Introduction

Bariatric surgery remains the most effective treatment leading to substantial long-term weight loss, improvement or resolution of co-morbidities, and even reduced mortality rates [1–3]. Laparoscopic adjustable gastric banding (LAGB) is the least invasive bariatric procedure involving the engagement of an inflatable band device around the proximal stomach to modulate the amount of food intake. At first, LAGB gained popularity due to perception of reversibility, significant and rapid weight loss, resolution of co-morbidities and low operative morbidity rates [4, 5]. However, prolonged follow-up revealed unsatisfactory weight loss in approximately 30–50% of cases. Additionally, complications such as band slippage, erosion, and pouch or esophageal dilatation necessitated revision in up to 20% of patients [6–9]. Although safe, re-banding demonstrated poor results in terms of further weight loss following surgery. Hence, the demand for other bariatric surgeries as a revision to failed LAGB is continuously increasing [10, 11].

Although revisional surgery poses a greater surgical challenge and is associated with increased complication rates compared to primary bariatric surgery [12], a number of bariatric procedures were shown to be safe and effective following failed LAGB. These include laparoscopic Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion (BPD), duodenal switch (DS), and laparoscopic sleeve gastrectomy (LSG) [10, 13–16]. LSG consists of resecting the greater curvature of the stomach, forming a vertical sleeve of the residual stomach portion [17, 18]. Increasingly gaining popularity as a standalone operation, this procedure provides similar outcomes to gastric bypass with regard to weight loss and comorbidity improvement/resolution yet is less technically challenging [19, 20]. Recently, a number of studies examined the benefits of LSG as a revisional surgery following failed LAGB in comparison to RYGB [9, 21–23]. Nevertheless, the surgery of choice following removal of gastric banding is yet undetermined. In this study, we report a series of patients in whom LAGB was converted to LSG. The recent literature regarding LSG following failed LAGB is reviewed.

Patients and Methods

We retrospectively reviewed the charts of all patients who underwent conversion of a failed gastric band to a sleeve gastrectomy in the bariatric surgery unit of the Tel-Aviv Sourasky medical center between January 2008 and August 2013. Excluded from this study were patients under the age of 18, those who underwent surgery due to acute LAGB complications, and patients who underwent band removal with no primary intent for LSG at the time of band removal surgery. Patient demographics, obesity-related co-morbidities, body mass index (BMI) before and after the procedure, post-operative complications, and length of hospital stay were documented. This study was approved by the Tel-Aviv Sourasky Medical Center institutional review board (IRB).

Surgical Technique

The operation was performed under general anesthesia in a supine position with the table in reverse Trendelenburg. Intravenous cephalosporin and a prophylactic dose of heparin were administered prior to incision. An orogastric tube was used and the stomach was decompressed. A supraumbilical Veress needle was inserted with insufflation of the abdominal cavity to a pressure of 15 mmHg. Five laparoscopic ports were inserted. The band was then transected and removed; fundal adhesions to the left diaphragm were lysed and the gastro-gastric plication taken down to completely mobilize the stomach and prevent leaving a large gastric pouch at the level of the gastroesophageal junction. The short gastric vessels were taken down along the greater curvature of the stomach with a Harmonic® scalpel (Ethicon Endo-Surgery, Inc.) or a ligasure® (Covidien, Inc.). Dissection started 4 cm proximal to the pylorus, extending cephalad and taking the adhesions down around the fundus of the stomach. Once mobilized, a bougie was inserted following the lesser curvature. The bougie size, 32–36 Fr, was a surgeons’ preference. Once the bougie tube was placed, sequential firings of the stapler (Covidien tri-stapler or J&J Echelon), were used to transect the lateral stomach, creating a vertical sleeve gastrectomy.

Statistical Analysis

The probability that variances in categorical parameters between the groups are significantly different was calculated using Fischer test. Parametric data are presented as mean ± standard deviation (SD), and statistical analysis was performed using Student’s t test.

Results

One hundred and nine patients underwent revision of a failed LAGB to a LSG. There were 78 females (71.5%), with a mean age of 43 ± 11.3 years and a mean BMI of 42.4 ± 7.4 kg/m2. The mean time interval from LAGB surgery was 8.5 ± 3.6 years. Patient demographics including their co-morbidities are summarized in Table 1.

Table 1 Patient characteristics and pre-op data
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LAGB failed for different reasons—some patients presented with hardware failure, others failed to lose weight or presented with weight regain, and some were unhappy with their quality of life.

Ninety-six patients (88%) underwent a one-stage conversion, while the remaining 13 patients underwent a staged approach with the band being removed in the primary procedure and the sleeve gastrectomy performed several months later (average 8.7 ± 4.3 months) In 2 patients of the one-stage group, a hiatal hernia was identified and primarily repaired during surgery.

Fourteen patients (12.8%) developed early (within 30 days) post-operative complications (Clavien-Dindo classification, grades 1 and 3b). These included a sleeve stricture, 2 leaks (1.8%), 3 post-operative bleeding (2.8%), 4 intra-abdominal collections (3.7%), and 4 hematomas (3.7%) (Table 2). All post-operative complication occurred in patients that underwent a one-step procedure. Early re-operation was necessary in four patients (3.7%) that underwent a one-stage conversion. Indications for re-operation included post-operative hemorrhage in three patients, and stenosis of the sleeve necessitating conversion to gastric bypass in one patient.

Table 2 Operation and operative outcome
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The overall average length of stay was 5.4 ± 5.95 days. The average length of stay of patients that underwent one-step procedure and those that had a two-step revision was 5.6 ± 6.2 and 3.76 ± 2, respectively (P = 0.29).

Within 2 years from surgery, seven patients underwent conversion to gastric bypass (Table 2). Indications for conversion to gastric bypass included weight regain in five patients, and dysphagia due to sleeve stricture not amenable to endoscopic dilatations in two patients.

The overall average BMI at least 1-year following surgery was 33.03 ± 5.3 kg/m2 (preoperative mean BMI 42.4 ± 7.4 kg/m2, excess weight loss (EWL) = 53.7%, Total weight loss = 22.64%). Mean EWL was 53.0 and 58.3% for patients that underwent one-step and two-step procedures, respectively, 1-year following surgery.

Discussion

Although LAGB remains a popular bariatric surgery, relatively high rates of weight loss failure and long-term complications are reported [6–8, 24]. Here, we assessed the safety and effectiveness of LSG as a revision surgery in patients in whom the LAGB results were unsatisfactory. One-stage conversion was performed in the majority of patients. Patients in this series had significantly higher rates of post-operative complications, increased length of hospital stay, and 30-day re-operations when compared to published data in large series of primary sleeve gastrectomy.

Several studies addressed the benefits and drawbacks of LSG as a conversion to failed LAGB (Table 3). Post-operative complications in the presented series, mainly consisting of bleeding and hematoma formation, leak, and abdominal collections, were assessed in accordance with the Clavien-Dindo classification [25]. Large variations in rates and classification of post-operative complication are found among previously published studies (Table 3). Noel et al. (2014) [21] reported a total post-operative complication rate of 4.5% in the primary LSG group and 2% in the LAGB to LSG group. This stands in contrast to our data both in rates of complications, which may be attributed to differences in classification, and in trends between groups. Nevertheless, rates of 1–2% leaks with no differences between groups were similarly demonstrated in both studies (Table 3). Trends for increased complications in the conversion group was also reported by Guetta et al. 2015 [26] with similar rates of total complications as in the presented study. Other groups demonstrated results ranging from 2% to over 10% post-operative complications in various degrees of severity (Table 3). Of note, major complication, including leak, abdominal collections, and hematoma, as well as rates of re-operations were comparable between all studies (Table 3). Our data is consistent with the observation that surgeries performed on a previously operated stomach lead to increased risk of complications. Moreover, Guetta et al. 2015 [26] showed that the risk for early major complication is doubled with each additional previous bariatric surgery performed before the current LSG. This can be attributed to technical difficulties in performing the operation due to adhesions etc., as well as the effect of the gastric banding on the healing of the stomach following LSG. This trend was also reflected by the increased rate of early re-operations. The length of hospital stay ranged from 2 days, as reported by Khoursheed et al. 2013 [27], to almost 6 days, as was reported by Goitein et al. 2011 [28]. In our series, length of stay was within this range, reflecting either increased rates of post-operative complications or an increased concern from their development.

Table 3 Studies of LSG following failed LAGB
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On the survey on LSG at the fourth international consensus summit on sleeve gastrectomy, the EWL was 59.3 at year 1, 59% at year 2, 54.7% at year 3, and 52.3% at year 4 [29]. Similar percentages were demonstrated in other large cohort studies [9, 21, 30]. In our series, the EWL was 53.7%. Noel et al. (2014) [21] reported that in a large series consisting of 300 conversions and 1060 primary LSG, the EWL was 62.2% ± 22.2 at a mean interval of 35 ± 24 months, and 75.9% ± 21.4 at a mean interval of 29 ± 19.8 months, respectively. The tendency of decreased weight loss following revisional LSG might be attributed to their inability to maintain dietary discipline, resulting in repetitive failures of restrictive procedures. Additionally, it is possible that yet unknown genetic characteristics contribute to decreased effectiveness of restrictive surgery. Finally, optimal mobilization of the stomach fundus enabling for its complete removal is a crucial part of the LSG for optimal outcomes. Adhesions around the band involving the gastric fundus and the left crus may sometimes limit mobilization resulting in sub-optimal fundus removal thus contributing to lesser outcomes. The increased failure rates in these patients are also reflected by the fact that 6.4% of them required a second conversion to a gastric bypass (Table 2).

The majority of our cohort underwent a single-stage procedure, with only 13 patients in the 2-stage group. Although not statistically significant, it is worth mentioning that all complications and re-operations occurred in patients having a one-stage operation.

Despite a relatively large series, the presented study does not lack limitations and drawbacks. This is an observational retrospective study. The follow-up time is relatively short and lacks data regarding the long-term effect of surgery on preoperative co-morbidities. The procedures were performed by four different bariatric surgeons using different bougie sizes (32-36Fr), thus contributing to some expected bias in outcomes.

We believe that these issues and others should be addressed in a large prospective randomized study aiming to establish proper guidelines for revisional bariatric surgery.

Conclusion

Our data suggests that conversion of failed LAGB to LSG is both safe and effective.

A staged approach might be safer, with a small sub-group in our series showing no complications when the sleeve was performed several months after excising the Band. Randomized controlled studies comparing conversion of a failed LAGB to Sleeve gastrectomy versus other bariatric operations are necessary to clarify the optimal conversion procedure.