How to Convert an Adjustable Gastric Band Procedure to a Roux-en-Y Gastric Bypass

This column recruits expert surgeons to share step-by-step technical pearls on bariatric procedures.

Column Editors: Raul J. Rosenthal, MD, FACS, FASMBS, and Daniel B. Jones, MD, MS, FACS

This Month’s Technique: How to Convert an Adjustable Gastric Band Procedure to a Roux-en-Y Gastric Bypass

This Month’s Featured Experts: Natan Zundel, MD, FACS, FASMBS, Clinical Professor of Surgery; Vice-Chairman Department of Surgery at Florida International University, Herbert Wertheim College of Medicine in Miami, Florida; Almino Ramos, MD, Gastro Obeso Center, Sao Paulo, Brazil; Elias Chousleb, MD, Department of Surgery at Florida International University, Herbert Wertheim College of Medicine in Miami, Florida; and Manoel Galvão Neto, MD, Gastro Obeso Center, Sao Paulo, Brazil

Funding: There was no funding for the preparation of this manuscript.

Disclosures: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2013;10(3):24–25.

Introduction
Adjustable gastric banding was a popular method for surgically induced weight loss. The number of adjustable gastric band procedures has decreased as the number of sleeve gastrectomy procedures have increased in popularity.[1]

We are currently being faced with a large population of patients who require conversions to another bairatric procedure due to these circumstances. There is good evidence that patients who undergo conversion from band to bypass will have similar outcomes as those who undergo primary bypass regarding weight loss,[2] however, there is a rise in the perioperative complications seen after revisional procedures.[3,4]

Given the high failure rate of gastric banding as well as the large numbers of patients who have undergone banding procedures around the world,[2,5] modern bariatric surgeons should be aware of the pitfalls of converting a gastric band to another bariatric procedure.

Preoperative Workup
All bariatric patients should undergo an exhaustive bariatric workup prior to attempting a conversion from a banding procedure. It is important to rule out the presence of erosion or slippage of the band, which can lead to failure of weight loss. Other pathology, such as a hiatal hernia, should also be interrogated although it might not always be evident on preoperative workup.

Step 1—Takedown of the anterior placation
The anterior plication should be taken down initially in order to return the stomach to a normal anatomic position. Attempting to create a pouch without taking the anterior plication down can lead to complications and creation of abnormally large gastric pouches. The takedown can be done safely using electrocautery or harmonic scalpel (Figures 1-3). When planning to convert to a bypass or sleeve gastrectomy at my facility, we leave the band in place throughout this part of the operation since it allows us to clearly identify the gastroesophageal (GE) junction. Once the plication is fully taken down, we gain access to the retrogastric space via the lesser curvature and place the first fire of the stapler to start creation of the gastric pouch.

Step 2—Creation of the gastric pouch
After the initial firing of the stapler, we proceed to open and remove the band (Figure 4). This points us in the direction of the GE junction. A second fire of the stapler is performed in toward the esophagus and the small gastric pouch is created (Figures 5-7). In my experience I have found that one or two cartridges are generally necessary for the creation of the pouch. If the area around the band is inflamed, we suggest upsizing of the stapler cartridge.

Step 3—Creation of the gastrojejunostomy
The gastrojejunostomy is now created in a standard fashion using a hybrid stapling and suturing technique (Figures 8-10). The alimentary limb may be brought up in an antecolic or retrocolic fashion as per surgeon preference. The anastomosis may be created alternatively with a purely handsewn technique or a stapled technique. Our limb is brought up using the Brazilian technique without division of the Roux limb until the end.

Step 4—Creation of the jejunojejunostomy and division of the Roux limb
A standard stapled jejunojejunostomy is created with sequential firing of a gastrointestinal anastomosis (GIA) stapler (Figure 11). Once this is completed, the Roux limb is divided with a single fire of a GIA stapler (Figure 12).

Conclusion
Conversion from band to bypass is a feasible and safe procedure in experienced hands. The workup has to be exhaustive to prevent unexpected findings in the operating room. Weight loss after conversion is similar to primary bypass procedures, however, morbidity is significantly higher for revisional operations.[3,4]

References
1.    Nguyen NT, Nguyen B, Gebhart A, Hohmann S. Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy. J Am Coll Surg. 2013;216(2):252–257.
2.    Moore R, Perugini R, Czerniach D, et al. Early results of conversion of laparoscopic adjustable gastric band to Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2009;5(4):439–443.
3.    Patel S, Eckstein J, Acholonu E, et al. Reasons and outcomes of laparoscopic revisional surgery after laparoscopic adjustable gastric banding for morbid obesity. Surg Obes Relat Dis. 2010;6(4):391–398.
4.    Mognol P, Chosidow D, Marmuse JP. Laparoscopic conversion of laparoscopic gastric banding to Roux en y gastric bypass: a review of 70 patients. Obes Surg. 2004:14(10):1349–1353
5.    Elnahas A, Graybiel K, Farrokhyar F etal. Revisional surgery after failed laparoscopic adjustable gastric banding: a systematic review. Surg Endosc. 2013;27(3):740–745.

Category: Past Articles, Surgical Pearls: Techniques in Bariatric Surgery