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Go deeper in detail on revision surgery

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Revision surgery in detail

Band revision to gastric bypass

Band revision to gastric sleeve

Revision surgery in detail

Studies show effectiveness of revision surgery

A recent meta study (a review of multiple studies) by Sharples et al looked at a number of studies into revision bariatric surgery following gastric banding. The objective of the study was to show the effectiveness of revision bariatric surgery. A secondary outcome was to compare outcomes with revision to bypass and revision to sleeve.

These latest results show a slightly different picture than that which we saw previously.

Most importantly, they showed that revision surgery is effective and that patients can expect to achieve broadly the same weight loss with the revision as they could expect if they had had the bypass or sleeve as their primary procedure. That was always the case with the bypass but previous studies had showed that results with revision to sleeve were poor compared to primary sleeve results. In this latest study the weight loss at 2 years after revision surgery was broadly the same.

It’s important to stress however that the sleeve data is quite ‘thin’ compared to that for bypass. The study concludes that more data, specifically randomised control trials, are required to properly compare the procedures. 

The study also noted that a high proportion of the revisions to sleeve were done as two stage procedures, meaning that the band was removed and the sleeve was done at a later date, usually about 3 months later. We believe that this approach was used to reduce the risk of staple line leakage, which remains the complication that causes most concern with the sleeve. In this study the leak rate was 2.2%. Most revisions to sleeve are now done as one stage procedures and it is possible that the leak rate would be higher were only one stage procedures reviewed. We suspect that would be the case but there is not the evidence to support it at this stage.

For now however, we can conclude that gastric band removal and revision to gastric bypass or gastric sleeve are safe and effective procedures with similar outcomes in terms of weight loss and post-operative complications.   

Band revision to gastric bypass

Band removal and revision to gastric bypass has been regarded as the premier revision surgery procedure for many years. Studies that were conducted some years ago by Coblijn et al in 2013 and Elnahas et al in 2012 confirmed this. These studies looked at co-morbidity resolution (Coblijn) and weight loss (Elnahas). They both showed superior outcomes with revision to bypass than with revision to sleeve. In Coblijn’s study he showed that although revision to bypass was safe, it did however carry a higher risk of complication than was the case with primary bypass.

A more recent study, by Sharples et al (2017), has looked at a wider dataset and shows that complication rates for revision gastric bypass surgery are broadly the same as those for primary bypass procedures. Furthermore, it confirms the Elnahas finding that weight loss outcomes are similar to those for primary bypass, specifically 54.2% excess weight loss at 12 months, 59.5% at 24 months and 60.7% at 36 months.

We suspect that the improvement in complication rates we have seen in the Sharples study is the result of improvements in surgical technique.

Looking in more detail at complications, Sharples shows overall morbidity of 16.5%, leak rate of 1.8% and return to theatre (any time) of 7.8%. The complication rates were lower in the group where revisions to bypass was done as a one stage procedure.

Based on the latest data we continue to regard revision to bypass as the gold standard in revision surgery as it is safe and offers good weight loss outcomes..

Band revision to gastric sleeve

A recent study has shown improved results when a gastric band is revised to a gastric sleeve procedure. Previously, studies have shown that both weight loss results and complication rates have been inferior to those achieved with revision to gastric bypass.

A recent study by Sharples et al has shown a different picture. This study was a meta-study that looked at over 30 separate studies into bypass and sleeve after gastric band surgery.

For the first time it reveals that both weight loss outcomes and complication rates are very similar for bypass and sleeve. In fact there is no statistically significant difference in the results.

We suspect that the improved results reflect the rapid evolution in sleeve surgical technique.

Both procedures show excess weight loss (EWL) of about 60% after 2 years. This is a big difference from the previous meta-study by Elnahas that showed 2 year EWL of just 22%. 

Sharples shows that the leak rate for revision to sleeve is 2.2%. This contrasts with a leak rate of 1.8% for band to bypass. Although the leakage rates are similar it is important to note that these studies do not show what the average extended stay in hospital was after a leak. It is also important to note that a large proportion of the band to sleeve procedures in this study were completed as two step procedures (band removed as a first step and the sleeve done at a later date). We suspect that would have reduced the leak rate. We also anticipate sleeve patients with a staple line leak would need longer in hospital than bypass patients experiencing a leak.

Staple line leakage in sleeve patients remains the complication that causes most concern as it can be difficult to seal and the recovery time can be very long. We think that it continues to be more realistic for patients to consider a higher leak rate for band to sleeve than for band to bypass. 

Before proceeding with a band to sleeve procedure you should ensure that you understand the leak risk and the implications if you experience one. Your surgeon will be able to explain this to you in detail, including the treatments used to manage a patient who experiences a leak. This will vary from surgeon to surgeon.

As for weight loss however, you can assume a similar outcome as for bypass. You may also prefer the sleeve as it does not require dissection of the bowel and you can assume a lower risk of micro-nutrient malabsorption than with the bypass.

In summary, there are pro’s and con’s for band to sleeve and band to bypass. We’ll be happy to discuss those with you at consultation and on the telephone beforehand.

External Links

If you would like to learn more, you can view the study called: Systematic Review and Meta-Analysis of Outcomes After Revisional Bariatric Surgery Following a Failed Adjustable Gastric Band. Click here.

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*Weight loss surgery results and benefits vary and are different for each individual. As such, Healthier Weight cannot guarantee specific weight loss goals.