Laparoscopic Revisional Bariatric Surgery

| February 18, 2010

by Ricardo Cohen, MD; Marcelo Cerdan Torres, MD

Drs. Cohen and Torres are from the Center for the Surgical Treatment of Morbid Obesity and Metabolic Disorders, Hospital Oswaldo Cruz and Baros Surgical Associates, Sao Paulo, Brazil.

Bariatric Times. 2010;7(2):16–18

Abstract
Video laparoscopy frequently has been used in obesity surgery with safe and excellent outcomes. Bariatric surgeries are growing exponentially, and as an expected consequence, the complications and need for reoperations has grown too. Revisional reoperations, traditionally performed by laparotomy, are difficult, and intra- and postoperative complications rates may be high. The authors summarize indications for laparascopic revisional bariatric surgery and desribe causes and options based on evidence and their own experiences.

Introduction
It is well established today that  surgical treatment is the most effective tool in controlling morbid obesity.[1] It is also unquestionable that laparoscopic access reduces the intensity of metabolic response after surgery morbidity in general and bariatric operations.[2]

Since the early 90s, video laparoscopy frequently has been used in obesity surgery with safe and excellent outcomes.[3,4] As bariatric surgeries have grown exponentially, it may be no surprise that complications and need for reoperations have grown as well. Revisional reoperations, traditionally performed by laparotomy, are difficult, and intra- and postoperative complications rates may be high. The challenge of reoperations under laparoscopy in bariatric surgery has been improved due to surgical technical improvement and enhancement of equipment and instruments. In this article, we summarize the main indications for laparoscopic revisional bariatric surgery and briefly describe causes and potential therapeutical options based on our own experiences.

Indications for Reoperation
Our group has conducted about 350 laparoscopic revisional procedures. The most common reason for revision was failed or complicated adjustable gastric banding (65% of the total).

The indications for videolaparoscopic revision are divided into the following:

A.    Reoperations in urgent or “acute” situations. These are indicated in life-threatening situations or early postoperative complications, such as peritonitis by gastrojejuno anastomosis leaks or intestinal obstruction.
B.    Revisonal reoperations. Reoperations are divided into three categories: unsatisfactory weight loss, primary procedure complications, and loss of quality of life. These indications will be individually detailed according to the following four primary procedures: vertical banded gastroplasty (VBG), adjustable gastric band (AGB), Roux-en-Y gastric bypass (RYGB) with and without pouch ring, and malabsorptive procedures.

Some important points in revisional bariatric surgery that must be considered include the following:
•  Knowledge of the previous surgery
•     Surgeon’s affinity with reoperations
•     Surgeon’s preparedness for long and sometimes tiresome surgeries
•     Surgical team’s ability to act in unexpected situations—they are frequent.

Why Reoperations Under Laparoscopy?
Morbidity rates after revisions in bariatric surgery may vary from 12 to 41 percent, mostly due to anastomotic fistulas, incision infections, hernias, intestinal obstruction, pulmonary embolism, atelectasis, and pneumonia.[5] In 2002, Gagner and Cohen[6,7] demonstrated a series of reoperations done under laparoscopy procedure without mortality or anastomotic fistulas. Cohen’s study[7] resulted in a morbidity rate of 16 percent, and Gagner’s study[6] resulted in a morbidity rate of 22 percent.

Laparoscopy tends to reduce morbidity for the following reasons: The absence of great incisions eliminates severe incision infections and hernias, and, in addition, it reduces the manipulation and consequently adhesions, adherences, and obstructive situations.[7] The pulmonary function is also preserved,[8,9] reducing the chances of infectious and restrictive pulmonary complications. Early deambulation safely reduces the incidence of thromboembolic venous phenomena, decreases time of hospitalization, and promotes swifter return to daily activities.

Reoperations in urgent or acute situations. In urgent or acute situations, the decision for reoperation must be balanced and made quickly because making an incorrect decision can result in serious complications or death.

Repair of iatrogenic visceral injuries. An iatrogenic visceral injury is a complication usually associated with videolaparoscopy that occurs at the moment of pneumoperitoneum confection or first trocar placement, both steps performed without direct vision. The most common injured region is the small intestine and, depending on the lesion’s size, can go unnoticed, causing postoperative peritonitis, which leads to a reoperation under videolaparoscopic access (depending on the patient’s systemic conditions).

Intestinal obstruction. According to Garcia-Caballero and Vara-Thorbeck,[10] the report of incidence of intestinal obstruction by adhesions decreased after the wide use of videolaparoscopy. One reason for the decrease may be due to the need for less manipulation of intracavitary structures and, therefore, reduction in visceral adherences formation. There have been reports, however, concerning intestinal obstruction in videolapaoscopy operations performed with retrocolic alimentary loops, even with the mesocolon orifice closure. This condition prompted some surgeons to use the antecolic route in these operations, which achieved a lower number of intestinal obstructions. Regarding intestinal obstruction by adherences after open surgery (bariatric or not), laparoscopy success and benefits for its treatment are well established in literature.[11]

Roux–en-“O” reconstruction (not Roux-en-Y). Roux–en-“O” reconstruction happens when the biliary limb is anastomosed to the gastric pouch instead of to the distal end of Roux-en-Y limb. This is a mistake made by untrained surgeons in advanced laparoscopy but it happens rarely in open surgery. It was described at the beginning of laparoscopic RYGB, but it tends to disappear with training and practice. If the problem is not identified during the operation, laparoscopic revision is mandatory and the correct Roux-en-Y reconstruction performed.

Gastrojejunal anastomosis leaks. Gastrojejunal anastomosis leaks are the largest cause of mortality in bariatric surgery. Once the gastrojejunal anastomosis leaks are diagnosed or suspected, surgical treatment is indicated, except in rare situations. Laparoscopy is feasible and safe in these situations. The conversion rate is reasonably high (30%) and is fundamentally dependent on the patient’s systemic conditions and on the degree of laparoscopic training of the surgical team. We had the opportunity to re-explore some gastrojejunal fistulas under laparoscopy after open and laparoscopic Roux-en Y gastric bypass, sometimes supported by transoperative peroral endoscopy. Leak repair and drainage are adequate alternatives. Gastrostomy can be performed under laparoscopic access if necessary.

Gastric/esophageal injury after AGB. This is an almost exclusive complication for untrained surgeons in advanced laparoscopy. If it is not diagnosed early during the placement of the band, the laparoscopic access allows the surgeon to repair the injury or injuries.

Duodenal stump fistula in Scopinaro/duodenal switch operations. A duodenal stump fistula is a rare situation, as the duodenum is usually normal, without any anatomical problems or disease. However, if a duodenal stump fistula is diagnosed, laparoscopic access allows repair of the fistula, when it is feasible, and allows washing and eventual draining of intracavitary abscess.

Revisional reoperations. The revisional reoperation rates in bariatric surgery vary between 10 and 25 percent.[5] Unsatisfactory weight loss is the most common cause for reoperation.[5–7] The following options for laparoscopic reoperations will be divided in conformity to performed primary procedure.

Reoperations after VBG. Until the late 80s, VBG was the most performed bariatric surgery in the United States.[1] It gained popularity worldwide early on in laparoscopy use in obesity surgery due to its technical simplicity. In 1998, Gemert et al,[12] after 12 years of follow up, reported 56 percent of revisions after VGB due to failure of weight loss. Many options were proposed, such as gastric rebanding, removal of gastric fundus segment based on Collis procedure for short esophagus, and replacement of silastic or marlex ring of the pouch’s outlet, but all the attempts had disappointing results just like the primary operation.[12]

In our opinion, the conversion to RYGB is the best choice in those restrictive operations with intact anatomy. Laparoscopic access produces excellent early and late outcomes in such situations and, in addition, offers the patient a better postoperative recovery and good long-term weight loss.

Reoperations after AGB. The main reasons for reoperation after AGB include the following:
•    Lack of weight loss/resolution of comorbidities
•    Slippage
•     Stomach /esophagus erosion
•     Severe gastro-esophageal reflux
•     Esophageal motility alterations.
There are many options available for dealing with reoperations. Since the indication of AGB was accepted, the incidence of complications has increased in all countries.[13] O’Brien et al[13] reported 25-percent reoperations and Heniford et al[11] reported 33.8 percent, following AGB.

Curiously, solutions to the same situation can vary, and some solutions are opposed to the others. For example, in the case of erosions (Figures 1A–C), O’Brien and Fielding[15] propose suturing the perforated viscera and replacing the other AGB, contradicting the classic principles of surgery. Other surgeons still go further, treating patients clinically without surgical intervention. According to most reports of world’s literature,[16]  the surgeon should remove the prosthesis, suture the perforation, and determine the best alternative for surgical treatment of the patient’s obesity. There are some instances where the band can be safely removed through endoscopy. After this is done, an elective remedial bariatric operation can be scheduled. We tend  to convert an AGB into RYGB (rarely into a biliopancreatic derivation with Scopinaro’s method) and recently to a sleeve gastrectomy. In other situations, such as slippage, lack of weight loss, and esophageal dismotility, revisions are reviewd case by case, and are indicated based on several clinical and laboratory parameters.  RYGB or sleeve gastrectomies as stand-alone procedures are options that can be considered.

The ones who defend biliopancreatic diversions point to the advantage of no contact with inflamed tissues around AGB.[16] But the risks of nutritional and metabolic complications after malabsortive procedures have to be taken into account.

The conversion of AGB into RYGB or sleeve gastrectomy is a complex procedure; however, it is feasible for experienced surgeons in advanced videolaparoscopy. The following points must be considered when a laparoscopic conversion from AGB to another bariatric procedure is indicated:[17]
•     Be aware of the band’s brand because it may vary in closure types and in resistance of the prosthesis material.
•     Adherences are frequent, especially in the presence of a complication.
•     Transoperative endoscopy can be useful.
•     Be prepared for exhausting and sometimes day-long work. Patience and training in advanced laparoscopy are essential qualities.

Reoperations after RYGB—Complications of gastric pouch banding. Some groups defend the use of restrictive rings around the gastric pouch[18] relating their importance for the initial weight loss and its long-term maintenance.[18] The band acts as a strange body around the small stomach, promoting erosions, which, even at a low incidence of 3 to 4 percent, are the most frequent cause for reoperation and prosthesis removal (marlex or silastic).[18] Some patients are indicated for revision due to stenosis and anastomosis obstruction near the ring, leading to vomiting that only improves after ring’s removal. However, when revision is indicated, some details should be considered. Those patients’ reservoirs are usually larger than those constructed in laparoscopic RYGB, making the pouch’s reconstruction a mandatory step. Remaking the gastrojejunal anastomosis with diameters between 1 and 1.2cm is also crucial.

At our clinic, we performed anastomosis with a linear stapler. After a follow up of 60 months, the anastomosis kept the same diameter or slightly increased and the pouch’s size kept the same approximate volume. Five years postoperatively, we could not strongly correlate weight loss with a wider or narrower anastomosis. There are hormonal changes and increased resting expenditure rate behind the mechanisms of action after RYGB. Restriction and/or malabsorption may play a secondary role in inducing and maintaining reasonable long-term weight loss.

Reoperations after RYGB—Gastrogastric fistula. It is an unusual situation; however, when a gastrogastric fistula occurs, the patient will stop losing weight or begin to regain weight. Redividing the stomach and separating the proximal and distal stumps can be difficult procedures, but are perfectly feasible under laparoscopy.

Reoperations after RYGB—Other causes of insufficient weight loss. Mason[19] believes an unsuccessful weight loss to be less than 40 percent of desired amount in two years, while O’Brien considers a loss less than 25 percent to be a failure after AGB.[13]

When inadequate weight loss occurs, the only option is to increase the size of the alimentary loop, attempting to improve the malabsorptive component (distal RYGB) after removing psychiatric causes and complications such as gastrogastric fistulas and gastric pouch or anastomosis dilatation.[20,21] Results after adding a malabsorptive component to RYGB are sometimes disappointing.

Reoperations after RYGB—Gastrojejunal anastomosis stenosis. Gastrojejunal anastomosis stenosis usually occurs between postoperative Weeks 4 and 5, and 99 percent of these occurences are solved with endoscopic dilation through a hydrostatic balloon. Reoperations may be necessary in a very small percentage of patients, and redoing the gastrojejunalanastomosis may be indicated.

Reoperations after malabsorptive procedures (Scopinaro or duodenal switch). Two main causes for laparoscopic reoperations after malabsorptive operations include the following:
Malnutrition/severe steatorrhea. Identifying the cause is crucial; however, sometimes this is difficult to establish. It is important to discern an “anatomical steatorrhea” produced by the surgery from a steatorrhea caused by bacterial super infection. Anatomical steatorrhea can be treated under laparoscopy, increasing the extension of the common channel and reducing the malabsorptive component. Bacterial steatorrhea is usually clinically managed. Surgery may be indicated if not controlled in rare situations.

Lack of weight loss. The first step is to review the primary surgery in order to guarantee if a malabsortive procedure has really been performed. If yes, the existence of a restrictive component of small degree can be checked through radiological studies, and the presence of steatorrhea can be detected through a fecal fat detection test. If steatorrhea is not confirmed, increasing the restrictive component (depending on the patient’s clinical and psychiatric evaluation) or decreasing the common channel length to add a malabsorptive component may be good options. On the other hand, if there is malabsorption, there is no consensus to solve the problem; nevertheless, we do not recommend in such situations to add any restrictive component, as we believe malnutrition will surely follow.

Conclusion
Laparoscopic revisional bariatric surgery is feasible and safe, but challenging.21 It must be performed in bariatric Centers of Excellence, with multidisciplinary teams to take part in the preoperative evaluation. The surgical team must be well trained and skilled in advanced laparoscopy.

References
1.     Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724–1737.
2.    Nguyen N, Goldman C, Ho HS, et al. Systemic stress response after laparoscopic and open gastric bypass. J Am Coll Surg. 2002;194(5):557–567.
3.    Schauer PR, Ikramudin S. Outcomes after laparoscopic Roux-en-Y gastric bypass. Ann Surg. 2001;232:515–529.
4.    Wittgrove A, Clark W. Laparoscopic gastric bypass: a five-year prospective study of 500 patients followed from 3 to 60 months. Obes Surg. 1997;6:500–504.
5.     Benotti P, Forse RA. Safety and long-term efficacy of revisional surgery in severe obesity. Am J Surg. 1996;172:232–235.
6.    Gagner M, Gentileschi P, Csepel J, et al. Laparoscopic reoperative bariatric surgery: experience from 27 consecutive patients. Obes Surg. 2002;12:254–260.
7.    Cohen RV, Schiavon CA, Correa JL. Reoperations after failed gastric banding. University of Pittsburgh Laparoscopic Bariatric Workshop Syllabus. Pittsburgh, PA: UPMC Press;2002;78–90.
8.    Cohen RV, Schiavon CA, Moreira L. Metabolic and Systemic Responses Following Interventional Laparoscopy. Austin, TX: RG Landes Medical Publishers;1994.
9.    Nguyen N, Wolfe B. Comparison of pulmonary function and postoperative pain after laparoscopic and open gastric bypass. J Am Coll Surg. 2001;192:469–476.
10.    Garcia-Caballero, Vara-Thorbeck. The evolution of postoperative ileus after laparoscopic cholecystectomy. Surg Endosc. 1993;7:416–419.
11.    Higa KD, Boone KB, Ho T. Complications of the laparoscopic Roux-en-Y gastric bypass: 1040 patients—What have we learned? Obes Surg. 2000;10:509–513
12.    Van Gemert WG, Van Wersch MM, Greve JWM. Revisional surgery after failed vertical banded gastroplasty: restoration of vertical banded gastroplasty or conversion to gastric bypass. Obes Surg. 1999;8:21–28.
13.    O’Brien PE, Brown WA, Smith A. Prospective study of a laparoscopically placed adjustable gastric band in the treatment of morbid obesity. Br J Surg. 1999;86:113–118.
14.    Heniford BD, Ianitti DA, Gagner M. Laparoscopic isolated gastric bypass using a transoral stapled anastomosis. Presented at: American College of Surgeons Annual Clinical Congress: October 1997; Chicago.
15.    O’Brien P, Fielding G. Banding the most challenged patients. University of Pittsburgh Laparoscopic Bariatric Workshop Syllabus. Pittsburgh, PA: UPMC Press; 2002:65–73.
16.     Giovanni D, Bernard CG, Himpens J. Laparoscopic conversion of adjustable gastric banding and vertical banded gastroplasty to duodenal switch. SOARD. 2009;5(6):678–678.
17.    Cohen RV, Schiavon CA, Correa JL. Conversion of adjustable gastric banding into gstric bypass. a challenging rescues operation done laparoscopically. University of Pittsburgh Laparoscopic Bariatric Workshop Syllabus. Pittsburgh, PA: UPMC Press; 2002:134–142.
18.    Fobi MAL, Lee H, Holness R. Gastric bypass operation for obesity. World J Surg. 1998;22:925–935.
19.    Mason E. Ten years of vertical banded gastroplasty for severe obesity. Prob Gen Surg. 1992;9:280–296.
20.    Behrns KE, Smith CD, Kelly KA, Sarr M. Reoperative bariatric surgery: lessons learned to improve patients selection and results. Ann Surg. 1993;218:646–653.
21.    Cohen RV, Pinheiro JC, Schiavon CA, Correa JL. Revisional laparoscopic bariatric surgery: myths and facts. Surg Endosc. 2005;19(6):822–825.

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