Revised Sleeve Gastrectomy: Our Experience

Abstract

Introduction:

Laparoscopic sleeve gastrectomy (LSG) has rapidly become increasingly popular in bariatric surgery. However, in the long-term follow-up, weight loss failure and intractable severe acid reflux after primary LSG can necessitate further interventions. The purpose of this study was to evaluate our initial case series regarding the complications and short-term weight loss results of the ReSleeve Gastrectomy (ReSG).

Methods:

From January 2010 to February 2016, all patients who underwent ReSG were included in this study. From a retrospective database, the demographic data, surgical history, comorbidities, American Society of Anaesthesiologists (ASA) score, time interval between the two procedures, and intra- and postoperative parameters and outcomes were analyzed.

Results:

ReSG was performed for 25 patients (7 men) with a mean age of 49 years (±11). Indications for ReSG were weight loss insufficiency for 1 patient (4%), weight regain for 23 patients (92%), and an acute dysphagia due to a residual fundic pouch for 1 patient (4%). Mean reoperation time before ReSG was 2.9 years (±1.5). The mean body mass index (BMI) for ReSG was 43.9 kg/m² (±9.4). The first 4 patients (16%) had a barium swallow and the next 21 (84%) patients a computed tomography scan volumetry with a mean gastric volume of 526.7 cc (±168). All procedures were completed by laparoscopy with no intraoperative complication. An additional procedure was carried out for 3 patients (12%), including 1 cholecystectomy and 2 hiatal hernia repairs. Mean length of hospital stay was 5.2 days (±4.2), with no postoperative death. The complication rate was 60% (n = 15) including a Dindo–Clavien grade 2 complication for 7 patients (28%) and grade 3 for 8 patients (32%). One patient was lost to follow-up (4%). The mean BMI before RSG was 43.9 kg/m² (±9.4). At a mean follow-up after ReSG of 37.3 months (range 6–80), the mean BMI and percentage of excess weight loss were, respectively, 35 kg/m² (±6.7) and 38.2% (±19).

Conclusions:

ReSG should be proposed only for well-selected cases. This study has led us to change our habits by selecting only patients with a large gastric pouch ≥500 mL or with unresected fundus. Further prospective clinical trials are required to compare the outcomes of ReSG with those of laparoscopic Roux-en-Y gastric bypass or duodenal switch for weight loss failure after LSG.

Introduction

Laparoscopic sleeve gastrectomy (LSG) has evolved from an initial operation for high-risk patients¹ to a primary surgical treatment modality for morbid obesity. During the past decade, LSG became the most common bariatric procedure initially in 2011 in France² and in 2013 in the United States.³ This was a natural evolution for several reasons. LSG presents a better quality of life with less vomiting than laparoscopic adjustable gastric banding (LAGB) and it seems to be a less complex procedure than laparoscopic Roux-en-Y gastric bypass (LRYGB) or duodenal switch (DS). LSG presents also less morbidity in the long-term follow-up with no risk of internal hernia or perianastomotic ulcer and minimal dumping syndrome or bone demineralization. Considering the weight loss results, different randomized trials reported similar results at 5 years.^4,5

Recently few studies regarding long-term results after LSG reported high reoperative rate, up to 20%, for insufficient weight loss or weight regain.^6,7 Thereby, the number of revisional procedures will increase in parallel with the primary procedures. A second intervention, such as revisional sleeve gastrectomy,^8–10 LRYGB,^1,7 or biliopancreatic diversion with DS (DS)¹¹ or its variant single-anastomosis duodenoileal bypass (SADI)¹² can be proposed. Identifying the importance of each mechanism in weight recurrence after LSG is of outmost importance to evaluate the indications and results of the revisional surgery. A clear algorithm must be used by each bariatric center for a more sensible evaluation of the results in terms of weight loss.

The primary bariatric procedures will always have better outcomes than the revisional procedures after LSG. Herein, we present our initial experience, and the purpose of this study is to analyze the complications and short-term weight loss results of the ReSG.

Methods

From January 2010 to February 2016, all patients who underwent ReSG at Montpellier University Hospital (CHU de Montpellier, France) were included in this study. From a retrospective database, the demographic data, past surgical history, comorbidities, American Society of Anaesthesiologists (ASA) score, time interval between the two procedures, and intra and postoperative parameters and outcomes were analyzed.

A postoperative complication was defined as an unexpected or undesired postoperative course, each graded according to the Dindo–Clavien scale.¹³ For statistical analysis we only considered postoperative complications with grade superior or equal to 2. All patients underwent a complete preoperative check-up including nutritionist, endocrinologist, psychologist, and surgeon evaluation. The reintervention for weight loss failure was decided in a multidisciplinary meeting. All patients were encouraged to quit smoking before surgery, they were individually informed about the technique and signed an informed consent.

The requirements for revisional surgery were insufficient weight loss at 18 months after the surgery (<50% of excess weight loss [EWL]), or progressive weight regain after an initial successful weight loss (defined as EWL >50%). The gastric anatomy was assessed with upper gastrointestinal (GI) series and the gastric residual volume was calculated using the computed tomography (CT) scan volumetry. The decision for a type of revisional surgery was chosen after a standard algorithm (Fig. 1). ReSG was proposed to the patient if the barium swallow or CT scan volumetry indicated an upper gastric pouch dilation, an unresected fundus (technical error) or a global dilatation of the sleeve ≥350 cc, without major gastroesophageal reflux disease (GERD). In case of residual gastric volume <350 cc and/or major GERD, a conversion to LRYGB was proposed. Major GERD was defined according to Montreal classification.¹⁴

FIG. 1.

Algorithm of treatment. GERD, gastroesophageal reflux disease; LRYGB, laparoscopic Roux-en-Y gastric bypass; ReSG, ReSleeve Gastrectomy.

Surgical procedure

All operations were performed under general anesthesia and by laparoscopic approach using the French technique (the surgeon standing between the patient's legs). Pneumoperitoneum was induced by the Hasson technique with an initial trocar placed at the umbilicus and maintained at a pressure of 16 mmHg.

Intraperitoneal attachments between the left lobe of the liver and the anterior gastric surface were carefully dissected, then a liver retractor was placed. Each procedure required five trocars. The previous staple line was dissected from antrum to left diaphragmatic crus. An important step was to dissect carefully and completely the posterior part of the stomach and to expose completely the left diaphragmatic crus to be able to remove an upper gastric pouch dilation, or an unresected fundus. The stomach is calibrated with a 36F tube (Midsleeve, Medical Innovation Development, Dardilly, France). To increase the accuracy and the reproducibility of the antrum conservation, the special distal balloon of the Midsleeve is inflated with 50 cc of saline. The stomach is divided by a laparoscopic linear stapler that is placed parallel to the Midsleeve tube along the lesser curvature.

The use of a buttressing material (Seamguard, W.L. Gore & Associates, Flagstaff, AZ) was reserved initially only for patients who presented a high risk of bleeding (hypertension, need for anticoagulation treatment), and at the end of study the use was systematically. Methylene blue test was performed at the end of the procedure. Drainage and nasogastric tube were not routinely used in our experience. The perioperative deep vein thrombosis prophylaxis by low molecular weight heparin and intermittent pneumatic leg compression was systematically used.

Statistical analysis

Statistical analyses were performed with SPSS 20.0 for Mac OS X (SPSS, Inc., Arlington, VA). Continuous variable was expressed as the mean ± standard deviation (min–max). Categorical data were compared with the chi-square analysis or Fisher's exact test, as appropriate, and continuous data with the Mann–Whitney U test. A bilateral P value <.05 was considered statistically significant.

Results

From January 2010 to June 2016, 25 patients (7 men and 18 women) with a mean age of 49 years (±11) underwent ReSG in Montpellier University Hospital. Patient characteristics are summarized in Table 1.

Table 1.

Patient Demographics

Patients' characteristic	Mean ± SD (min–max) or n (%)
Age (years)	49 ± 11 (23.1–69.3)
Gender (men/women)	7/18 (28/72)
BMI (kg/m²)	43.9 ± 9.4 (29.4–65.3)
ASA score
1	12 (48)
2	10 (40)
3	6 (24)
History of LAGB	10 (40)
CT scan volumetry (cc)	526.7 ± 168 (191–838)
GERD	7 (28)

ASA, American Society of Anaesthesiologists; BMI, body mass index; CT, computed tomography; GERD, gastroesophageal reflux disease; LAGB, laparoscopic adjustable gastric banding; n, number; SD, standard deviation.

Indications for ReSG were weight loss insufficiency for 1 patient (4%), weight regain for 23 patients (92%), and an acute dysphagia due to a residual fundic pouch for 1 patient (4%). Mean reoperation time before ReSG was 2.9 years (±1.5). The mean body mass index (BMI) at the moment of the ReSG was 43.9 kg/m² (±9.4) and 10 patients (40%) had a laparoscopic adjustable gastric banding (LAGB) history.

For analysis of gastric residual volume, the first 4 patients (16%) had a barium swallow and the next 21 (84%) patients had a CT scan volumetry analysis. The CT scan volumetry analysis showed a mean gastric volume of 526.7 cc (±168).

Major comorbidities were represented by sleep apnea syndrome for 12 patients (48%), hypertension for 10 patients (40%), and type 2 diabetes mellitus for 6 patients (24%). Seven patients (28%) suffered from a GERD.

Intraoperative data

All procedures were completed by laparoscopy with no intraoperative complication. An additional procedure was carried out for 3 patients (12%), including 1 cholecystectomy and 2 hiatal hernia repairs. A mean of 6.5 linear stapler chargers (±1.7) were used with bioabsorbable staple line reinforcement (Seamguard^®) for 17 patients (77.2%). The mean operative time was 84.5 minutes (±34.2).

Postoperative outcomes

Mean length of hospital stay was 5.2 days (±4.2), there was no postoperative death. We reported a complication rate of 60% (n = 15) including a Dindo–Clavien grade 2 complication for 7 patients (28%) and grade 3 for 8 patients (32%).

De novo GERD occurred for 8 patients (32%), global postoperative rate of GERD of 56% (n = 14) is significantly higher in statistical analysis (P = .016).

The major complications are summarized in Table 2 and occurred in 8 patients (32%). They needed a total of four endoscopic treatments (16%) and seven reoperations (28%). During the follow-up, the first patient developed an incisional hernia of the umbilical port, he underwent a retromuscular mesh repair during an abdominoplasty. Another patient (#3) developed a subphrenic abscess with a leakage at the upper part of the gastric tube at postoperative day 5 identified on CT scan and requiring an immediate reintervention for drainage. At the fifth month postoperatively, after successive failed endoscopic procedures, a Roux-en-Y fistulojejunostomy was performed by laparotomy for chronic fistula.

Table 2.

Postoperative Complications

Postoperative complications	n (%)
Postoperative GERD	14 (56)
De novo GERD	8 (32)
Leakage	4 (16)
Stricture	3 (12)
Bleeding	1 (4.2)
Incisional hernia	1 (4.2)
Pulmonary embolism	1 (4.2)

GERD, gastroesophageal reflux disease.

Another patient (#4) developed stenosis of the midpart of the sleeve at the second postoperative month, requiring a laparoscopic gastric myotomy. This procedure was complicated by a new leakage requiring new laparotomy for drainage and healed after 21 days.

Another patient (#5) developed a stenosis of the midpart of the sleeve at the second postoperative month, requiring two successful endoscopic pneumatic dilatations.

Another patient (#20) developed a leakage of the upper part of the sleeve revealed by an upper GI bleeding, requiring an urgent reoperation for drainage associated with an endoscopic stent placement. Then, positioning of endoscopic double pigtail allowed a healing of the fistula in 75 days.

At postoperative day 13, another patient (#22) was diagnosed with a leak. The initial treatment consisted of repetitive endoscopic placement of pigtail. Unfortunately, the leak evolved to a chronic fistula associated with stricture. The reconstructive definitive surgery with Roux-en-Y fistulojejunostomy was performed by laparotomy after 6 months.

Another 2 patients (#23 and #24) underwent LRYGB after 24 months and, respectively, 18 months for severe GERD.

On statistical analysis, the only risk factor of postoperative complication Clavien ≥3 is the BMI (P = .043). Statistical analysis is presented in Table 3.

Table 3.

Risk Factors for Postoperative Complication Clavien ≥3

Risk factor	P
BMI	.043
Age	.84
CT scan volumetry	.79
History of LAGB	.67
ASA 3	1
Sleep apnea	.41
High blood pressure	1
Type 2 diabetes	1

ASA, American Society of Anaesthesiologists; BMI, body mass index; CT, computed tomography; LAGB, laparoscopic adjustable gastric banding.

One patient was lost to follow-up (4%). The mean BMI before RSG was 43.9 kg/m² (±9.4) At a mean follow-up after ReSG of 37.3 months (range 6 to 80), the mean BMI and %EWL were, respectively, 35 kg/m² (±6.7) and 38.2% (±19).

Discussions

Even if LSG was accepted as a simple bariatric procedure, the learning curve to significantly decrease the risk of the procedure and to improve the results is longer. LSG has few key points: respecting the incisura angularis, a symmetric resection of the anterior and posterior part, and the removal of the entire gastric fundus with complete visualization of left diaphragmatic crus.

The number of revisional procedures is continuously increasing in parallel with the increasing number of total bariatric procedures. A full history for the patients with weight regain after any bariatric procedure is mandatory. It should include the detailed evolution of weight with the purpose to clearly differentiate the patients with weight regain from those with weight loss insufficiency. Their alimentary habits must be evaluated and all maladaptive eating disorders should be associated with further psychological intervention before any discussion of the different options for bariatric revisional procedures.

The anatomy assessment represents an import part of any work-up for revisional bariatric surgery. It includes both upper GI series and volumetric CT scan. The upper GI series offer the advantage of having a dynamic aspect. The volumetric CT scan is limited by the subjectivity of the total gastric volume measurement that is dependent on the radiologist's reading. The presence of the short gastric vessels on the CT scan can be considered an indication for an ReSG, proving an incomplete dissection of the gastric fundus during the primary procedure.

The issue of weight loss failure after LSG is common for all bariatric procedures, including the LRYGB. There are two main differences between the LSG and LRYGB. The limited number of surgical options for revision after LRYGB, hence LSG, is more frequently revised for the same weight regain. Second, LSG is also more frequently performed as a first step in a two-stage approach for superobese patients (BMI >50), case when LSG is improperly considered as revisional surgery.

Karmali et al.¹⁵ have identified five main causes for weight loss failure after different bariatric procedures: nutritional noncompliance, hormonal/metabolic imbalance, mental health, physical inactivity, and anatomical/surgical factors. The success in bariatric surgery is variably defined by %EWL >50%, Bariatric Analysis and Reporting Outcome System >3, BMI <35 kg/m², and/or the Biron criteria. A clear correlation between the residual gastric volume after LSG and the success of the procedure were reported by Deguines et al.¹⁶ Different reasons account for the anatomical failure of LSG such as the calibration of the stomach with an excessively large gastric bougie¹⁷ and incomplete section of the gastric fundus (from where ghrelin is secreted).¹⁸

The dilatation of the gastric wall after LSG is frequently identified, creating a source of major debates in the literature. The gastric volume can double (from 108 to 250 mL) on CT scan volumetry between day 3 and 36 months postoperatively as it has been reported by Braghetto et al.¹⁹ on their study followed through 15 patients. This finding was not associated with weigh loss failure as none of these patients experienced weight regain. A completely different finding was reported by Langer et al.²⁰ who analyzed 23 patients with UGI contrast studies. The dilatation was noticed for only 1 patient, but the weight loss failure occurred in 3 patients at an interval of 20 months.

Mostly at the beginning of the LSG experience, the hiatal region was incompletely dissected, and the gastric pouch could become a source of dysphagia and GERD. In our experience, 1 patient underwent ReSG with complete remission of his symptomatology. A similar case wherein ReSG was a valid option for the remission of dysphagia was also reported by Gagner and Parikh.²¹

The intralumenal pressure could be involved in the dilatation of the gastric tube. This was assessed by Yehoshua et al.²² who reported a mean pressure of 43 mmHg in the sleeve compared with a mean pressure of 26 mmHg in the removed stomach. Their conclusion was that the notably higher pressure in the sleeve reflects its markedly lesser distensibility compared with that of the whole stomach and that of the removed fundus.

The ReSG has already been described as a revision of LSG/DS itself.^9–11,23,24 Although the operation seems to be technically easier, without need of the conversions, in our experience the cumulative risk of postoperative complication Clavien ≥3 is more important (32%) than described by Noel and others⁸ who reported one bleeding and two stenosis in 61 patients (5%). In our study, we explain this high risk of stenosis, by stapling near from the angulus, on scar tissues with less flexibility that can lead to a too much tight sleeve with high intraluminal pressure. Consequences are multiple, GERD, dysphagia, and fistula. Management of those complications is difficult, requiring first endoscopic procedures using dilatation or tents, and in case of failure, conversion to a Roux-en-Y gastric bypass. We think that during an ReSG, the stapling should be separate in two times, first of all by resecting the antrum, then resecting the upper part of the sleeve starting above the angulus.

Conclusions

Footnotes

Disclosure Statement

T.C., M.N., C.F., M.L., R.S., and A.N. have no conflicts of interest or financial ties to disclose. M.N. has honorarium for speaking engagements from Ethicon. D.N. has consultant honorarium from MID, and speaking honorarium from Gore and Ethicon.

Funding Information

No funding was received for this article.

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