Ben Amor, Imed

Debs, Tarek

Gugenheim, Jean

Kassir, Radwan

Kassir, Rani

Lointier, Patrice

Petrucciani, Niccolo

Tiffet, Olivier

English

Archivio della ricerca- Università di Roma La Sapienza

lable at ScienceDirectInternational Journal of Surgery 44 (2017) 7e8Contents lists avaiInternational Journal of Surgeryjournal homepage: www.journal-surgery.netLetter to the EditorRevision bariatric surgery: What technical choices should be takendepending on the first intervention?Keywords:Bariatric surgeryRevision bariatric surgerySleeve gastrectomyLaparoscopic roux-en y gastric bypassGastric bandinghttp://dx.doi.org/10.1016/j.ijsu.2017.05.0751743-9191/© 2017 IJS Publishing Group Ltd. Publishedis impweighDear Sir,Surgical reinterventions in general should be considered in pa-tients after bariatric surgery because of weight gain or because ofa defective surgical act which causes clinical problems such aseating disorders like diarrhea or vomiting, GERD, refractory anasto-motic ulcers, malnutrition or vitamin deficiency [1].The following points are important to consider in surgicalreintervention:(1) It is important to inform these patients that a secondaryinterventional surgery is more dangerous than the initial actand it can expose the patient to more morbidity, and evenmortality [2]. This specific information should be clearlystated in the consent form and it should also be stated in thereply letter to the referring doctor of the patient. Care shouldbe taken not to be too optimistic about the results of theretreatment as the surgeon can be blamed for bad outcomes.(2) A psychiatric consultation is crucial.Obesity is a chronic disease in which weight gain is inevitable insome patients. The eating behavior of the patient should beanalyzed. Excessive obesity can be a “suffering”. A carefulassessment should be made on the “Weight Efficacy” of a pa-tient, and excessive body weight can have harmful effects on co-morbidities and repercussions on the daily life of a patient.Some patients may have experienced sexual harassments andmay even have suicidal ideas. It is not uncommon that obesepatients beg surgeons to operate on them again, and promise tolose weight. Any further intervention should be carefully dis-cussed with the patient or else the patient my regain bodyweight again rapidly.(3) Realistic expectations in obesity surgery.In deciding on a re-intervention, it is important to take intoconsideration the initial BMI, the current BMI before and thetargeted BMI of the patient after re-intervention. It is necessaryto assess precariously the risk/benefit ratio of the surgery. Amultidisciplinary patient care program should be established. Itby Elsevier Ltd. All rights reserveortant not to rush into surgery and the real cause of thet gain should be clarified.(4) Should technical choice of re-intervention be dependent onthe first intervention?Following is the discussion on the choice between restrictiveintervention or mixed secondary intervention:[A] Sleeve Gastrectomy or Gastric Bypass after failed GastricBanding.d.According to the Expert Consensus, either of these twotechniques can be chosen. During the reoperation, the gastricband should be ablated.In special cases of intragastric migration of gastric bands,penetration of the band into the stomach lining happens in0.1e15% of patients within an average of 43 months. This canoften be asymptomatic but weight gain can be alarming. Thedepths of penetration of the band should be assessed usingesophagogastroduodenoscopy. Sometimes a deeply pene-trated band can be taken off by a gastroenterologist.Surgery is not urgent. It is often required and it should bedone laparoscopically. The closing system of the band shouldbe studied before the surgery, and it is often found under theliver. The ‘patch’ band should be ablated under the hole ofpenetration in the stomach. It is advisable to use a contactdrain and not to use a Kehr drain because of development ofa direct fistulation. To grab and to remove the band, a shortgastrotomy should be carried out in a healthy gastric area.The band should be removed without touching the inflam-matory area around the gastric band which serves as aforeign body.Ablation of the band inevitably results in body weight gainand a secondary interventional surgery should be recom-mended to follow.Gastric bypass is the intervention of choice but sometimes apartial gastrectomy is necessary. The post-operative out-comes are better if explantation of the band and the redosurgery is done in a single operation. This results in lessmorbidity, a shorter recovery period with the same expec-tation in achieving weight loss.A two-phase surgery should be carried out in patients withintragastric migration of a gastric band because of fibrosisand inflammation which do not allow the creation of anadequate gastric pocket and because of a high risk offistulation.It is important not to be too optimistic about the outcomes ofthe second surgery. Surgeons can usually only achieve thelowest body weight of the patient after the first surgery, butno better.Letter to the Editor / International Journal of Surgery 44 (2017) 7e88[B] Conversion of sleeve gastrectomy in gastric bypass or theuse of biliopancreatic diversion.Any weight gain after sleeve gastrectomy is the result of aninitial technical error in making the gastroplasty. A failedsleeve gastrectomy can be defined if the weight loss is lessthan 50% after 18e24 months.In patients with antral dilatation, surgeons have to be carefulabout the possibility of gastric motor disability, i.e. gastro-paresis. The surgeons should be very careful and not tochoose resleeve gastrectomy when there is dilatation of thestomach. Recutting the stomach is technically not easy andcan result in complications like fistula, mid-gastric stenosis,or gastric torsion. Resleeve gastrectomy is useful in patientswith secondary GERD with a neofundus (i.e. with a lot ofgastric tissue left after the first operation next to the angle ofHIS). However, gastric bypass is the gold standard to convertsleeve gastrectomy in patients with severe GERD.In an obese patient with a BMI >50 kg/m2 and with weightgain after sleeve gastrectomy, it is preferable to do bil-iopancreatic diversion rather than gastric bypass. However, itis important to verify the technical aspect and the volumeleft after sleeve gastrectomy before the re-intervention.[C] Failure of Gastric Bypass.The principle is to increase the volume of the gastric re-striction. A gastroscan should be done to search for a dilatedgastric packet [3]. The diameter of the gastrojejunal anasto-mosis should be assessed. Good results are obtained whenthe diameter is less than 20 mm. Increasing the restriction tothe stomach can enhance dumping syndrome. Banding of thegastric bypass can be done but there is a risk of erosion intothe stapling line. It is preferable to implement a secondgastric band when the stapling line has healed. Finally, it istechnically possible to convert gastric bypass to sleevegastrectomy.Conflict of interestThe authors declare no conflict of interest.References[1] I.B. Amor, N. Petrucciani, R. Kassir, A. Al Munifi, T. Piche, T. Debs, J. Gugenheim,Laparoscopic conversion of one anastomosis gastric bypass to a standard Roux-en-y gastric bypass, Obes. Surg. 27 (5) (2017 May), 1398.[2] R. Kassir, P. Blanc, O. Tiffet, Laparoscopic conversion of an omega loop gastricbypass to Roux-en-y gastric bypass, Surg. Obes. Relat. Dis. 11 (4) (2015 Jul-Aug) 980e981.[3] P.K. Kowalewski, R. Olszewski, A.P. Kwiatkowski, K. Pasnik, Revisional bariatricsurgery after failed laparoscopic adjustable gastric banding - a single-center,long-term retrospective study, Wideochir Inne Tech. Maloinwazyjne 12 (1)(2017) 32e36.Radwan Kassir*Department of General Surgery, CHU Hospital, Jean MonnetUniversity, Saint Etienne, FrancePatrice LointierDepartment of Digestive Surgery, clinique de la Cha^taigneraie, 63110Beaumont, FranceOlivier TiffetDepartment of General Surgery, CHU Hospital, Jean MonnetUniversity, Saint Etienne, FranceTarek Debs, Niccolo PetruccianiDepartment of Bariatric Surgery, Hospital Archet 2, Nice, FranceRani KassirDepartment of Pediatric Surgery, CHU Felix Guyon, Saint Denis, Lareunion, FranceImed Ben Amor, Jean GugenheimDepartment of Bariatric Surgery, Hospital Archet 2, Nice, France* Corresponding author. Department of General Surgery, CHUHospital, Jean Monnet University, Avenue Albert Raimond, 42270Saint Etienne, France.E-mail address: Radwankassir42@hotmail.Fr (R. Kassir).19 May 2017Available online 7 June 2017

Revision bariatric surgery. What technical choices should be taken depending on the first intervention?

Radwan Kassir

Patrice Lointier

Olivier Tiffet

Tarek Debs

Niccolo Petrucciani

Rani Kassir

Imed Ben Amor

Jean Gugenheim

Crossref

International Journal of Surgery

Revision bariatric surgery: What technical choices should be taken depending on the first intervention?

https://iris.uniroma1.it/bitstream/11573/1018639/4/Kassir_Revision_2017.pdf

Revision bariatric surgery. What technical choices should be taken depending on the first intervention?

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