Sleeve gastrectomy or gastric bypass as revisional bariatric procedures: retrospective evaluation of outcomes. Abstract Background Methods:

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1 Sleeve gastrectomy or gastric bypass as revisional bariatric procedures: retrospective evaluation of outcomes. Mousa Khoursheed, Ibtisam Al-Bader, Ali Mouzannar, Abdulla Al-Haddad, Ali Sayed, Ali Mohammad, Abe Fingerhut. Surg Endosc 2013;27: Abstract Background: A considerable number of patients require revisional surgery after laparoscopic adjustable gastric banding (LAGB). Studies that compared the outcomes of revisional sleeve gastrectomy (r-sg) and revisional Roux en- Y gastric bypass (r-rygb) after failed LAGB are scarce in the literature. Our objective was to determine whether significant differences exist in outcomes between r-sg and r-rygb after failed LAGB. Methods: From 2005 to 2012, patients who underwent laparoscopic r-sg and r-rygb after failed LAGB were retrospectively compared and analyzed. Data included demographics, indication for revision, operative time, hospital stay, conversion rate, percentage excess weight loss (%EWL), and morbidity and mortality. Results: Out of 693 bariatric procedures, 42 r-sg and 53 r-rygb were performed. The median preoperative weight (107.7 and kg, respectively, p = 0.02) and body mass index (BMI) (38.5 vs kg/m2, respectively, p = 0.01) were statistically significantly lower in r-sg than in r- RYGB. The mean operative time and median hospital stay were significantly shorter in r-sg than in r-rygb (108.4 vs min, p\0.01) (2 vs. 3 days, p = 0.02), respectively. One patient underwent conversion to open surgery after r-rygb (p = 0.5). The reoperation rate was lower in r- SG than in r-rygb (0.0 vs. 3.8 %, p = 0.5). There was one

2 postoperative leak in the r-rygb, and the overall complication rate was significantly lower in r-sg patients than in r-rygb patients (7.1 vs %, p = 0.05). The mean follow-up was significantly shorter in the r-sg group (9.8 vs months, p>0.01). However, the mean postoperative BMI was not different at 1 year (32.3 vs. 34.7, p = 0.29) as well as mean %EWL was (47.4 vs %, p = 0.77). Conclusions: Both r-sg and r-rygb are safe procedures with similar outcomes in terms of %EWL. As a result of the long-term potential nutritional complication of r-rygb, r-sg may be a better option in this group of patients. Longer follow-up is needed. Critical Appraisal 1. This study retrospectively examined the outcomes for morbidly obese patients who underwent laparoscopic sleeve gastrectomies (r-sg) or laparoscopic roux-en-y gastric bypasses (r-rygb) after failed laparoscopic adjustable bands (LAGB). The study included all patients revised between the years 2005 and r-sg and 53 r-rygb patients were included in the analysis. The researchers compared patient demographics, indication for revision, operative times, hospital stay, conversion rate, percentage excess weight loss (%EWL), morbidity and mortality. 2. All patients had the band removed and either the r-sg or the r- RYGB performed at the same operative intervention. 3. Based on their data, they concluded that both procedures could be safely performed laparoscopically and as a single operative procedure. Additionally, although the mean postoperative BMI

3 and %EWL were similar for both procedures at the one year follow up, r-rygb procedures had statistically significantly longer operative times and lengths of stay, a higher reoperation rate, and a statistically significantly higher overall complication rate. 4. Only 1 patient required conversion from the laparoscopic to an open procedure for bleeding (1.9%) and there was only 1 leak (1.9%). The overall complication rates for the r-sg and the r- RYGB were 7.1% and 20.8% respectively, which are acceptable for revisional bariatric surgery and would suggest that the surgeons were adequately skilled in both procedures. 5. The authors conclude that the r-sg might be a better choice for patients electing to have their LAGB removed vs. the r-rygb since the weight loss is similar, the complication rate is lower, and the risk of long term nutritional complications less. Study Limitations 1. This was a retrospective analysis and not a prospective trial. The groups are not similar so the outcome comparisons must be interpreted with that in mind. The patients were not randomized into the 2 groups. The earlier patients were only offered the r- RYGB and more of the later patients the r-sg. There is no description for how patients were selected for the 2 procedures. Additionally, the r-rygb patients were older (although this was not statistically significant, it might be if the series was larger). Importantly, r-rygb patients were statistically heavier. Therefore, the change in BMI and %EWL results will be biased in favor of the lower weight group.

4 2. Mean follow up was not comparable between the 2 procedures. r- RYGB patients had a mean follow up of months vs months for the r-sg. It was statistically significantly longer for the r-rygb group (p <0.01). 3. The authors describe the operative techniques for the 2 procedures. For the r-rygb they report creating the gastric pouch below the band scar and do not state that the gastrogastric wrap was taken down. These operative steps could result in larger gastric pouched which could influence weight loss. 4. The authors do not define band failure. For example, how many patients lost no weight or gained all the lost weight back vs. how many patients had inadequate weight loss but lost some weight? Were these patients equally distributed between the groups? Is the one year follow up %EWL for the r-sg and r-rygb calculated from preop band placement or preop conversion? 5. One year follow up was poor for both groups, only 9 of the 42 r-sg patients (21.4%) were evaluated and 25 of the 53 r-rygb patients (47.2%). Therefore the 1 year outcome data presented must be viewed with caution. 6. The authors conclude that the r-sg might be a better choice for patients electing to have their LAGB removed vs. the r-rygb since the weight loss is similar, the complication rate is lower, and the risk of long term nutritional complications less. However: A. The weight loss results are biased by the lack of patient randomization, significant starting weight differences between the groups, potential for large gastric pouches in the r-rygb patients, and the poor 1 year follow up. B. The complication rate was lower in this study for the r-sg

5 patients which is compatible with other published data but maybe biased by the lack of similarity between the 2 groups. C. No nutritional data was presented to make any nutritional inferences in this patient population. Scott A. Shikora, MD, FACS, FASMBS Director, Center for Metabolic and Bariatric Surgery Brigham and Women s Hospital Associate Professor of Surgery Harvard Medical School Boston, Massachusetts, USA

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