Revision for Malabsorption
The need to surgically correct BPD-DS for excessive weight loss and/or
malnutrition was rare (1.4%). It usually occurred in patients presenting with
other aggravating factors making the evaluation and the follow-up difficult. It
was also precipitated by the appearance of unexpected associated disease. The
decision between lengthening the non-bypassed bowel versus a complete
reversal depends on the severity of the malnutrition and the difficulty of
follow-up. When lengthening is done, it should be done at the expense of the
biliary limb and both the common channel and alimentary channel are
lengthened: The kissing anastomosis technique is easier because it limits the
procedure to only one new anastomosis but the long term risk of creating a
loop has not yet been demonstrated.
Lengthening of the alimentary tract usually does not result in major
weight gain and relieves the malabsorption in 80% of the patients. A complete
reversal removed the malabsorption but was also followed by major weight
regain. The surgical technique consisting in joining the distal end of TAC
(transected above the ileo-ileostomy) to the proximal jejunum (end-to-side) is
easier and leaves the patient with only a duodenal diversion and a 150 cm
short bypass.
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Simon Marceau, Simon Biron, Frédéric-Simon Hould et al.
REVISION FOR INSUFFICIENT WEIGHT LOSS
Patient Characteristics
Definition of "insufficient weight loss" after bariatric surgery is not yet
clearly defined. It is generally agreed that a BMI ≥40 represents a handicap
sufficient in itself to justify surgery, hence we consider failure when a patient
with an initial BMI greater than 50 does not reach a BMI below 40 or when a
patient with an initial BMI less than 50 does not reach BMI less than 35. This
goal is reached in almost 90% of cases after BPD-DS with a mean weight loss
of 55 kg. The decision to proceed with a revision for insufficient weight loss
depends essentially on patients themselves in relation to the risk involved. In
this series, 40 patients required a revision for insufficient weight loss. Revision
was performed at a mean 8 years after the primary surgery (range: 1 to 15
years). Overall the group had lost a mean of 31.5 kg; their BMI was 40.3 ±5.7;
the gender ratio (f/m) was 31/9 and their mean age 47 years old. Two of them
were patients with Prader-Willi syndrome.
Surgical Procedure
In 8 patients, before revision was done, the measurement of both the
alimentary and common channel were found to be as expected (250/100 cm);
in 14 they were elongated by 20 to 80% and in the other 18, the measures were
not reported.
In 13 patients, it was decided to do only a shortening; in 18 only a resleeve and in 9 a re-sleeve plus a shortening was performed. When shortening
was done the goal was to restore the initial intestinal length (250/100 cm). A
segment of the TAC was resected including the ileo-ileal anastomosis, and a
new end to end ileo-ileostomy and a new end to side ileo-ileal anastomosis at
100 cm from the ileo-ceacal valve were performed.
RESULTS
One patient suffering from Prader-Willi died early after re-sleeve and
shortening. There were 4 late deaths from unrelated causes: (trauma after 10
years, cancer after 16 and 20 years, cerebral vascular accident after 20 years).
Surgical Procedures for Failure of Biliopancreatic Diversion …
147
After shortening (n:13) an additional 14 kg weight loss (range: 3-38 kg)
was obtained, with a follow-up of 8 years and a final total weight loss of 49 kg
and final BMI of 34 without protein malabsorption. Only one patient required
a second shortening.
Re-sleeve only (n: 18) resulted in additional weight loss similar to
shortening of the intestine (19 vs 14 kg) (p = 0.18). Intestinal shortening
accompanied by regastrectomy did not increase weight loss but this addition
was undertaken in patients who had already shown greater resistance to weight
loss after the initial procedure having lost only 22 kg versus 35 kg for the
others. Furthermore this latest group remained with a greater BMI (42 vs 34
kg/m2) and a lower percent excess weight loss (35 vs 63), at a mean 16 years
after the initial surgery, confirming their weight loss resistance.
Conclusion Regarding Reoperation to Add Weight Loss
Revision for insufficient weight loss is rarely necessary after BPD-DS
(1.6%). If intestinal segments are found within the expected length, a simple
regastrectomy would seem the procedure of choice with better additional
weight loss. For patients who initially show resistance to weight loss, the
addition of a regastrectomy together with shortening of the bowel will almost
double the initial weight loss without protein malabsorption. With this strategy
a second attempt gave an additional 14 kg weight loss.
GENERAL CONCLUSION
Lengthening the functional intestine will be efficient to cure protein
malabsorption in 80%, and cause minimal weight gain. However 20% of the
patients will eventually require a total reversal. For increasing weight loss,
regastrectomy was more efficient than shortening of the functional intestine
but we believe that when the channels are found to be 50% longer than
expected, they should also be shortened and if there is evidence of resistance
to weight loss, an attempt to restore the proper length of the bypass is
indicated.
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Simon Marceau, Simon Biron, Frédéric-Simon Hould et al.
ACKNOWLEDGMENTS
Sincere thanks to Paule Marceau, databank manager who assisted for the
collection of data and to Helene Trudel from the department of Audiovisual
for the figures.
REFERENCE
Marceau P, Biron S, Marceau S, Hould FS, Lebel S, LeScelleur O, Biertho L,
Simard Serge, Kral JG. Long-Term Metabolic Outcomes 5 to 20 Years
after Biliopancreatic diversion. OBES SURG doi 10.1007/s/1695-0151599-5.
In: Management for Failed Bariatric Procedures
ISBN: 978-1-63483-753-8
Editors: J. Himpens and R. Vilallonga © 2015 Nova Science Publishers, Inc.
Chapter 9
FAILED BPD
Giuseppe Maria Marinari1,, Vincenzo Borrelli1
and Luc Lemmens2
1
Humanitas Gavazzeni, Bariatric Unit, Bergamo, Italy
2
AZ Nikolaas, Sint-Niklaas, Belgium
ABSTRACT
The failure in weight loss after BPD is an unpleasant event and it is
poorly described in the literature: little has been written on the rate of
inadequate weight loss, and how to handle it. From the limited available
data it seems that after BPD weight loss is less than 50% of the excess
weight in about 10% of cases The solution to this issue varies depending
on the eating habits of the patients and on their tolerance to side effects
and diet that BPD entails. Surgery can be an eventual solution to weight
loss failure but patients should be informed of the small size of the data
on which to decide.
1. INTRODUCTION
Insufficient weight loss and weight regain constitute an important problem
for all bariatric procedures. The percentages of these problems will vary

Corresponding author. Giuseppe Maria Marinari, Humanitas Gavazzeni, Bariatric Unit, Va
Mauro Gavazzeni 21, 24125 Bergamo, Italy, [email protected].
150
Giuseppe Maria Marinari, Vincenzo Borrelli and Luc Lemmens
depending on the different procedures: 50% or more for adjustable gastric
banding (AGB), 20 to 30% for the standard gastric bypass (SGB), 30 to 50%
for the sleeve gastrectomy (SG). BPD or BPD-DS are still considered the most
powerful operation in terms of weight loss, weight maintenance and resolution
of co-morbidities. Nevertheless this procedure is not free of failures. There are
few data published on this topic, but failures occurred in 8 - 10% of our
patients.
Because of their efficacy malabsorptive procedures are actually
considered the most powerful procedure, not only as a primary but especially
as a redo procedure after the failure of a restrictive operation [1, 2, 3]. In the
author‟s series weight loss after BPD can be considered very good: at two
years a mean BMI of 27 is reached, and the weight loss is sustained, leading to
a mean BMI of 28 in the long term. Nevertheless, even BPD can fail in some
cases, particularly in long term follow up: since few papers face this problem,
it is difficult to estimate at which percentage a failure can happen. In the few
papers available the failure rate varies from 1.5% [4] to 10% [5]: as far
author‟s unpublished data, in GMM - VB series in 2.1% of cases the weight
loss was less than 25% of the excess weight (EW) and in 8.1% the weight loss
was less than 50% of the EW, whilst in LL series, in 2.3% of cases the BMI
remained over 35, and 8% regained weight (unpublished data). Goal of this
chapter is trying to determine an algorithm to manage a malabsorption failure.
2. REASONS FOR FAILURE
There are three main reasons for failure to loose sufficient weight or for
weight regain after BPD.
1. Sweet eating is a pitfall for all type of procedures. Although BPD is a
malabsorptive procedure, simple sugars absorption is preserved and
there is no restriction in the food intake. This may lead to an extra
absorption of hundreds of calories per day, particularly when these
sweets are taken in between meals. This drawback must be explained
to patients before the operation and must be repeated later during
consultation: unfortunately, people sometimes become sweet eater
after surgery.
2. Hunger. As in other bariatric procedures, in very early follow up the
hunger feeling is diminished after BPD due to the reduced gastric
volume and to the change in gut hormones. In contrast with other
Failed BPD
151
procedures, while BPD patients are able to eat normal meals early
after the operation they usually manage to keep their weight loss. It
has been shown that after BPD a threshold mechanism of absorption
for fat and starch [6] should allow to eat great amount of food at a
stable weight, provided it happens in three-four meals per day. Per
meal only 300 til 500 Kcal can be absorbed. Extra meals or grazing
will jeopardize this mechanism of weight maintenance: in a BPD
series of 15 subjects with Prader Willi Syndrome, where a compulsive
hyperphagia is present, half of the patients were failures [7]. After a
longer period of follow-up some patients will start to complain of a
significant increase in the hunger feeling with polyphagia and
hyperphagia, and therefore of weight regain as a consequence. This
must be highlighted, because compulsiveness and eating disorders
have been suggested as particular indications to BPD, but at the same
time they can be reason of a BPD failure.
3. Intestinal adaptation [8], can be a reason of weight regain in a few
patients. The diagnosis is difficult and can only be made after
exclusion of other reasons (i.e., sweet eating or grazing) of weight
regain. It should only occur several years after the operation.
3. TREATMENT
The first step in tackling weight issues after BPD is always an in-depth
nutritional counseling in order to evaluate:
1)
2)
3)
4)
Daily simple sugar intake
Daily protein intake
Number of meals per day
Presence of compulsive hyperphagia
Different causes of weight regain will need different solutions.
a) Sweet eating. There is no surgical solution in case of pure sweet
eating: if the patient cannot control it, the help of a dietician and a
psychological support can be offered. Results are strongly dependent
on patient compliance
b) Compulsive hyperphagia. Patients can become very hungry several
years after BPD and some of them will start eating several times per
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Giuseppe Maria Marinari, Vincenzo Borrelli and Luc Lemmens
day and even during the night. These patients may complain of
frequent large stools and weight regain will be an important problem.
Psychological support can be offered, but results are in most of the
cases disappointing. In case of polyphagia with enough protein intake
(> 150 g per day) and normal albuminemia, a surgical solution may be
proposed. The resection of the stomach fundus (Figure 1), similar to
Sleeve Gastrectomy, can decrease the ghrelin‟s levels and therefore
may induce weight loss (9). Literature is sparse and inaccurate: it is
impossible to predict how much of the excess weight can be lost with
this type of revisional surgery. The risk of protein malnutrition should
always be kept in mind: in this case a further revision to gastric
bypass will still be possible. Nevertheless, in LL unpublished data,
this type of revision has led to a good weight loss (about 10 points of
BMI). In 19 patients the BMI had initially decreased from 46,3 to 27,7
after the BPD. On the long run there was a weight regain to a BMI of
36,3 and a fundus resection was performed. After revision there was
an average BMI loss of 10 points down to 25,9. Three patients
suffered from protein deficiency and 2 of them needed TPN. Also
other authors suggest a secondary Sleeve Gastrectomy as a solution
after BPD failure [9].
c) Intestinal (over)adaptation. When there is no sweet eating, protein
intake is adequate (80-100 g/day), eating habits are regular (3,
maximal 4 meals per day), and volumes unchanged intestinal
(over)adaptation must be ruled out. The solution one may offer is a
limb length revision, with shortening of both the alimentary and the
common limb. Unfortunately, there is no literature on this subject.
There was only a short experience of one of the authors (GMM) at
University of Genoa School of Medicine with Scopinaro‟s series.
Shortening the limb length was attempted in 4 cases. The revision was
practically ineffective in 3 long term patients and led to a small BMI
loss in 1 patient, who had been operated on elsewhere just 18 months
before, and in whom the limbs were too long. In analogy with
previous reoperations performed for incisional hernias years after
standard BPD (alimentary limb cm 200, common limb cm 50) in
patients with good weight loss (> 70% of EW) and good nutritional
status, in whom the length of the alimentary and of the common limb
was found to be cm 240 and cm 70 respectively, in the 4 cases cited
above, the alimentary and the common limb length was shortened to
cm 240 and to cm 70 respectively (Figure 2). Revision was uneventful
Failed BPD
153
both on bowel movements and on protein levels. Shortening the
alimentary and the common limb in order to provide a better weight
loss is a big challenge: an aggressive revision could lead to protein
malnutrition and excessive bowel movements, whilst a limited
shortening will be ineffective.
Figure 1. Resection of the stomach fundus.
d) In case of unsatisfactory weight loss in BPD patient with low
tolerance, i.e., excessive bowel movements or protein deficiency, a
conversion to gastric bypass is feasible (Figure 3). This is quite a
drastic intervention since BPD must be taken down altogether and
converted into a regular gastric bypass. This includes a subtotal
gastrectomy, which makes the operation irreversible. Patients with an
intestinal (over)adaptation may be converted into a gastric bypass as
154
Giuseppe Maria Marinari, Vincenzo Borrelli and Luc Lemmens
well. The early results of conversion are good with an acceptable
weight loss, normalization of bowel movements and normalization of
vitamin A, E and K; in case of protein malnutrition, serum proteins
levels will come to normal values. However, in the longer follow-up,
in comparison with a primary gastric bypass, a higher risk of weight
regain has been observed. For this reason one of the authors (LL)
suggests now a banded gastric bypass, with a silicone ring of 6.5 or 7
cm. Nevertheless, conversion into a gastric bypass is the best solution
for patients with BPD side effects: protein malnutrition, excessive
bowel movements, vitamin deficiencies, odor problems, other. This
conversion can easily be done by laparoscopy, especially in case of
previous laparoscopic BPD. In the medium term follow-up the authors
found a loss of about 5 points in BMI.
Figure 2. Shortening of the alimentary limb and of the common channel.
Failed BPD
Figure 3. Conversion to Roux-en-Y gastric bypass.
Figure 4. Algorithm for the management of BPD failure.
155
156
Giuseppe Maria Marinari, Vincenzo Borrelli and Luc Lemmens
CONCLUSION
About 10% of patients after BPD will have an insufficient weight loss or a
weight regain. Because of the large burden of nutritional consequences and
side effects that malabsorption entails, the number of failures should be
reduced by selecting and directing sweet eaters to strategies other than BPD.
Nevertheless, some patients will fail in any case, due to compulsive
hyperphagia or intestinal adaptation. The first step in finding a solution is a
thorough nutritional counseling, and only in very selected cases can a surgical
revisio be suggested. Compulsive hyperphagia with high daily protein intake
can be addressed by a stomach fundus resection, whilst regular eating habits
and low tolerance for BPD side effects or for high-protein diet can be
addressed by conversion of BPD into a gastric bypass (see Algorithm in Figure
4).
Before surgical revision of the biliopancreatic diversion patients should be
fully informed that:
1. very few data are available on BPD revision;
2. in case of stomach fundus resection the reduced intake of food could
lead to protein malnutrition;
3. the conversion to gastric bypass involves a subtotal gastrectomy.
Conversion to gastric bypass is an effective solution for BPD side effects
but very little is known about weight effect in the long term.
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Daskalakis M, Scheffel O, Theodoridou S, Weiner RA. (2009)
Conversion of failed vertical banded gastroplasty to biliopancreatic
diversion, a wise option. Obes. Surg.; 19:1617-23.
Keshishian A, Zahriya K, Hartoonian T, Ayagian C. (2004) Duodenal
switch is a safe operation for patients who have failed other bariatric
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Marceau P, Biron S, Hould FS, Lebel S, Marceau S, Lescelleur O,
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Slater G, Duncombe J, Fielding GA. (2005) Poor weight loss despite
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Scopinaro N, Marinari GM, Pretolesi F, Papadia F, Murelli F, Marini P,
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Friedman D, Marinari G, Camerini G, Baschieri G, Simonelli A,
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INDEX
A
abolition, 94
abuse, 91
acarbose, 110
access, 44, 64, 88
accommodation, 37
acid, 36, 43, 44, 47, 104, 105, 115, 123
ADA, 10
adaptation, 151, 152, 153, 156, 157
adhesions, 49, 50, 99, 104, 128
Adjustable Banded RYGB, 62
adjustable gastric band, 17, 52, 53, 57, 58,
69, 70, 71, 75, 82, 150, 156, 157
adjustment, 60, 65
adults, 10, 21, 118
age, 10, 14, 76, 80, 130, 146
alcohol consumption, 43
algorithm, 31, 34, 81, 134, 150
alimentary limb (AL), 88, 89, 90, 98
alimentation, 130
allergy, 6
analgesic, 28
anatomical aberrations of the bypass, 88
anatomy, 2, 5, 6, 38, 39, 53, 54, 75, 88, 92,
99, 104, 111, 114, 118, 121, 122, 130,
131, 132, 134, 138
anemia, 121
anesthesiologist, 94
angina, 15
angulation, 42
anorexia, 141
antrum, 95, 99, 101, 103
arterial hypertension, 93
asparagus, 67
aspiration, 37, 53
aspiration pneumonia, 53
assessment, 27, 34, 38, 44, 46, 47, 49, 54,
92, 117, 127, 134
asthenia, 141
asymptomatic, 43
atherosclerosis, 14
B
Band Failures, v, 57, 59
bariatric procedures, 9, 24, 25, 32, 36, 58,
74, 75, 82, 84, 88, 91, 137, 149, 150
bariatric-metabolic surgery, vii
barium, 5, 37, 106
base, 39
behavior modification, 2
behaviors, 7
Belgium, 87, 149
beneficial effect, 15
benefits, 14, 15, 16, 74, 97
bezoar, 67
bile, 117, 120, 121, 122, 123, 134, 140
biliary peritonitis, 117, 122, 134
160
Index
biliopancreatic diversion, 25, 60, 67, 70, 84,
101, 113, 156, 157
blame, 115
bleeding, 26, 27, 28, 30, 75, 77, 80
blood, 4, 11, 12, 13, 14, 15, 27, 28, 31, 33,
51, 91, 94, 121, 140
blood pressure, 11, 14, 15
blood supply, 33, 94, 121
blood transfusion, 31
body mass index (BMI), 11, 12, 14, 15, 16,
21, 25, 26, 51, 62, 63, 71, 76, 77, 80, 81,
95, 120, 126, 127, 130, 146, 147, 150,
152, 154
body weight, 7, 15, 26
bone, 55
bowel, 30, 31, 36, 53, 59, 62, 63, 64, 97,
102, 106, 108, 111, 112, 122, 130, 144,
145, 147, 153
bowel obstruction, 30, 31
Brazil, 9
bronchial epithelium, 37
burn, 48
C
cachexia, 2
calcium, 140
caliber, 35
calibration, 126
cancer, 2, 146
candidates, 18, 93, 97
capillary, 13, 14
car accidents, 109
carbohydrates, 91, 93, 108, 109
cardiovascular disease, 16
cardiovascular risk, 14, 16, 20, 21
case study, 84
category b, 18
catheter, 131
cellulose, 104, 105
cheese, 6
China, 15
cholesterol, 14, 20
chronic fatigue, 109
chyle, 108
cigarette smoking, 105
cirrhosis, 141
clinical symptoms, 24, 109
cloaca, 106
closure, 67, 89, 104, 106, 108, 112, 142,
144
collaboration, 141
colon, 89, 157
color, 28
communication, 7, 104
community, 55, 88
complement, 101
complete blood count, 27
compliance, 7, 57, 59, 87, 92, 93, 96, 97, 98,
151
complications, 2, 4, 8, 19, 24, 25, 26, 27, 28,
30, 33, 37, 38, 40, 41, 49, 50, 51, 52, 53,
54, 55, 57, 60, 61, 62, 67, 70, 73, 74, 75,
76, 77, 78, 80, 82, 83, 88, 91, 95, 96, 97,
110, 111, 118, 121, 127, 137
composition, vii
computed tomography, 24, 29, 40, 53, 54,
55, 137
consensus, 26, 28, 77, 84, 138
constant rate, 83
construction, 38, 44, 88, 89, 90, 91, 92, 93,
97, 110
consumption, 43
contraction, 107
controlled studies, 14, 82
controlled trials, 21
controversial, 137
conversion, 3, 7, 48, 57, 59, 60, 62, 64, 65,
66, 67, 68, 70, 71, 72, 76, 77, 78, 80, 82,
84, 92, 97, 114, 117, 118, 121, 122, 123,
134, 138, 153, 156
cooperation, 55
coronary heart disease, 10
correlation, 11, 12, 15, 58
cost, 10, 30, 76, 80, 82
counseling, 6, 19, 60, 66, 75, 108, 151, 156
criticism, 118, 122
CRP, 27, 28, 31
CT scan, 30, 31, 33, 37, 38, 41, 67, 106
cure, 97, 147
Index
D
danger, vii, 134
deaths, 15, 145, 146
defects, 36, 89, 90, 108, 112
deficiencies, 91, 97, 112, 154
deficiency, 130, 131, 141, 152, 153
deflation, 66, 67, 68
deformation, 106
dehiscence, 94
delayed gastric emptying, 75
depth, 151
detection, 28, 47
developed countries, 24
developing countries, 23, 24
deviation, 27, 28, 30
diabetes, 9, 10, 11, 12, 15, 16, 18, 19, 20,
21, 26, 93, 115, 127
diabetes mellitus, 9, 20, 21
diabetic patients, 12, 14, 15, 19, 21
diarrhea, 80, 109, 130, 131, 141, 142
diet, 3, 4, 7, 13, 16, 59, 65, 91, 96, 98, 149,
156
dietary habits, 59, 87, 91, 108
dilation, 5, 6, 55, 58, 59, 62, 65, 66, 75, 88,
91, 96
disability, 10
discomfort, 48
diseases, 9, 10, 11, 19, 93, 141
dislocation, 65
displacement, 33
dissatisfaction, 26, 48
distal gastric bypass, 97, 101, 114
diversity, vii
drainage, 31
drug addict, 141
drugs, 12
dumping, 4, 36, 93, 109, 110
duodenal switch, 25, 47, 60, 70, 74, 79, 82,
83, 84, 85, 127, 145, 157
duodenal ulcer, 106
duodenum, 52, 74, 88, 110
dyslipidemia, 15, 93
dysphagia, 42, 48, 77, 104, 106
dysplasia, 122
161
dyspnea, 28
E
eating disorders, 117, 151
education, 2, 21, 65
effluent, 28
effusion, 30
Egypt, 23
elongation, 5, 6
e-mail, 57
emergency, 10, 68, 108
emission, 9
encephalopathy, 44
endocrinologist, 92, 93
endoscope, 42, 44, 48
endoscopy, 2, 5, 24, 38, 42, 43, 44, 46, 47,
48, 60, 93
enlargement, 6, 35, 37, 47
epidemic, 10, 23, 24
epithelium, 37
ERD, 77
erosion, 5, 33, 40, 47, 48, 55, 58, 59, 62, 63,
64, 66, 67, 72, 95, 105
ESO, 104
esophagus, 59, 66, 74, 104, 105, 122
etiology, 115
evacuation, 31, 36
evidence, 5, 9, 14, 28, 77, 115, 147
evolution, 11, 88, 91, 93, 96
exclusion, 151
exercise, 4, 7
expenditures, 10
exposure, 30, 36, 40
extraction, 48
F
fasting, 11, 13, 14, 15, 18, 37, 39, 41
fasting glucose, 18
fat, 48, 140, 151
fever, 27, 28, 31
fibers, 67
fibromyalgia, 109
162
Index
fibrosis, 75
films, 36
fistulas, 61
fitness, 15
fixation, 66, 107
flaws, 2, 88, 91, 108
fluid, 31, 33, 36, 108
food, 26, 43, 66, 67, 68, 75, 91, 92, 108,
140, 150, 151, 156
food intake, 150
formation, 32, 36, 38, 40, 43, 47, 49, 106
formula, 5
France, 117
G
gangrene, 33
gastric pouch, 5, 6, 33, 36, 37, 38, 39, 43,
54, 61, 62, 76, 79, 89, 92, 94, 95, 96, 97,
98, 104, 117, 118, 122, 123, 124, 126,
127, 128, 134
gastrin, 105
gastritis, 47, 48
gastro-enteral anastomosis, 95, 98
gastroenterologist, 92, 93
gastroenterostomy, 36, 37, 40
gastroesophageal reflux, 7, 56, 115
gastrointestinal bleeding, 28
gastrojejunostomy, 4, 5, 6, 42, 118, 122,
123, 124, 132
Germany, 23, 70
glucagon, 39
glucose, 11, 12, 13, 14, 18, 91, 109, 115
grading, 56
granules, 39
grazing, 97, 151
growth, 24
guidance, 42, 110
H
healing, 108
health, 3, 7, 10, 15, 118
health expenditure, 10
health insurance, 7
heart disease, 10, 15
heartburn, 122
hematemesis, 28
hematoma, 31
hemoglobin, 11, 16, 27, 28
hemorrhage, 52
hernia, 5, 6, 30, 31, 36, 53, 56, 66, 71, 89,
91, 107, 115, 121
hernia repair, 6, 115
herniated, 33, 108
hiatal hernia, 5, 6, 32, 35, 40, 48, 50, 56, 66,
71, 91, 115
history, 3, 19, 47, 82, 93
hormone, 101
hormones, 2, 150
hospitalization, 15
hypercholesterolemia, 14
hyperplasia, 122
hypertension, 14, 15, 26, 93
hypertriglyceridemia, 14
hypoglycemia, 4, 7, 98, 109, 110, 115
hypotensive, 6
hypothesis, 2, 20, 106
I
ideal, 93, 114
identification, 98, 128
ileostomy, 142, 143, 144, 145, 146
images, 39
impairments, 10
improvements, 15
impulses, 106
incarceration, 68
incidence, 15, 19, 23, 30, 42, 43, 51, 65, 73,
75, 77, 82, 95, 107, 108, 110, 118, 123
incisional hernia, 152
incisors, 5
India, 15
Indians, 21
individuals, 10, 21, 24, 91, 97, 98, 108, 109
infarction, 15, 20
infection, 33, 40, 43, 48, 62, 66, 77, 95, 131
inflammation, 42, 43, 67
Index
inflation, 65, 67
ingest, 6
ingestion, 5, 67, 109
inhibition, 101, 109
injections, 109
injury, 30
insertion, 66
institutions, 24, 70
insulin, 11, 12, 13, 14, 15, 16, 19, 109, 110,
115
insulin resistance, 16
integrity, 92
intervention, 2, 7, 9, 10, 15, 16, 19, 21, 24,
25, 27, 31, 32, 38, 39, 40, 41, 48, 50, 59,
60, 87, 93, 96, 153
intestinal obstruction, 121
intestinal tract, 38, 144
intestine, 130, 140, 147, 157
intussusception, 30, 91, 106
inversion, 33, 46
iodine, 39
ischemia, 42, 43, 105
Islam, v, 23
Israel, 54
issues, 2, 4, 6, 30, 105, 111, 151
Italy, 149
J
jejunum, 64, 119, 143, 144, 145
K
kidney, 10
kidney failure, 10
L
lactose, 6
lactose intolerance, 6
laparoscopy, 24, 31, 49, 50, 68, 88, 99, 136,
154
leakage, 26, 27, 28, 30, 32, 59, 60, 67, 75,
76, 77, 106, 118, 121, 122, 127, 134
163
leaks, 61, 117, 121
learning, 41
lesions, 58
leukocytosis, 27, 28, 31
liberation, 105
life expectancy, 118
lifestyle changes, 92
ligament, 77, 119, 143
light, 109
lipid metabolism, 115
lipids, 15
liver, 141
localization, 38
low-density lipoprotein (LDL), 11, 14
lower esophageal sphincter, 6
lumen, 48, 106
lupus, 141
lying, 95
M
magnitude, 128
majority, 2, 11, 65, 74, 140
malabsorption, 2, 97, 114, 140, 141, 144,
145, 147, 150, 156
malnutrition, 97, 108, 117, 118, 120, 121,
124, 129, 130, 131, 132, 134, 145, 152,
153, 154, 156
management, 13, 14, 24, 27, 31, 38, 48, 51,
52, 53, 55, 78, 105, 111, 112, 115, 155
mass, 21, 51, 62, 63, 67, 76, 95
measurement(s), 5, 38, 46, 146
meat, 5
median, 11
medical, 3, 9, 10, 15, 21, 48, 54, 130, 131,
141
medical care, 16
medication, 11, 18, 19, 92
melena, 28
mellitus, 9, 20, 21
memory, 19
mesentery, 30, 90, 95, 112
meta-analysis, 21, 25, 51, 74, 83, 85, 115,
123
164
Index
metabolic, v, 8, 9, 14, 21, 23, 51, 69, 73, 83,
112, 148
metabolic responses, 2
metabolism, 91, 109, 115
meter, 124
metformin, 12
methylene blue, 119, 128
migration, 26, 33, 55, 71
minigastric bypass, 137
modifications, 11, 60
Moon, 113, 115
morbidity, 10, 27, 51, 74, 76, 77, 82, 117,
126, 134
mortality, 10, 11, 15, 19, 20, 74, 75, 85,
118, 136
mortality rate, 10, 75
mucosa, 47
multidisciplinary consultation, 88
myocardial infarction, 15, 20
N
nasogastric tube, 119
nausea, 4, 28, 36, 42, 106, 108, 122
necrosis, 68, 107
nephropathy, 19
Netherlands, 57, 77
neutrophils, 51
Nissen fundoplication, 6
nitrogen, 157
nursing, 10
nutrition, 131
nutritional status, 131, 152
O
obesity, 2, 8, 10, 20, 23, 24, 30, 36, 38, 50,
52, 53, 54, 55, 57, 58, 69, 70, 71, 73, 74,
83, 85, 112, 113, 115, 117, 118, 131,
136, 137
obesity surgery, 30, 38
obstruction, 30, 31, 33, 59, 91, 104, 106,
121
occlusion, 108
oedema, 37, 44
oesophageal, 35, 43, 47, 56
omentum, 119, 128, 129
operations, 10, 51, 75, 77, 82, 88, 110, 114,
156
optimization, 55
organ, 30
outpatient, 10
overtime, 36
overweight, 24
P
pacemaker, 106
pain, 27, 28, 31, 33, 48, 67, 68, 106, 107,
108, 109, 130, 141, 145
pancreas, 109
pancreatitis, 36
parenteral alimentation, 130
participants, 12
pasta, 5
pathology, 42
pathway(s), 34, 69
peptic ulcer, 137, 144
peptidase, 13, 14
peptide, 11
perforation, 32, 42, 65, 68, 105, 106
peritonitis, 37, 106, 117, 122, 123, 134
physiological mechanisms, 112
physiology, 2, 94, 113
pilot study, 55
pneumonia, 30, 53
policy, 66, 99, 108, 123
polypropylene, 104
poor weight loss, 70, 88, 157
population, 4, 10, 19, 23, 24, 126
population size, 24
positive correlation, 15
potential benefits, 74
Prader-Willi syndrome, 146
preparation, 6, 27, 118, 134
preservation, 101
prevention, 20, 21
principles, 3, 138
probability, 15
Index
proteins, 154
proton pump inhibitors, 105
psychologist, 59, 92
public health, 118
public opinion, 58
Q
quality assurance, 70
quality of life, 19, 137
questionnaire, 3
R
radiation, 30, 37, 40, 54
reading, vii, viii
reconstruction, 30, 38, 106
recovery, 108, 140
recurrence, 10, 12, 14, 16, 17, 18, 19, 42,
66, 105, 131
redo surgery, 127
redo-bariatric surgery, vii
reinforcement, 119, 128
relevance, 137
remission, 9, 11, 12, 14, 15, 16, 18, 19, 20,
21, 26, 93, 101
repair, 6, 66, 67, 71, 104, 105, 115
resection, 58, 94, 105, 106, 107, 126, 127,
128, 132, 152, 156
resistance, 16, 147
resolution, 12, 65, 73, 74, 96, 112, 150
resources, 10
response, 11, 92, 109
restoration, 124, 131
restrictions, 92, 98
retinopathy, 19
revision, 3, 4, 7, 8, 25, 57, 59, 60, 63, 67,
69, 70, 73, 74, 75, 76, 77, 80, 82, 84,
114, 117, 118, 120, 121, 134, 140, 141,
145, 146, 152, 156, 157
Revisional bariatric surgery, 1, 2, 8, 83, 84
Revisional procedures, 127
revisional surgery, 2, 7, 18, 63, 75, 76, 79,
80, 82, 84, 135, 140, 152, 157
165
revisional weight loss surgery, vii
rhythm, 131
risk(s), 1, 2, 14, 15, 16, 20, 21, 27, 37, 50,
51, 52, 58, 63, 67, 68, 74, 75, 77, 94, 97,
104, 105, 118, 123, 127, 130, 132, 134,
141, 144, 145, 146, 152, 154
risk factors, 14, 20, 21
Roux-en-Y gastric bypass, 8, 9, 10, 20, 25,
31, 52, 53, 55, 69, 70, 71, 72, 74, 82, 84,
87, 88, 89, 111, 112, 113, 114, 115, 118,
137, 138, 155
S
safety, 11, 62, 71, 73, 74, 93, 111
saliva, 67
science, 69
sclerosis, 127
scope, 5, 96
secrete, 123
secretion, 110
security, 118, 124
selectivity, 109
seminars, 3
sensation, 4, 93
sensitivity, 28, 50
serum, 131, 154
shape, 37, 46, 92, 93, 122
showing, 10, 16, 24, 44, 76, 111, 131
side effects, 4, 77, 91, 97, 149, 154, 156
signs, 24
sleeve gastrectomy, 7, 17, 24, 25, 28, 30,
35, 37, 39, 40, 44, 46, 48, 51, 52, 53, 54,
55, 60, 69, 70, 74, 75, 76, 80, 82, 83, 84,
85, 90, 114, 118, 119, 134, 135, 144, 150
small intestine, 157
smoking, 42, 43, 105, 123
solution, 65, 93, 127, 149, 151, 152, 154,
156
South America, 15
Spain, 73, 87
sphincter, 6, 48, 101
spontaneous recovery, 140
standardization, 26
starch, 151
166
Index
stasis, 36, 66
state, 87
stenosis, 25, 35, 36, 42, 44, 46, 47, 80, 107
stent, 84
stoma, 42, 43, 44, 114
stomach, 21, 33, 35, 36, 39, 42, 44, 47, 48,
52, 58, 59, 60, 61, 64, 66, 67, 68, 74, 75,
80, 88, 89, 94, 99, 101, 103, 104, 108,
110, 122, 123, 128, 129, 131, 134, 152,
153, 156
stress, 39
strictures, 4, 55, 75
stroke, 10, 15
structure, 100
style, 26, 60, 65, 96
success rate, 73, 74
Sudan, 8, 69
Sun, 115
supplementation, 92
surgical complications, 73, 74, 80, 88
surgical intervention, 2, 7, 16, 19, 31, 37, 88
surgical removal, 67
surgical technique, 113, 145
suture, 69, 106, 108, 119, 122
sweets eating, 87, 93
symptomology, 145
symptoms, 4, 6, 24, 36, 41, 48, 65, 66, 91,
98, 104, 106, 109, 122, 123, 131, 141
syndrome, 2, 4, 6, 106, 109, 110, 146
T
T2DM, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18,
19, 93, 97, 101, 109, 115
tachycardia, 27, 28, 31, 52
tachypnea, 27, 28, 31
target, 13, 14, 106
Task Force, 8, 69
teams, 90
techniques, 1, 24, 39, 43, 49, 96, 123, 142
testing, 3, 6
texture, 6
therapeutic change, 92
therapy, 11, 14, 21
time-frame, 26
tissue, 75, 101
total cholesterol, 14
transection, 94, 105, 111
transfusion, 31
trauma, 146
treatment, 2, 9, 10, 13, 14, 15, 16, 18, 19,
21, 28, 42, 50, 57, 58, 62, 66, 69, 70, 81,
93, 94, 105, 106, 109, 110, 113, 115,
118, 122, 130, 136, 140
tremor, 109
trial, 7, 21, 69, 70, 83, 112, 113, 118
triglycerides, 15
tumor, 109
twist, 102
type 2 diabetes, 9, 10, 20, 21, 93, 115
U
ulcer, 6, 30, 36, 42, 47, 53, 94, 105, 106,
115, 117, 120, 121, 123, 137, 144
uniform, 35
United States (USA), 3, 10, 27
urbanization, 24
usual dose, 13
V
vacuum, 119
valuation, 53, 115
valve, 97, 117, 130, 134, 146
variations, 88
vessels, 94
videos, 54
visualization, 105
vitamin A, 154
vitamins, 140
volvulus, 32
vomiting, 4, 28, 36, 42, 48, 75, 77
W
water, 34, 37, 39
weight gain, 25, 33, 37, 43, 47, 145, 147
Index
weight regain, 4, 7, 12, 14, 25, 32, 46, 59,
62, 65, 73, 74, 76, 77, 91, 92, 96, 97, 98,
113, 114, 117, 126, 127, 128, 134, 145,
149, 150, 151, 152, 154, 156
white blood cells, 51
withdrawal, 110
work absenteeism, 10
workstation, 39
167
worldwide, 23, 24, 25, 58, 83, 112
worry, 58
wound infection, 77
Y
young adults, 118