by Manish Parikh, MD; Marc Bessler, MD
Both from Center for Obesity Surgery, Columbia University, New York-Presbyterian Hospital, New York, New York
Disclosures: Autosuture (teaching), Ethicon Endosurgery (consulting), Bariatric partners (consulting), Inamed/Allergan (consulting), and Karl Storz Endoscopy (research).
The Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric procedure in the US. However, the long-term failure rate after RYGB is 20 to 35 percent. Particularly in superobese patients (BMI≥50Kg/m2), this failure rate can be as high as 40 to 60 percent, depending on how failure is defined.
Poor weight loss often leads patients to request a revision procedure. Indeed, the most common indication for reoperation after RYGB is inadequate weight loss. Revision bariatric surgery is technically complex, associated with a high incidence of morbidity, and historically has had questionable efficacy. In the current laparoscopic era, reoperative bariatric surgery has become more popular due to quicker recovery and decreased wound complications compared to open reoperative series. Perhaps even more promising are new endoluminal therapies which avoid intra-abdominal surgery altogether. This review describes the various revision options for failed RYGB, including emerging endoluminal therapies.
Careful nutritional and anatomic evaluation is helpful in understanding the causes of weight loss failure. It is important to differentiate between patients who have never succeeded with the RYGB and patients who regained weight after significant excess weight loss (EWL) with the primary RYGB. Most patients report 50 to 60 percent EWL within two years and then subsequent weight regain. These are the patients who seem to benefit most from a revision procedure to eliminate the weight regain. The patients who never succeeded with a RYGB constitute a difficult population to treat. A thorough assessment of dietary patterns is helpful (e.g., volume-eaters vs. “grazers”). Some benefit from a more restrictive procedure such as the addition of an adjustable band on the gastric pouch. Others may benefit from conversion to the more malabsorptive biliopancreatic diversion with duodenal switch (BPD-DS).
In patients who present with failed RYGB, it is often useful to perform both upper endoscopy and upper gastrointestinal (GI) contrast studies, as they are complementary in the evaluation of anatomy and cause of weight gain after bariatric surgery. Endoscopy provides useful information about the pouch and stoma while upper GI detects esophageal and Roux limb abnormalities. These modalities also effectively diagnose staple line dehiscence and gastrogastric fistula.
We consider a pouch dilated if it is greater than 120cc in volume and a stoma dilated if it is greater than 2cm in diameter. Occasionally patients present with weight regain secondary to maladaptive eating behavior from stomal obstruction. However, most patients who present to us with weight regain after RYGB have technically intact anatomy (i.e., no evidence of gastrogastric fistula) with a dilated pouch and/or dilated stoma.
Surgical Therapies for Weight Loss Failure after RYGB
storically revision for failed RYGB involved reduction of the gastrojejunostomy stoma. In Mason’s series, a significant number (15%) of these patients required an additional revision procedure. Schwartz reported a 50-percent complication rate and negligible weight loss in 42 RYGB patients undergoing gastrojejunostomy revision. Muller, et al., described this laparoscopically (“pouch resizing”) and reported a mean BMI decrease of 3.9Kg/m2 at 11 months.
Others recommend conversion of the failed RYGB to a distal gastric bypass. This entails disconnecting the Roux limb and reconnecting it closer to the ileocecal valve, usually 50 to 150cm proximal to the ileocecal valve. Fobi, et al., reported an average 20Kg weight loss and mean BMI decrease of 7Kg/m2 in 65 patients converted to distal RYGB. However, 23 percent of patients developed protein malnutrition and almost half of these patients required revision surgery for this. Similarly, Sugerman, et al., reported 69-percent EWL at three years in 27 patients undergoing conversion to distal RYGB.10 Five of 27 had a common channel of 50cm and the remainder had a common channel of 150cm. The shorter common channel led to an “unacceptable” morbidity and mortality (all required revision, and two died of hepatic failure). The longer common channel was still associated with a 25-percent incidence of protein malnutrition and a significant number required operative revision. A recent report by Muller, et al., comparing a matched cohort (based on age, gender, and BMI) of standard RYGB (150cm Roux limb) and distal RYGB (150cm common channel) found no significant difference in weight loss or comorbidity reduction at 4 years.
Conversion to the more malabsorptive BPD-DS is another surgical option. The incidence of protein malnutrition seen with BPD-DS may be less than with distal RYGB, partly because the larger stomach and sparing of the first portion of the duodenum affords better digestive behavior. Keshishian, et al., reported 69-percent EWL at 30 months in 46 patients revised to BPD-DS (26 were from RYGB). However, they did report a significantly higher complication rate in the RYGB revision patients, including a 15-percent leak rate.
At our institution, we frequently offer the adjustable gastric band as a surgical option for failed weight loss after RYGB. It is a technically simpler and safer operation to perform compared to other revision procedures and offers reasonable weight loss. The adjustable band is placed around the proximal gastric pouch and above the gastrojejunostomy. The remainder of the RYGB is left in-situ. O’Brien, et al., and Kyzer, et al., originally described converting any failed bariatric procedure (including gastric bypass) to the Lap-Band system.[14,15] Both series reported good weight reduction; however, subgroup analysis for failed RYGB was not provided.
A previous report from our own institution looked specifically at the use of adjustable gastric banding as a revision procedure for failed RYGB in eight patients. Mean BMI prior to revision was 44.0±4.5Kg/m2. Patients had an average of four band adjustments over one year. Mean EWL was 38.1±10.4 percent at 12 months and 44.0±36.3 percent at 24 months. Another more recent report from NYU Medical Center revealed a mean 6.3Kg/m2 BMI decrease and approximately 20.8±16.9-percent EWL at 12 months in 11 failed RYGB patients. Both series had minimal complications (mostly port-related).
Key technical points in placing the adjustable band on the upper pouch include the use of upper endoscopy to verify that the band is placed around the gastric pouch and not the esophagus, making sure that the band is at least 1cm proximal to the gastrojejunostomy, and using the fundus and the anterior wall of the bypassed stomach to plicate (with permanent sutures) above and below the band to ensure adequate anterior fixation. Sometimes, the gastric pouch alone is large enough to be used for the fundoplication.
Endoscopic Therapies for Weight Loss Failure after RYGB
Endoscopic therapies consist of either sclerotherapy or transoral endoscopic reduction. The goal of sclerotherapy of the gastrojejunostomy is to reduce the diameter of the gastrojejunostomy in a minimally invasive, low-risk manner. Specifically, submucosal and intramusuclar injections of five percent sodium morrhuate are placed circumferentially around the gastrojejunostomy to reduce the stomal diameter (by inducing tissue retraction and scarring). Data is limited regarding the efficacy of this technique. Spaulding reported a small series (n=20) of RYGB patients with weight gain who underwent sclerotherapy.18 Although sclerotherapy was 100-percent successful in diminishing the diameter of the gastrojejunostomy, the clinical effects were marginal: Seven to nine percent EWL overall, 25 percent regained weight, and only 45 percent noticed a “lasting difference.” Catalano, et al., recently reported more favorable results with sclerotherapy in 28 RYGB patients with weight regain (>18Kg after initial successful weight loss) and a stoma size >12mm. They injected 2 to 4mL of sclerosant (sodium morrhuate) per quadrant circumferentially. Success (defined as stoma size <12mm and loss of >75% of regained weight) was achieved in 64 percent of patients. Mean stoma diameter decreased from 17 to 12.7mm and average weight loss was 22.3Kg (ranging from 3Kg weight regain to 37Kg weight loss). Problems encountered included shallow ulcers at the anastomosis (in nearly one-third of patients), stomal stenosis (requiring dilation), and post-injection pain (in 75% of patients).
Another emerging endoscopic technique is endoscopic suturing to narrow or plicate the gastrojejunostomy and thus reduce the stomal diameter. Schweitzer reported successful stomal plication in four patients; although all patients experienced early satiety, the absolute weight loss was not reported.
Thompson, et al., reported a series of eight patients with gastrojejunostomies greater than 2cm who underwent endoscopic anastomotic reduction using the EndoCinch suturing system (C.R. Bard Inc., Murray Hill, NJ). Seventy-five percent(6/8) of the patients lost weight (mean 10kg) at four months and overall EWL was 23.4 percent. There are several other promising endoluminal therapies on the horizon.[22-23] Further studies are required to determine if these new techniques deliver sustained weight loss.
Patients who have failed RYGB (especially after initial successful weight loss) are challenging. As the number of RYGB increase in the US, bariatric surgeons are likely to see this problem more frequently. Surgical treatment options include revision of the gastrojejunal anastomosis, placement of an adjustable gastric band on the pouch, conversion to distal gastric bypass, and conversion to duodenal switch.
Emerging endoluminal therapies include sclerotherapy and stomal plication. Longer-term studies are required to determine which treatment option is best. Careful risk benefit analysis is warranted in dealing with this difficult clinical and technically challenging situation.
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Category: Surgical Perspective