Abstract
Introduction:
The recurrence of the morbid obesity disease after laparoscopic sleeve gastrectomy is a well-known complication. The banded resleeve gastrectomy (ReSG) is considered an innovative procedure and an alternative restrictive option to other malabsorptive procedures.
Materials and Methods:
We present an edited video on the placement of a MIDCAL™ (MID, Dardilly, France) ring during a revised sleeve gastrectomy with the main steps of the procedure. The subject is a male patient with a body mass index of 44 kg/m2. After the fundus resection, the MIDCAL is placed and fixed to the stomach by two sutures.
Results:
We present the steps of the operation. The intervention is performed by posterior approach using a three-port technique. The dissection of the previous staple line of the sleeve was continued upward with the visualization of the left crura. The gastric tube was calibrated with a 36F bougie. The restapling of the previous sleeve was carried out by respecting the incisura angularis. The dissection of the pars flaccida allowed the posterior passage of the MIDCAL ring, which was locked and then fixed to the gastric wall with two nonabsorbable sutures. The operative outcome was favorable. The total body weight loss was 9% at 1 month and 27% at 2 years follow-up.
Conclusion:
Banded ReSG is a safe procedure with acceptable results at short term. Other comparative studies are suitable to provide with long-term follow-up results.
Introduction
Even if bariatric surgery is the most successful tool for the treatment of morbid obesity disease, it remains a chronic disease with acceptable recurrence rates after different bariatric procedures. For almost a decade, laparoscopic sleeve gastrectomy (LSG) is the most common bariatric procedure performed worldwide.1,2 Despite many advantages offered by this procedure in terms of long-term complications or quality of life, 3 the long-term results4–14 reported in the literature confirmed that weight regain after LSG is a matter of concern. A particular attention must be offered both in the preoperative and in the postoperative evaluation of each patient. A new surgical concept used with the intention to improve long-term results after LSG is represented by the placement of a nonadjustable band around the gastric tube, described by some authors,15–17 with interesting results in the long term. Considering this concept, banding could be used even for resleeve gastrectomy (ReSG). Herein, we present the technical details for banded ReSG (See Supplementary Video S1).
Materials and Methods
We present a male patient, 48 years old, with a body mass index (BMI) of 44 kg/m2, suffering from obesity for 15 years and regaining weight 12 months after a first gastric sleeve performed in another hospital. The patient argued that he followed a strict diet and exercise program but was able to eat large quantity of food even few months postoperatively. Three years after the initial procedure, the patient came back to his initial weight and asked for a banded ReSG that would make it easier to control his weight.
The patient was against any proposition for a malabsorptive procedure such as gastric bypass or single-anastomosis duodeno-ileal bypass. The clinical questionnaire identified no sign of acid reflux disease. The patient had no diabetes, no hypertension, or any other comorbidity except for a back pain. He had no other previous surgery except LSG and no familial history of hypertension, diabetes, or obesity.
The preoperative workup identified a vit D3 deficiency corrected with a 4 weeks supplementation. The upper gastro-intestinal swallow identified a typical mild dilatation of the gastric pouch. The upper endoscopic evaluation did not find any contraindication to a revisional sleeve surgery and showed no esophagitis and no other sign of reflux disease.
Results
Technical description
We started the insufflation of the abdominal cavity with a Veress needle positioned in the left subcostal area. The entire procedure was performed under 15 mm Hg of pressure. The patient was positioned in supine position with the surgeon between the legs. Three ports were positioned as follows: a 5 mm port for the optical system 15 cm from the xyphoid appendix, a 15 mm port in the right side of the umbilicus, and a 5 mm port in the left subcostal area.
The first step started with the freeing of the previous staple line of the sleeve until we discovered the left crura. This dissection was continued in the opposite direction till 4 cm from the pylorus. The adhesions were taken down between the liver and the stomach as well. A 36F bougie (MID-TUBE™; MID, Dardilly, France) was introduced by the anesthesiologist into the stomach. After a proper evaluation of the shape and the width of the sleeve, a limited revised sleeve gastrectomy was decided by using an Endo GIA tri stapler 60 with one green and one black cartridges. A mild pouch at the upper part of the sleeve was resected. A buttresses material (Seamguard) was used for the first firing.
The next step of the procedure was the band placement. For this purpose, we used a MIDCAL™ (MID, Dardilly, France) ring of 10 mm width locked at 70 mm of length. We started the dissection at the level of pars flaccida of the lesser curvature. This dissection was facilitated by the previous posterior dissection with a minimal passage to allow a complete passage and the positioning of the MIDCAL around the upper part of the sleeve. The band was then fixed to the gastric wall with two nonabsorbable sutures of Ethibon 2-0. The entire banding procedure was done under the presence of the calibration tube. The procedure was finished with the extraction of the gastric specimen and the closure of the port accesses.
The recovery was favorable, and 6 hours after the surgery, the patient was able to drink. He has been discharged the following day with a prescription of proton pump inhibitors (pantoprazole 40 mg) for 30 days and clexane 0.4 IM for 5 days. After 2 weeks of liquid diet, he started on 2 weeks of mashed food before experiencing solid food 1 month after the surgery. At 1 month, the patient lost 9% of his total body weight (TBW), and at 2 years of follow-up, he lost 27% of his TBW and stabilized his appetite.
Discussion
Having the potential advantage of limiting the gastric dilation of the sleeve procedure, the MIDCAL ring has been proposed to increase the effect of the ReSG by reinforcing his period of efficiency. In this case, the banded revised sleeve gastrectomy at 2 years follow-up permitted to accomplish a correct weight loss after an initial failed sleeve, with a good quality of life and without regurgitation or acid reflux. This technique is still very confidential and controversial but could be able to extend the efficiency of a revisional sleeve gastrectomy at 5 years follow-up. This was already confirmed for a primary LSG by different authors.15–17
The factors incriminated for recurrence of weight after LSG are very different and this is representing a very common question for bariatric professionals. A systematic review of weight regain after bariatric surgery identified five principal etiologies: nutritional noncompliance, hormonal and metabolic imbalance, mental health, physical inactivity, and anatomic and surgical factors. 18 For the latter one, Deguines et al. 19 have found a correlation between residual gastric volume and LSG success as defined by percent of excess weight loss >50%, bariatric analysis and reporting outcome system >3, BMI of >35 kg/m2, and/or the Biron criteria. Thus, avoiding recurrent gastric dilation after ReSG could improve the outcome of this restrictive bariatric procedure.
Conclusions
Banded ReSG is a safe procedure with acceptable results at short term. Other comparative studies should be carried out to obtain long-term follow- up results.
Footnotes
References
Supplementary Material
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