Failure of laparoscopic sleeve gastrectomy--further procedure?

Abstract

Background: Worldwide, the incidence of morbid obesity is increasing, and surgery is the only effective longterm treatment. Laparoscopic sleeve gastrectomy (LSG) is associated with acceptable weight loss and reduced comorbidities. It is considered a safe procedure with sporadic complications. This publication aims to describe failures of LSG in terms of ineffective weight loss or early weight regain, and analyze secondary treatment options.

Methods: From October 2001 to December 2010, 937 patients underwent LSG in our department. Initially, all procedures were scheduled as a two-stage procedure (LSG followed by biliopancreatic diversion with duodenal switch). However, the second procedure was not performed in 64 patients (body mass index > 60 kg/m(2)). Since 2005, the frequency of second stage procedures after weight regain has been increasing; their outcome is analyzed.

Results: Of the 937 patients, 17 (1.8%) experienced staple line leakage. Mean time to first reintervention or endoscopic stent placement was 15.6 ± 22 days (range 2-78). From 2005 to 2010, 106 secondary procedures were performed. Insufficient weight loss or weight regain were the indications in 88 cases. Sixteen (15%) patients had severe gastroesophageal reflux which was resolved by Roux-en-Y gastric bypass (RYGB). Stenosis was observed in 2 (2.6%) patients, which required endoscopic dilatation and stent placement in one case and gastric bypass in the other.

Conclusions: LSG is a feasible and popular bariatric procedure. Mortality (0.4%) was much higher than after gastric bypass (0.03%) and gastric banding (0%) The knowledge of potential complications and their management is crucial. All restrictive procedures require patient compliance, but increased food uptake after RYGB and LSG is common. Malabsorptive procedures are more effective for long-term weight loss. Duodenal switch and omega-loop gastric bypass are more efficient second stage procedures than re-sleeve or RYGB.

Copyright © 2011 S. Karger AG, Basel.

Figures

Fig. 1

Number of standard procedures (gastric banding, gastric bypass, sleeve gastrectomy) during the last 17 years.

Fig. 2

BMI classes of all patients for obesity surgery from 2011 to 2010 in the Krankenhaus Sachsenhausen Frankfurt am Main (Germany).

Fig. 3

Virtual CT after sleeve gastrectomy 3rd postoperative day: normal finding after calibration with 42 French tube.

Fig. 4

Virtual CT after sleeve gastrectomy: surgical mistake with fundus in placed (uncompleted resection).

Fig. 5

Virtual CT after sleeve gastrectomy: prepyloric dilatation of the antrum 6 years after LSG.

Fig. 6

Laparoscopic view on adhesiolysis and intraoperative gastroscopy for stenosis.

Fig. 7

BMI drop after different secondary procedures (ring placement, re-sleeve, Roux-en-Y gastric bypass (RYGB), omega-loop gastric bypass, and biliopancreatic diversion with duodenal switch (BPD-DS); BMI loss 1 and 2 years after revisional surgery.