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The main aim of this study is to analyze and report the intermediate term outcomes after laparoscopic revision Roux-en-Y gastric bypass (RYGB) surgery for failed and/or complicated Vertical Banded Gastroplasty (VBG). The foremost outcome measurements are 1) Fat loss mainly measured as weight loss and expressed as trends in BMI, %EWL, and/or %EBL. 2) Trend in Comorbidity status. 3) Subjective Satisfaction and Health-Related Quality of Life "HR-QoL" are measured by a standardized, non-validated satisfaction questionnaire and by a validated, disease-specific worldwide used HR-QoL questionnaire. 4) Morbidity & Mortality include nutritional status and metabolic complications.
Consequently, secondary objectives of this study are the following. 1) To assess failure rate defined as percentage of excess weight loss < 50%, lowest BMI >35 for morbidly obese (MO) or >40 for superobese (SO), and/or lack of resolution/improvement of major comorbidities at the point in time when assessed at each postoperative year after the surgery under study. 2) To evaluate the metabolic and nutritional status by measurements of particular clinical and biochemical parameters.
Full description
There is no real standardization for any of the previously stated "modern standard bariatric procedures" endorse by the ASMBS; thus, outcomes vary widely with each one of them. For purposes of this study, the term Vertical Banded Gastroplasty (VBG) is used to encompass several types of vertical gastroplasties with a reinforced stoma such as nondivided vertical banded gastroplasty, nondivided vertical ringed gastroplasty, transected or divided vertical ringed or banded gastroplasties among others. VBG, in various forms, was used extensively for more than 2 decades after its original description by Mason in 198217. Designed to avoid the long-term nutritional implications and complexity of gastric bypass, VBG evolved and permitted us to infer some mechanism of failure and modify other bariatric procedures. Regardless of a laparoscopic approach, VBG is no longer a viable option for the treatment of morbid obesity because of less overall weight loss, high failure and late complication rates.
The following are the main investigators that have addressed diverse revisional strategies including restoration or conversion of VBG into a modern bariatric procedure, either by open or laparoscopic approach, because of failure and/or technical complications:
I. Open approach. Most of the scientific literature available on redo bariatric surgery is based on open surgery series. There is no consensus on what type of revisional procedure is the best; however, there are several options available.
A) Restoration or re-VBG is no longer a viable option.
B) Other revisional option is adjustable gastric band (AGB).
C) Other recently added strategy to the revisional armamentarium is Sleeve Gastrectomy (SG). Iannelli et al in 2009 published the analysis of 41 patients undergoing revisional SG for failed AGB (n=36) or VBG (n=5). No subset analysis was provided however postoperative morbidity was 12.2%; at a mean of 13.4 months, mean BMI, %EWL, and %EBL were 42.7%, 42.7%, 47.4% respectively; and re-operation rate for failure was 14.6% (n=6).
D) Another reported revisional procedure is Biliopancreatic Diversion with Duodenal Switch (BPD-DS).
E) However, most published studies about revisional surgery for failed or complicated VBG support RYGB as a revisional procedure. Previously some investigators have shown the RYGB superiority over VBG. Specifically, RYGB has more overall weight loss, less late complications and less revision rates than VBG.
Therefore, based on all this observational studies, the open conversion of VBG to RYGB has been demonstrated to be an effective procedure with defined complications.
II. Laparoscopic Approach. Increasing experience with minimally invasive bariatric surgery has prompted surgeons to approach most revisions procedures laparoscopically.
A) Because most published studies about open revisional surgery for failed and/or complicated VBG support RYGB as the revisional procedure of choice, most laparoscopic bariatric surgeons follow this principle.
Summarizing, there is lack of standardization of primary and revisional bariatric surgery compounded by a scant long-term outcome data. The treatment of inadequate weight loss, weight recidivism, and most severe technical complications after primary bariatric surgery remains refractory to non-operative treatment. Failure and secondary revisional rates after VBG can be as high as 56% and 68%, respectively. Indication for further surgical intervention remains controversial, as does what type of procedure to recommend but the most widely documented and with best risk-benefit ratio option is RYGB. After extensive literature search, there is no outcome study employing a laparoscopic revisional strategy with a HSA reporting outcomes comparable to primary gastric bypass in an unselected obese population. Thus, we formally analyze our experience with the laparoscopic approach to these complex and challenging patients.
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