Conversion of Adjustable Gastric Banding to Roux-en-Y Gastric Bypass

Abstract

laparoscopic adjustable gastric banding (LAGB) at 3 years had only a median of 15.9% of baseline weight loss compared with 31.5% for Roux-en-Y gastric bypass (RYGB). Also, there were 77 subsequent procedures following 610 LAGBs during 3 years vs 4 subsequent procedures in more than 1691 RYGBs. Hence, conversion of adjustable gastric banding to another intervention (sleeve gastrectomy, gastric bypass, or duodenal switch) is on the rise. In this issue of JAMA Surgery, Thereaux et al 2 have retrospectively reviewed their prospective database of a singleuniversity surgical center and compared primary gastric bypass with revision gastric bypass, mainly bands revised to gastric bypass. However, the authors looked only at 30-day outcomes because one would be interested in weight loss differences over time, marginal ulcer incidence, gastric pouch enlargement, and gastroesophageal reflux disease, with or without hiatal hernias and esophagitis. In 831 patients who had primary gastric bypass and in 177 patients who had conversion of gastric banding to gastric bypass, the 30-day major outcome rates were similar (7.8% and 8.5%, respectively).Their article diverges from previous Longitudinal Assessment of Bariatric Surgery data in which revision surgery was associated with more severe complications. 3 In that study, compared with those undergoing revision surgery, primary surgery patients with obesity were younger and more likely to be male, weigh more, and have more comorbidity. This was not the case in the 2013 series, in which conversion from LAGB to RYGB was associated with a higher percentage of female patients and with fewer comorbidities. 1 Therefore, one can conclude that the groups were not comparable and were highly selected before surgery. In the earlier study, 3 operative time for revision procedures was longer and associated with greater blood loss, and adverse outcomes were more frequent after revision surgery (15.1% vs 5.3%, P < .001).There is not always an easy reversal or removal of an adjustable gastric band. The foreign body is known to have caused severe capsular reactions, taking the left lobe of the liver, diaphragm, gastric remnant, superior pole of the spleen, and pan- creas posteriorly. Hence, this dissection time is added to the procedure, and longer operating time in bariatric surgery under a pneumoperitoneum of 15 mm Hg increases the likelihood of complications, such as thromboembolism, and gastric pouch construction may not be optimal. Thereaux et al 2 havenot provided the number of stapling events required to fashion their pouch; a safe margin from the band would be necessary to create a healthier and well-vascularized anastomosis. The leftover capsule remodels to become thinner over time, and the gastric pouch is likely to expand to an unusual size, causing a higher risk for marginal ulceration. A larger pouch is also likely to increase the frequency of weight regain later (beyond 3 years), and a few patients may need a second revision. In that sense, a 2-stage approach may be more desirable. Att...

Quantitative analysis of bariatric procedure trends 2001–13 in South Australia: implications for equity in access and public healthcare expenditure

“…This is consistent with recent data suggesting that within Australia almost 20% of gastric band patients will require revisional surgery within 3 years. 29 Failing gastric banding leads to requirements for further surgical procedures 30 that are costly to the public healthcare system and introduce additional risks to patients. The findings suggest the need for further research to investigate why revisions/reversals are becoming more prevalent.…”