OBES SURG (2012) 22:1909–1915 DOI 10.1007/s11695-012-0779-9
CLINICAL REPORT
Repeat Sleeve Gastrectomy Compared with Primary Sleeve Gastrectomy: A Single-Center, Matched Case Study Lionel Rebibo & David Fuks & Pierre Verhaeghe & Jean-Baptiste Deguines & Abdennaceur Dhahri & Jean-Marc Regimbeau
Published online: 22 September 2012 # Springer Science+Business Media, LLC 2012
Abstract Longitudinal sleeve gastrectomy (LSG) has been validated for the treatment of morbid obesity. However, treatment failures can appear several months after SG. Additional malabsorptive surgery is generally recommended in such cases. The objective of the present study was to evaluate the outcomes of repeat SG (re-SG) relative to first-line SG. This was a retrospective study included 15 patients underwent re-SG after failure of first-line SG (i.e. University Hospital, France; Public Practice). These patients were matched (for age, gender, body mass index and comorbidities) 1:2 with 30 patients having undergone first-line SG. The efficacy criteria comprised intra-operative data and postoperative data. The overall study population comprised 45 patients. The re-SG and first-line SG groups did not differ significantly in terms of median age (p0NS). The median BMI was similar in the two groups (43 kg/m2 vs. 42.3 kg/m2, p0NS). The two groups were similar in terms of the prevalence of comorbidities. The mean operating time was longer in the re-SG group (116 vs. 86 min; p≤0.01). The postoperative complication rate was twice as high in the re-SG group (p00.31). Two patients in the re-SG group developed a gastric fistula (p00.25) and one of the latter died. At 12 months, the Excess Weight Loss was 66 % (re-SG group) and 77 % (first-line SG group) (p00.05). Re-SG is feasible but appears to be associated with a greater risk of complications. Nevertheless, re-SG can produce results (in terms of weight loss), equivalent to those obtained after first-line SG. L. Rebibo : D. Fuks : P. Verhaeghe : J.-B. Deguines : A. Dhahri : J.-M. Regimbeau (*) Department of Digestive Surgery, Amiens University Hospital and Jules Verne University of Picardie, Place Victor Pauchet, 80054 Amiens Cedex 01, France e-mail:
[email protected]
Keywords Longitudinal sleeve gastrectomy . Repeat sleeve gastrectomy . Obesity . Revisional bariatric surgery
Introduction Longitudinal sleeve gastrectomy (LSG) is part of the surgical armamentarium for the treatment of morbid obesity. The procedure was first described by Marceau et al. [1] as part of a more complex operation (such as biliopancreatic diversion). Longitudinal sleeve gastrectomy has been validated in the surgical management of morbid obesity [2] as a restrictive procedure, unlike the duodenal switch (DS) or Roux-enY gastric bypass (RYGBP). Indeed, it is acknowledged that LSG is associated with good results (in terms of weight loss), an acceptable complication rate (with a gastric fistula rate of between 1 and 5 % [3]), and relative ease of surgery. Nevertheless, treatment failures (with insufficient weight loss or, in some series, renewed weight gain) appear some months or years after surgery in 9 % of cases [4]. Additional surgery (such as a DS [5] or a RYGBP) is generally recommended in such cases. However, some researchers have suggested performing re-LSG (if technically possible) in the event of primary LSG failure [6, 7]. The objective of the present study was to evaluate case-matched results for re-LSG and primary LSG (in terms of morbidity, mortality, and weight status).
Patients and Methods Population From June 2007 to January 2011, all patients undergoing re-LSG were included in the study, which was thus a
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retrospective review of a prospective database in a group of patients having undergone re-LSG (n 015). Surgery was performed by the same bariatric surgeon (PV) in all cases. The group of 15 patients was matched 1:2 with another group of 30 patients selected from among 450 patients having undergone primary LSG during the same period (i.e., June 2007 to January 2011) in our institution. The indication for bariatric surgery had been validated in a multidisciplinary staff meeting and in accordance with French national guidelines [8]. All patients attended a surgical consultation, a nutritional and dietetics consultation, and pulmonary, endocrine, and psychological assessments. Screening for hiatus hernia and Helicobacter pylori infections was performed gastroscopically. Respiratory function tests were used to screen for obstructive sleep apnea syndrome. Re-LSG was performed for patients with insufficient excess weight loss (EWL ≤ 50 %), renewed weight gain, or an excessively high residual gastric volume (>250 cm 3, as assessed by gastric computed tomographic volumetry). Although the performance of a malabsorptive procedure as RYGBP or DS was always discussed as an option in multidisciplinary staff meetings, re-LSG was preferred because of the high residual gastric volume. During the same period, two RYGBPs were performed following LSG with insufficient weight loss and a residual gastric volume below 250 cm3. Patients were provided with clear information on each type revisional bariatric surgery (re-LSG and RYGBP), with a presentation of the risks and benefits of each type of operation. We explained that a low residual gastric volume after successful re-LSG was expected to produce good results in terms of weight loss. The primary endpoint was the rate of postoperative complications, based on the Clavien classification [9]. The secondary endpoints were the gastric fistula rate, the total operating time, the length of hospitalization, weight changes, and comorbidities. The variables studied prospectively included demographic parameters [age, gender, body mass index (BMI) before and after surgery, and comorbidities before surgery], intraoperative data (duration of the procedure, surgical approach, conversion to laparotomy, and the latter’s causes), immediate postoperative data (length of hospitalization, postoperative complications according to the Clavien classification, and the gastric fistula rate), and followup data 1, 3, 6, and 12 months after surgery (BMI, percentage of EWL, percent weight loss, and changes in comorbidities after surgery), in accordance with current guidelines [10].
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Gastric Volumetry Procedure Patient provided their written, informed consent to participation in the present study, which was registered at ClinicalTrials.gov [“Impact of the Residual Gastric Volume in Laparoscopic Sleeve Gastrectomy’s Failure (GASTROMANCH);” identifier, NCT01539967]. The residual gastric volume was measured by filing the gastric remnant with carbon dioxide, as follows. The patient had drunk first a sodium bicarbonate solution (4 g in 10 cl of water) and then a tartaric acid solution (4 g in 10 cl of water). Low-dose CT acquisitions were made 30 and 60 s after the tartaric acid intake. The residual gastric volume was defined as the volume between the gastroesophageal junction and the pylorus (i.e., anatomic structures that are easily recognized on a CT scan). The volume was measured separately by two radiologists using Myrian® software (Microsoft Inc., Redwood City, CA, USA) and expressed in cubic centimeter. Differences of opinion between the two radiologists were resolved by consensus: the largeness of the two volume determinations was considered as being closest to the patient’s true residual gastric volume. Surgical Procedures Incisions were made at the previous trocar incision sites. The first step in the procedure was to remove any fibrosis between the stomach and the liver and then to release the entire left side of the gastric tube until the left diaphragmatic pillar was seen. This is perhaps the most difficult part of the procedure to perform because one needs to have access to the whole of the left gastric tube in order to realize the optimal section of the gastric tube. We then inserted a 34-French bougie to guide the staple line. The stomach was stapled along the left edge of the bougie and over the entire greater curvature of the stomach. At the end of the procedure, a methylene blue test was systematically performed. In all cases, we always removed abdominal drainage along the staple line of the gastric resection line. On postoperative day 1, all patients underwent another methylene blue test (via a nasogastric tube) and an upper gastrointestinal study with oral contrast (gastrografin) study, in order to check for the absence of complications and enable oral feeding to be initiated. Primary LSG was performed as described by Verhaeghe et al. [11]. The LSG was performed according to a fourtrocar procedure. Six centimeters of antrum were maintained, and the diameter of the stomach tube was standardized by use of a 34-French gauge bougie. The immediate postoperative follow-up was the same as in the re-LSG group.
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In both groups, we used Endo GIA Universal XL 60 with two blue reloads of 3.5 mm then four or five green reloads of 4.8 mm (Covidien France SAS, Elancourt, France). The beginning of the gastric section started 6 cm above the pylorus for both groups. The technique at the time of LSG in the re-LSG group was similar to the technique in the first line LSG group. All the patients who underwent re-sleeve were initially operated for sleeve in our center by the same surgeon (PV). The Case-Matching Procedure Each re-LSG case was manually paired by gender, age, body mass index, and preoperative comorbidities [hypertension, type 2 diabetes, dyslipidemia, metabolic syndrome (NCEP ATP 3), and obstructive sleep apnea syndrome] with two LSG cases. We used the case-matching procedure in order to avoid bias which would otherwise have influenced our results. Statistics Intergroup comparisons of quantitative variables were performed with a Fisher’s exact test. Intergroup comparisons of quantitative variables (including the primary endpoint) were performed with a Chi-squared test. Unless otherwise stated, the results were expressed as the mean ± standard deviation and range (for quantitative variables) or as the number and percentage (for qualitative variables). The threshold for statistical significance was set to p≤0.05. All statistical analyses were performed with SPSS software (version 17 from SPSS Inc., Chicago, IL).
Results Preoperative Data The re-LSG group consisted of 15 women with a median age of 47 years (25–65 years). The mean time interval between the completion of LSG and performance of the re-LSG was 48 months (11–68 months). Prior to the primary LSG, the median preoperative BMI was 47.2 kg/m2 (35.2– 60.1). Three patients (20.0 %) had a BMI of ≥50 kg/m2. In all, 29 comorbidities were recorded in 12 patients, as follows: diabetes (60.0 %, n09), hypertension (60.0 %, n09), dyslipidemia (20.0 %, n03), metabolic syndrome (53.3 %, n08), and obstructive sleep apnea syndrome (13.3 %, n02). Before completion of re-LSG, the median preoperative BMI was 43 kg/m2 (27.4–54.7). Two patients (13.3 %) had a BMI of ≥50 kg/m2. Indications for surgery were insufficient weight loss (with an EWL of ≤50 %) for 80 % of patients
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(n012) and renewed weight for 20 % (n03). A total of 24 comorbidities were recorded and affected ten patients (66.6 %), as follows: diabetes (53.3 %, n08), hypertension (53.3 %, n08), dyslipidemia (6.6 %, n01), metabolic syndrome (40 %, n07), and obstructive sleep apnea syndrome (13.3 %, n02). Thirteen of the 15 patients underwent preoperative gastric volumetry (86.6 %). The mean gastric volume was 367 cm3 (260–609) (Fig. 1). The LSG group consisted of 30 women with a mean age of 45 (20–63). The median preoperative BMI was 42 kg/m2 (30.1–55.0). Two patients had a BMI of ≥50 kg/m2 (6.6 %). A total of 47 comorbidities were recorded and affected 19 patients (63.3 %), as follows: diabetes (50 %, n015), hypertension (36.6 %, n011), dyslipidemia (23.3 %, n07), metabolic syndrome (33.3 %, n010), and obstructive sleep apnea syndrome (13.3 %, n04). There were no significant intergroup differences in any of the matching factors. The study population’s characteristics are summarized in Table 1. Intraoperative Data There was one conversion to laparotomy (prompted by bleeding related to injury of the left gastroepiploic vein) in the re-LSG group (6.6 %) and one in the primary LSG group (3.3 %; poor exposure related to the formation of adhesions after previous cholecystectomy) (p00.56). The median total operating time was 116±50 min (50–220) in the re-LSG group and 86±21 min (55–130) in the primary LSG group (p00.008) (Fig. 2; Table 2). Postoperative Data Mortality and Morbidity There was one postoperative death (6.6 %) in the re-LSG group and none in the primary LSG group. Three postoperative complications (20 %) occurred in the re-LSG group, including two gastric fistulas (13.3 %). All three required further laparoscopic surgery. One of the gastric fistula patients died (6.6 %) after the appearance of pulmonary embolism on day 30. The management of this fistula required revisional surgery and then an endoscopic procedure, with the introduction of a double pigtail stent. The fistula was resolving when the patient presented with pulmonary embolism. The third patient had hyperthermia; exploratory laparoscopy did not reveal any abnormalities, and the final diagnosis was acute left pyelonephritis. The average length of hospitalization in the re-LSG group was 6.2±6.9 days (3–30). In the primary LSG group, there were three postoperative complications (10 %), one of which is requiring further surgery for bleeding on the staple line. We found one case of gastric fistula in the primary LSG
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Fig. 1 Gastric volumetry before (a) and after (b) re-LSG
group (3.3 %). The two other patients had pneumonia. The average length of hospitalization in the primary LSG group was 3.6±1.9 days (2–13). All the upper gastrointestinal studies with oral contrast in both groups were normal and could not predict a gastric fistula later. We did not find any stricture or slow transit on this test. The re-LSG and primary LSG groups did not differ significantly in terms of the complication rate—the study’s primary endpoint—compared (20 vs. 10 %, respectively; p0 0.31). This was also true for serious complications (Clavien score of ≥3), with rates of 20 and 6.6 %, respectively (p0 0.19). We did not find any significant intergroup differences in the secondary outcome measures, i.e., the gastric fistula rate (13.3 and 3.3 % in the re-LSG and primary LSG groups, respectively; p00.25) and mean length of hospitalization (6.2 vs. 3.6, respectively; p00.065) (Table 2). Body Weight Loss There was no loss to follow-up in either group at 1 year. In the re-LSG group, the median BMI was 39.4 kg/m2 at 1 month, 37.3 kg/m2 at 3 months, 35.7 kg/m2 at 6 months, and 33.2 kg/m2 at 12 months. In the primary LSG group, the Table 1 Demographic and clinical data for the re-LSG and primary LSG groups
Median age (range) Number of cases Median BMI (range) Hypertension (%) Type 2 diabetes (%) Dyslipidemia (%) Metabolic syndrome (%) OSAS (%)
Re-SG group
First-line SG group
p value
47 (25–65) 15 43 (27.4–54.7) 8 (53) 8 (53) 1 (6) 6 (40) 2 (13)
45 (20–63) 30 42 (30.1–55.0) 11 (37) 15 (50) 7 (23) 10 (33) 4 (13)
0.56 0.56 0.227 0.54 0.17 0.45 0.68
OSAS obstructive sleep apnea syndrome, SG sleeve gastrectomy, BMI body mass index
median BMI was 40.5 kg/m2 at 1 month, 38 kg/m2 at 3 months, 33.7 kg/m2 at 6 months, and 29.8 kg/m2 at 12 months. The EWL at 12 months was 65.95±20.2 % in the re-LSG group and 79.9±25.6 % in the primary LSG group (p00.08). The percentage of weight loss at 12 months in the re-LSG and primary LSG groups was 29.6±9.2 and 32.4±9.8 %, respectively (p00.37) (Table 3). Comorbidities One year after the re-LSG, a total of six comorbidities had been recorded and affected four patients (28.6 %), as follows: diabetes (0 %, n00), hypertension (21.4 %, n03), dyslipidemia (0 %, n00), metabolic syndrome (21.4 %, n03), and obstructive sleep apnea syndrome (0 %, n00). One year after primary LSG, a total of 15 comorbidities had been recorded and affected nine patients (30 %), as follows: type 2 diabetes (6.6 %, n02), hypertension (20 %, n06), dyslipidemia (3.3 %, n01), metabolic syndrome (9.9 %, n0 3), and obstructive sleep apnea syndrome (10 %, n03). We did not find any significant intergroup differences for any of these factors (Table 4). Gastric Volume After Re-LSG The mean gastric volume after re-LSG was 120 cm3 (70– 370) (Fig. 1) for 8 of the 13 patients who underwent re-LSG (61.5 %).
Discussion The prevalence of obesity has increased in recent decades in the USA [12]. The same is true in Europe, where the increase in obesity affects all ages, socioeconomic class, and regions [13]. Health education campaigns and lifestyle changes have failed to solve all the problems linked to obesity [14]. Bariatric surgery is a valid therapeutic option in the treatment of individual obesity and is associated with good results in terms of weight loss, the correction of cardiovascular risk factors, a reduction in the cancer risk,
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Fig. 2 Intraoperative photographs of re-LSG. a Release of the left side of the gastric tube; b introduction of the 34-French bougie for calibration of the re-LSG, permitting to see the previous gastric line section (white arrow); c beginning of the gastric section line 6 cm upstream the pylori; d stomach stapling. Omega symbol majus omentum, delta symbol 34-French bougie, section sign the spleen
and thus an 89 % reduction in the relative risk of death [15]. Longitudinal sleeve gastrectomy has become particularly popular because of its good outcome in terms of weight loss [16, 17], the reduction of comorbidities, [18] and an acceptable rate of complications (especially gastric fistula) [19, 20]. Nevertheless, about 10 % of LSGs are followed by insufficient weight loss and renewed weight [4, 21]. There are several criteria for assessing the failure of bariatric surgery, such as a BAROS below 3 [22] and Reinhold’s criteria with a postoperative BMI above 35 kg/m2 [23]. The most frequently cited of which is EWL ≤50 % [24]. In our present study, EWL of ≤50 % was the most frequently invoked criterion in the decision to perform revisional surgery (n012, 80 %). Possible explanations for LSG failure include expansion of the residual stomach, calibration of the Table 2 Intraoperative and postoperative data for the re-LSG group and primary LSG group
Operating time (min) Conversion (%) Hospitalization (days) Mortality (%) Complications (%) Clavien of ≥3 (%) Gastric fistula (%) SG sleeve gastrectomy
Re-SG group
First-line SG group
p value
116 1 (6.6) 6.2 1 (6.6) 3 (20) 3 (20) 2 (13.3)
86 1 (3.3) 3.6 0 (0) 3 (10) 2 (6.6) 1 (3.3)
0.008 0.56 0.065 0.31 0.19 0.25
stomach with an excessively large gastric bougie [25], and incomplete section of the gastric fundus (from where ghrelin is secreted) [26]. There are several options for post-LSG revisional surgery: a DS (given that the LSG was originally developed as part of the first step in the DS procedure [27], an RYGBP [28], or a re-LSG [7]. In a series comparing 59 DS with 88 LSG, Topart et al. [29] reported that the complication rate was higher after DS than that after LSG. In a meta-analysis performed by Hutter et al. [30], LSG had a lower reintervention rate than RYGBP did. In our series, the patients in the re-LSG and primary LSG group were similar in terms of gender, age, BMI, and preoperative comorbidities (Table 1). Performance of a re-LSG was based on gastric volumetry data (Fig. 1) suggestive of Table 3 Changes in BMI, EWL, and percent weight loss in the reLSG and primary LSG groups over the 12 months of follow-up
Initial BMI BMI at 1 month BMI at 3 months BMI at 6 months BMI at 12 months EWL at 12 months Percent weight loss at 12 months
Re-SG group
First-line SG group
p value
41.5 39.4 37.6 35.7 32.9 63.8 29.1
42.6 40.5 38 33.7 29.8 79.9 32.4
0.58 0.7 0.35 0.13 0.06 0.3
SG sleeve gastrectomy, BMI body mass index, EWL excess weight loss
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Table 4 Status of comorbidities 1 year after surgery Re-SG group First-line SG group p value Hypertension (n) 3 Type 2 diabetes (n) 0 Dyslipidemia (n) 0 Metabolic syndrome (n) 3 OSAS (n) 0
6 2 1 3 3
0.6 0.46 0.68 0.28 0.3
OSAS obstructive sleep apnea syndrome, SG sleeve gastrectomy
dilatation of the stomach or a nonoptimal diameter of the greater curvature (despite the use of a 34-French bougie in all cases) [31]. In Braghetto et al.’s [32] study, 15 LSG patients underwent gastric volumetry on postoperative day 3 and, then again, 24 to 36 months after surgery. The researchers found that the mean gastric volume had increased from 108 to 250 ml, with weight loss stabilization at 2 years. Weight regain was observed in only three cases. We drew the same conclusions following a recent study of 76 patients; a residual gastric volume of ≥250 cm3 was found to be a failure factor for re-LSG [21]. This is why we chose a gastric volume of 250 cm3 as the threshold for initiating re-LSG. When the residual gastric volume was below 250 cm3, we preferred to perform a malabsorptive procedure (such as RYGBP). The fistula rate in our control (LSG) group was acceptable (3.3 %) and similar to literature values (an overall rate of 2.4 % and up to 2.9 % for a BMI over 50 kg/m2 [33]); this was similar to the post-RYGBP fistula rate of 2.1 % reported by Csendes et al. [34]. Furthermore, the morbidity rate in the present study (20 %) was lower than the value following primary RYGBP (14.7 %) in the series studied by Higa et al. [35]. These observation results prompt us to consider that the LSGs performed in our institution were of high quality. In our present series, the complication rate was higher in the re-LSG group than that in the primary LSG (20 vs. 10 %, respectively; p00.31), although the difference was not statistically significant. The same was true for the gastric fistula rate (13.3 vs. 3.3 %, respectively; p00.25). This may have been due to the fact that dissection of the curvature of the stomach is more difficult in repeat surgery, as reflected by the higher conversion rate (6.6 % in the re-LSG group vs. 3.3 % in the primary LSG group; p0NS), a longer total operating time (116 vs. 86 min, respectively; p00.008), and longer hospitalization. Our findings differ from those of Iannelli et al.’s study [36] of 13 re-LSGs, in which the short mean operating time (43 min) and the lack of reported intraoperative complications suggested that re-LSG is a simple procedure. Although our morbidity results were not excellent, Langer et al. [37] reported a morbidity rate of 13 % (with no mortalities) for eight patients undergoing
RYGBP after primary LSG. The series reported by Spyropoulos et al. [38] further showed that revisional surgery of any type is associated with a high morbidity rate (33.9 %). The morbidity rate of 20 % for re-LSG (i.e., revisional surgery) in our present study can be compared to the value for primary RYGBP reported by Higa et al. [35]. After a year of follow-up, we found that the re-LSG’s results for weight loss (BMI, EWL, and percent weight loss) were equivalent to those of primary LSG (Table 3). With regard to comorbidities, there were similar and significant reductions in the prevalence of all comorbidities in both the re-LSG and primary LSG groups (Tables 1 and 4). Admittedly, our follow-up period of 12 months was probably not long enough for the full assessment of efficacy. However, most studies of RYGBP after primary LSG have covered the same monitoring period and have provided far less detail on complications than we do here. This suggests that a post-LSG RYGBP is simple to perform. In contrast, our study emphasizes an important point: successful re-LSG is not easy—even for specialists in bariatric surgery. Nevertheless, these results suggest that re-LSG with an appropriate residual gastric volume yields the same results as primary LSG does. It also helps avoid revisional surgery, since malabsorptive procedures are associated with more severe vitamin deficiencies (relative to LSG) [39, 40] and neurological sequelae [41] and can be burdensome for patients.
Conclusion Revision of LSG with re-LSG is technically feasible but has greater complication and gastric fistula rates. However, when the residual gastric volume is below 250 ml, re-LSG can yield weight loss results that are as good as those seen after primary LSG. Despite the small sample size, our present series provides new data on re-LSG, showing that re-LSG is feasible in highly screened patients. These data emphasize the value of extensive discussions in a multidisciplinary meeting. We believe that these patients at a high risk of postoperative complications require specific clinical preoperative evaluation. They should be thoroughly informed of the high complication rate and the prolonged length of stay in this situation. In the current state, re-LSG must be considered as an option to RYGBP reserved for expert centers, in anticipation of more elaborate series with longer follow-up. Further research is required to compare the outcomes of re-LSG with those of RYGBP or DS after LSG.
OBES SURG (2012) 22:1909–1915 Acknowledgments I would like to acknowledge Christelle Blot for her valuable help in this work. Conflict of interest None.
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