Systematic Review On Reoperative Bariatric Surgery

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Surgery for Obesity and Related Diseases 10 (2014) 952–972Review articleSystematic review on reoperative bariatric surgeryAmerican Society for Metabolic and Bariatric Surgery RevisionTask ForceStacy A. Brethauer, M.D.a,*, Shanu Kothari, M.D.b, Ranjan Sudan, M.D.c,Brandon Williams, M.D.d, Wayne J. English, M.D.e, Matthew Brengman, M.D.f,Marina Kurian, M.D.g, Matthew Hutter, M.D.h, Lloyd Stegemann, M.D.i, Kara Kallies, M.S.b,Ninh T. Nguyen, M.D.j, Jaime Ponce, M.D.k, John M. Morton, M.D.laBariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OhioDepartment of Surgery, Gunderson Health System, La Crosse, WisconsincDepartment of Surgery, Duke University Medical Center, Durham, North CarolinadVanderbilt Center for Surgical Weight Loss, Nashville, TennesseeeDepartment of Surgery, Marquette General Hospital, Marquette, MichiganfAdvanced Surgical Partners of Virginia, Richmond, VirginiagDepartment of Surgery, New York University Bariatric Surgery Associates, New York, New YorkhDepartment of Surgery, Massachusetts General Hospital, Boston, MassachusettsiBetter Weigh Center, Corpus Christi, TexasjDepartment of Surgery, University of California Irvine Medical Center, Orange, CaliforniakDalton Surgical Group, Dalton, GeorgialDepartment of Surgery, Stanford University, Palo Alto, CaliforniaReceived January 30, 2014; accepted February 10, 2014bAbstractBackground: Reoperative bariatric surgery has become a common practice in many bariatricsurgery programs. There is currently little evidence-based guidance regarding specific indicationsand outcomes for reoperative bariatric surgery. A task force was convened to review the currentevidence regarding reoperative bariatric surgery. The aim of the review was to identify procedurespecific indications and outcomes for reoperative procedures.Methods: Literature search was conducted to identify studies reporting indications for and outcomes after reoperative bariatric surgery. Specifically, operations to treat complications, failedweight loss, and weight regain were evaluated. Abstract and manuscript reviews were completed bythe task force members to identify, grade, and categorize relevant studies.Results: A total of 819 articles were identified in the initial search. After review for inclusioncriteria and data quality, 175 articles were included in the systematic review and analysis. Themajority of published studies are single center retrospective reviews. The evidence supportingreoperative surgery for acute and chronic complications is described. The evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weightloss and co-morbidity reduction after reintervention. Procedure-specific outcomes are described.Complication rates are generally reported to be higher after reoperative surgery compared to primarysurgery.Conclusion: The indications and outcomes for reoperative bariatric surgery are procedure-specificbut the current evidence does support additional treatment for persistent obesity, co-morbid disease,This project was supported by an unrestricted educational grant by Covidien.*Correspondence: Stacy A. Brethauer, M.D., Bariatric and Metabolic Institute, Cleveland Clinic, 9500 Euclid Avenue, M61, Cleveland, OH 44195.E-mail: 014.02.0141550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Reoperative Bariatric Surgery / Surgery for Obesity and Related Diseases 10 (2014) 952–972953and complications. (Surg Obes Relat Dis 2014;10:952–972.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.Keywords:Reoperative; Revisional; Bariatric; Weight regain; ComplicationsMorbid obesity is a chronic disease that requires lifetimetreatment. While bariatric surgery is highly effective anddurable therapy, as with many other chronic diseasesrequiring medical or surgical therapy, there will be patientswho respond well to an initial therapy and others with onlya partial response. There will also be a subset of patientswho are nonresponders or have recurrent or persistentdisease or complications of therapy; these patients mayrequire escalation of therapy, a new treatment modality, orcorrection of complications [1].The paradigm of revisional, adjuvant or escalation oftherapy is well established in many medical and surgicalspecialties. For example, total joint arthroplasty for thetreatment of chronic degenerative joint disease has anestablished early success rate. Patients receiving a successful joint replacement, though, will have varying degrees offunctional recovery based on their underlying disease,technical aspects of the procedure, and their functionalstatus before surgery. Over time, there is also a wellestablished revision rate [2–4] with joint replacement and,when this initial therapy fails, a revision, replacement, orconversion procedure is offered.There are many other examples of surgical procedureswith known long-term need for revision such as coronaryartery bypass grafting, heart valve surgery, abdominal wallhernia repairs, and oncologic operations. In all of thesecases, the necessity of reoperative procedures or the use ofadjunctive therapy is clear and covered by payors. Reviewof several major nationwide health plans and plans for stateemployees in the United States found no limitation withregard to revisional surgery for orthopedics, cardiac surgery, or any other specialty except bariatric surgery [5]. Theparadigm of chronic treatment for other diseases is applicable to the chronic disease of morbid obesity and itscomplications. Therefore, revisional or additional therapy isjustified if a primary bariatric procedure does not sufficiently treat the disease of morbid obesity.Many patients with morbid obesity are not providedinsurance coverage for the treatment of this disease or areoffered only 1 lifetime procedure to treat it or face nearinsurmountable barriers to access care. Patient selection forthe initial procedure is often determined by the patient’s andprimary care physician’s perspective of risk and benefits fortheir individual medical situation, insurance coverage, andtheir operative risk in consultation with their surgeon andbariatric program. Patients and surgeons in consultationoften choose the operation that best fits their risk and benefitpreferences. The opportunity to convert or revise a primaryoperation that does not achieve adequate weight loss or comorbidity improvement is therefore necessary to provideeffective therapy for these patients. As with other surgicalspecialties, reoperative bariatric surgery is more challengingthan primary procedures and is associated with a higher rateof 30-day adverse events [6]. However, when reoperativesurgery is performed by experienced surgeons who performa variety of revisional procedures, risk and complicationrates are acceptable [7–10].The purpose of this systematic review is to provide asummary of the current evidence regarding reoperativebariatric surgery. Specific nomenclature has been developedto provide descriptive categories of revisional procedures.MethodsEvidence search strategyMEDLINE 1996–present was queried for the followingterms: “bariatrics/ or *bariatric surgery” OR “gastricbypass/ or gastroplasty/” OR “band/ banding” OR “anastomosis, roux-en-y/ or biliopancreatic diversion/ or gastrectomy/” AND “revis .mp” OR “conver .mp.” OR “revers .mp.” OR “fail .mp.” OR “Reoperation/ reop .mp.” OR“redo / redo” OR “regain.mp. or Weight Gain/”. The searchwas limited to articles in the English language with humanpatients.A task force comprised of private practice and academicbariatric surgeons with expertise in reoperative bariatricsurgery and critical evidence review was convened toreview this topic. The ASMBS Insurance, Research, Clinical Issues, Quality Improvement, and Access to Carecommittees were represented on the task force. A medicalresearcher not affiliated with the ASMBS was contracted toperform the literature search and assist with evidencereview. Members of the task force reviewed all citationsand abstracts that met search criteria. The evidence wasgraded and sorted by procedure type and type of reoperationaccording to the nomenclature below. Secondary searchesfor specific procedures and topics were conducted by thetask force based on key articles and bibliographies obtainedin the primary search. A flow diagram of the citationselections process is shown in Fig. 1.NomenclatureConversion. Procedures that change from an indexprocedure to a different type of procedure.

954S. A. Brethauer et al. / Surgery for Obesity and Related Diseases 10 (2014) 952–972819Articles identified in initial search.29Articles identified from other sources749Articles remained after limiting to Englishlanguage and human subjects125Articles excluded after initial screeningfor duplicates and other, irrelevanttopics653Articles remained after excluding duplicatesand initial screening117Case reports/series (N 10) excluded536Full text articles reviewed(no case reports)361Articles excluded by taskforce review(low level evidence, poor follow-upduration)175Articles included in qualitative andquantitative synthesisFig. 1. Flow diagram of article selection process for systematic review.Corrective. Procedures addressing complications orincomplete treatment effect of a previous bariatric operation.Reversal. Procedures that restore original anatomy.I. Treatment of insufficient weight loss or weight regainafter bariatric surgeryWhile the majority of bariatric patients do achieve successful outcomes after their primary operation, the patients whopresent with insufficient weight loss, continued co-morbiddisease, or weight regain after bariatric surgery represent achallenging population. This group of bariatric patients maybenefit from additional surgical therapy to treat their obesityand should be thoroughly evaluated by a multidisciplinaryprogram to determine the potential causes for their poorresponse. This evaluation may include nutritional and behavioral health assessment and anatomic evaluation based on theoriginal procedure performed. The decision to proceed withadditional medical or surgical therapy should be based on thismultidisciplinary assessment and the patient’s specific risk/benefit profile for a reoperative procedure [11].Roux-en-Y gastric bypassIndications for corrective procedures after gastric bypass areinadequate weight loss, weight regain, or recurrence of weight-related co-morbid conditions. Since these options involvemodifying a portion of the bypass anatomy or adding acomponent to the existing bypass anatomy, they are classifiedas corrective procedures rather than conversion based on theabove nomenclature. The degree of weight regain thatwarrants a corrective procedure varies widely depending onthe patient’s original weight and co-morbidities. Mandatorywaiting periods for insurance approval (6 mo of weightmanagement or nutrition visits or documentation of prolongeddisease burden, for example) are not indicated and are notsupported by the evidence. Preoperative weight loss in specificpatients may facilitate the laparoscopic approach or decreasetechnical difficulties of the operation and participation andduration of preoperative weight loss should be at the discretionof the surgeon and program managing the patient [12].One type of corrective procedure is intended to increaseor restore gastric restriction that contributed to the satietysensation that assisted patients with their initial weight loss.Endoscopic therapy to reduce the pouch and gastrojejunal(GJ) stomal size has been shown to arrest weight gain [13]and achieve short-term weight loss with minimal risk [14–16], but most of the published studies are small noncontrolled series and many of the devices reported in theliterature are no longer commercially available. Surgicalrevision of the pouch and GJ may be indicated when thereis significant pouch or stoma dilation that allows for a

Reoperative Bariatric Surgery / Surgery for Obesity and Related Diseases 10 (2014) 952–972significant reduction in size with surgical therapy or whenthere is a gastrogastric fistula with inadequate weight loss ora persistent marginal ulcer [17,18]. In some cases, additional therapy or anatomic change is reported to add to theexisting Roux-en-Y gastric bypass (RYGB) anatomy that isintact. Reported options include placement of an adjustableor nonadjustable band around a gastric pouch to achieveadditional gastric restriction [7,19,20], lengthening thebiliopancreatic or Roux limb to increase the malabsorptiveor bypass component of the operation, or conversion toduodenal switch (DS) [21]. All of these series reportimproved weight loss after salvage procedures, but thecurrent evidence supporting these strategies is limited [22].Complication rates of published studies evaluating procedures for weight gain after RYGB are shown in Table 1.Laparoscopic adjustable gastric bandingLaparoscopic adjustable gastric banding (LAGB) is uniquein that the device is placed without major anatomic alteration.The lack of anatomic alteration is thought to account for thesignificant lack of hormonal effect associated with LAGB.The average weight loss with LAGB is well documented tobe lower than that of the other procedures mentioned. Thereis currently evidence that the LAGB can be converted to bothRYGB, laparoscopic sleeve gastrectomy (SG), and DS toachieve additional weight loss [8,23–34].Conversion procedures are intended for patients whoexperienced satisfactory weight loss and correspondingresolution of co-morbidity after LAGB and then experiencesubsequent weight gain and/or co-morbidity recurrencewithout a significant anatomic abnormality identified inthe corrective surgery section below. Alternatively, somepatients initially have insufficient weight loss to resolvetheir weight-related co-morbidity and do not achieve anacceptable degree of efficacy after band placement.Other indications for conversion, as discussed below,include complications (slippage, dilation, migration, erosion,port/tube problems or band intolerance). There is someevidence to suggest that fewer complications occur whenconversion to another procedure is performed in 2 stages(band removed with interval procedure 2–6 mo later to allowgastric tissue healing) [24,35–38]. Weight loss and comorbidity outcomes of LAGB patients converted to RYGB,SG, biliopancreatic diversion (BPD), or DS have beenreported and are similar to the outcomes for primary RYGB,SG, and BPD/DS [8,24–33,37–39]. Specific evidence tosupport the safety and efficacy of conversion proceduresafter LAGB is discussed below, and morbidity and mortalityrates of conversion procedures are shown in Table 2.Conversion to RYGBReported incidence of conversion from LAGB to RYGB is2–28.8% [25–27,40]. Medium-term (up to 4 yr) weight loss955outcomes after conversion of LAGB to RYGB are comparableto primary RYGB outcomes [25,26,28,29,41,42], and complication rates are acceptable and most series report early adverseevent rates similar to or slightly higher than primary RYGBcomplication rates [25,43–46]. A recent systematic review of15 studies (588 patients) evaluating conversion of LAGB toRYGB reported an overall complication rate (major andminor) of 8.5% with anastomotic leak and bleeding rates of.9% and 1.8%, respectively. Excess weight loss was between23% and 74% with follow-up periods ranging from 7–44months. Decreases in body mass index (BMI) after conversionranged from 6–12 points with the majority of studies reportingaround a 10-point decrease [46].Conversion to SGConversion of LAGB to SG is most commonly performed for inadequate weight loss [7,8,30–32,47–51].Acceptable morbidity rates and short-term (up to 2 yr)weight loss improvement after conversion to SG has beendemonstrated in published studies [46], but some seriesreport higher leak rates than primary SG. This is postulatedto be a result of the scar tissue at the angle of His thatoccurs after banding. A recent systematic review of 8studies (286 patients) evaluating conversion of LAGB toSG reported an overall complication rate (major and minor)of 12.2% with staple line leak rate of 5.6%. Three leaksrequired reoperation. For studies that reported follow-upperiods after revision (6–36 mo), the excess weight loss(EWL) ranged from 31–60% [46].Removal of a LAGB with conversion to SG can beperformed in a single-stage procedure or in 2 stages withband removal and interval conversion to SG. There is someevidence that the staged approach results in fewer leaks atthe time of SG but the data are limited [52].Conversion to BPD/DSThere is some evidence reporting outcomes after LAGB isconverted to a malabsorptive procedure. These reports arelimited to small case series with short-term follow-up [42,53].Conversion to BPD or BPD/DS results in weight loss similarto a primary malabsorptive procedure with published complication rates that are higher than a primary BPD/DS [39].SGFor patients who need additional therapy for weight lossor develop weight regain after SG, conversion to RYGB orBPD/DS is reported [7,54–56]. For high-risk or high BMIpatients, utilizing the SG as the first stage of a plannedstaged approach is an established strategy [57–61]. In thispatient group, the sleeve provides initial weight loss and comorbidity reduction with improvement in functional statusbefore the second-stage operation (RYGB or BPD/DS) thatprovides continued weight loss and co-morbidity reduction

956Table 1Selected Papers Reporting Gastric Bypass ConversionsPublication nyearPrimaryRevisionalprocedure(s) procedure(s)Shimizu,et al. [7]2013154Khaitan,et al. [9]200537Hallowell, 2009et al. [10]46RYGB, long limb 2.4 1.5 Total 29.9% (n ¼ 46); ogradeRYGB,yr (n ¼2 16.9% (n ¼ 26); Zgrade 3RYGB, SG,VBG or136)13% (n ¼ 20); early 20.8%rebanding,horizontal(n ¼ 32); late 9.1% (n ¼ 14)band overgastricpouch, BPDbypass,reversal,SG, AGB,RYGBJIB, minireversal, redogastricGJbypass,BPD5RYGB5 mo33% overall 5 earlyVBG,complications, 9 lateRYGB,complications (5 leaks)JIB, LGBRYGB,RYGB1 yr2 (4.3%) strictures, 2 (4.3%) 5VBG, JIBulcers, 0 PE, 5 (11%) leaks, (11%)11 (24%) 30-d readmissionsRYGBEndoscopic6 mo1 pulmonary edemasutured TOReimmediately postprocedureThompson, 2013et al.[13]TORe (n ¼50) orshamprocedure(n ¼ 27)Leitman,2010et al. [14]64Himpens,2012et al. [15]88Irani, et al.[20]432011Follow-up Complicationsduration(range)Leaks30-dPreoperative PrerevisionBMImortality BMI (atprimaryprocedure)Prerevisionweight loss0, 1 late 54.4 13.8 44.0 13.7relatedtoCOPD53.7 29.3 for62.4 24.1primaryfor .6 35.155.4 24.8for primaryfor l fromprimaryoperation–revisionInterval7.5 9.6yr0 early, 1 NRlate43.3 9.9NRPostrevision BMI 1–28 yr37.4 9.20NR45.4 10.2NRPostrevision BMI33.5 5.648.537.6 4.9 in 73.2 20.5 in 15.9 20.90 in 58.8 25.7mo (n ¼TORe group–TORe–TORe48) in(n ¼ 43)group (n ¼groupTORe7.7 20.18 in50)38.6 6.2groupcontrol group73.7 21.5in control67.5 (n ¼ 26)in controlgroup24.5 (n ¼group (n ¼27) in26)controlgroup39.5nadir BMI 31 7.3 kg (0–31)5 yr005.8 (3–12) 2 (3%) intraoperativemocomplications (equipmentfailure), 1 observed for bleed(no transfusion)48 (18–Overall reoperation rate: 7.3%, 12.10% 0LRYGBDistal RYGB,122) mo overall severe complication(with andfobi ringrate: 20.7%, overall leak ratewithoutaround pouch,12.1%prior VBG bypassor AGB)reconstruction,LSG, plication0RYGBSalvage banding 26 1412 adverse events: 1(6–66)enterotomy requiring bandmoremoval; 1 SBO, 1 GI bleed,3 esophageal dilationsresolved with band deflation,1 minor port leak, 1 port flip,1 band slip, 1 case ofpersistent dysphagia, and 2cases of intragastric bandmigrationRYGBPostrevisionweight loss42.7 19.7 39.1 11.3 12.4 9.3% Postrevision BMI 3.0 yr(33.0–(30.8–51.8)( 1.0–29.1)29.6 12.4(1.5–8.0)56.6)(18.0–45.5)50.4 (35–60) 43.3 (34–60) 17% EWLPost-LAGB BMI: 223

after bariatric surgery While the majority of bariatri c patients do achieve success-ful outcomes after their primary operation, the patients who present with insufficient weight loss, continued co-morbid disease, or weight regain after bariatric surgery represent a challenging populati

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