Medium-term outcomes of converting laparoscopic adjustable gastric band to Roux-en-Y gastric bypass in patients with body mass index <35 kg/m2: a uniquely Australian perspective.

BACKGROUND: The rates of primary laparoscopic adjustable gastric banding (LAGB) have declined in the last 5 years due to band removal secondary to complications and the subsequent weight regain that requires revisional procedures. OBJECTIVES: This study aimed to present medium-term weight loss results and the safety profile of converting LAGB to Roux-en-Y gastric bypass in patients with body mass index (BMI) <35.0 kg/m2 who presented with LAGB intolerance or complications. Many health services do not permit such procedures on low BMI patients. SETTINGS: Single-surgeon series, including public and private practice, Brisbane, Australia. METHOD: A prospectively maintained database was reviewed and retrospectively analyzed for LAGB patients with a BMI <35.0 kg/m2 who underwent conversion to Roux-en-Y gastric bypass by a single surgeon. Indications for conversion, weight loss data, and early (30 d postoperative) and late complications were recorded with follow-up out to 5 years. RESULTS: One hundred thirty-two adult patients with a BMI <35.0 kg/m2 underwent conversion from 2009 to 2016. The main indications for conversion were reflux and band complications. Median BMI at bypass was 32.8 kg/m2 (23.1-35.0). Median percentage excess weight loss was 77%, 90%, 73%, 47%, 49%, and 44% at 1, 2, 3, 4, and 5 years, respectively among patients who were eligible and present at follow-up. Median BMI was <30.0 kg/m2 (29.1-40.9) at 5 years with only 1 subject exceeding >35.0 kg/m2. Mortality was 0%. Early morbidity occurred in 31.8% of patients. The most common late complication was gastrojejunostomy stricture requiring endoscopic dilation. CONCLUSIONS: In combination with our 2014 study showing morbidity data in the short-term period being comparable to patients with BMI >35.0 kg/m2, our study demonstrates that converting LABG to Roux-en-Y gastric bypass in low BMI patients is a feasible and safe option that avoids weight regain and maintains adequate weight loss at 5 years, with acceptable morbidity and no mortality.

A 12-Month Review of Revisional Single Anastomosis Gastric Bypass for Complicated Laparoscopic Adjustable Gastric Banding for Body Mass Index over 35.

BACKGROUND: In many countries, laparoscopic adjustable gastric banding (LAGB) was previously the most commonly performed bariatric procedure due to its operative safety and early efficacy. This procedure is now superseded because of doubtful long-term results and late complications. Many people eventually required revisional bariatric surgery such as conversion to single anastomosis gastric bypass (SAGB). This study aims to assess the safety and durability of single-stage conversion from LAGB to SAGB in patients who are intolerant to LAGB and who also fail to lose weight, or re-gain weight. METHODS: Seventy-four patients with BMI > 35 kg m-2 were selected from a prospective bariatric database between July 2012 and December 2015 for revisional laparoscopic SAGB surgery and were followed up at 6 weeks, 3, 6 and 12 months after their operation. RESULTS: The mean BMI at 6 weeks, then 3, 6 and 12 months were 41.6 ± 7.66, 38.8 ± 7.54, 35.4 ± 7.10 and 33.2 ± 7.34 kg m-2, respectively. The mean percentage EWL at 6 weeks then 3, 6 and 12 months were 21.0 ± 9.12, 37.8 ± 12.5, 55.1 ± 15.8 and 67.0 ± 19.6%, respectively. Postoperative follow-up at these times were 97, 85, 69 and 46%, respectively. Early (< 30 day) morbidity was 20.3% with major complications of CD grade 3a or more of 13.5%. CONCLUSIONS: This study demonstrates that single-stage revisional SAGB after a failed LAGB achieved good short-term weight loss and low 30-day morbidity.

Laparoscopic adjustable gastric band revisional surgery: a single surgeon series.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is a safe and proven surgical option for morbid obesity; however, the need for revisional surgery is being increasingly reported. This study reports outcomes and incidence for a large cohort of patients requiring revisional LAGB surgery for various indications. METHODS: A retrospective review of prospectively collected data for 1524 primary LAGB placed between 2003 and 2013 by a single surgeon at a single institution was performed, analysing data for all patients in this cohort requiring revisional LAGB surgery. RESULTS: A total of 434 revisions were performed on 349 patients. A total of 278 patients had a single revision, with 71 patients having two or more revisions. Revisions amounting to 213 were band repositions, 68 were band removal only and 153 were band removal with conversion to another bariatric procedure, mostly Roux-en-Y gastric bypass (n = 143). A total of 47 (35.1%) 'band-to-band' revision patients were lost to follow-up. Patients undergoing 'band-to-band' revision for a slipped band, patient intolerance and mechanical band failure had mean excess weight loss (EWL) at 4 years of 49.9% (n = 35), 38.6% (n = 10) and 67.4% (n = 6), respectively. Port or tubing revisions were not included. Mean follow-up for 'band-to-band' revision patients was 33.4 months (standard deviation 26.4 months). 22.9% of patients required one or more band revision procedures by 2013, increased from 13% in 2008. CONCLUSION: Continued EWL is achieved with repositioning or replacement of a LAGB. However, a significant and increasing rate of re-operation over time exists.

Roux-en-Y gastric bypass after successful weight loss with a laparoscopic adjustable gastric band: rationales and early outcomes in patients of body mass index<35 kg/m(2.).

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has a number of well-established acute and chronic issues that can require revisional surgical procedures. There is no existing data to evaluate conversion of band patients with body mass index (BMI)<35 kg/m(2) from LAGB to a Roux-en-Y gastric bypass (RYGB). This study aims to report on the indications for and the safety profile of conversion of the LAGB to RYGB in patients with BMI<35 kg/m(2). METHODS: A review of data from 200 consecutive conversions of LAGB to RYGB was conducted. Fifty-two patients whose BMI was<35 kg/m(2) were included in this analysis. Indications for conversion, technical details, early morbidity, length of hospital stay, and weight loss data were assessed. RESULTS: Laparoscopic conversion to RYGB was performed in 100% of patients. The median BMI pre-RYGB was 32.8 kg/m(2). The most common indication for surgery was weight regain after removal of LAGB (28.8%). There was no mortality. Early morbidity was seen in 25% of patients; the most common complication was stricture of the gastrojejunal anastomosis (9 patients). CONCLUSION: Morbidity resulting from conversion of LAGB to RYGB in patients with BMI <35 kg/m(2) is similar to that seen in the BMI>35 kg/m(2) population. The procedure is technically challenging and morbidity rates are higher than those reported for surgically 'naïve' patients. It is recommended that this procedure be undertaken by appropriately trained surgeons in high-volume bariatric centers to optimize safety and outcomes.

Efficacy and safety of active negative pressure peritoneal therapy for reducing the systemic inflammatory response after damage control laparotomy (the Intra-peritoneal Vacuum Trial): study protocol for a randomized controlled trial.

BACKGROUND: Damage control laparotomy, or abbreviated initial laparotomy followed by temporary abdominal closure (TAC), intensive care unit resuscitation, and planned re-laparotomy, is frequently used to manage intra-abdominal bleeding and contamination among critically ill or injured adults. Animal data suggest that TAC techniques that employ negative pressure to the peritoneal cavity may reduce the systemic inflammatory response and associated organ injury. The primary objective of this study is to determine if use of a TAC dressing that affords active negative pressure peritoneal therapy, the ABThera Open Abdomen Negative Pressure Therapy System, reduces the extent of the systemic inflammatory response after damage control laparotomy for intra-abdominal sepsis or injury as compared to a commonly used TAC method that provides potentially less efficient peritoneal negative pressure, the Barker's vacuum pack. METHODS/DESIGN: The Intra-peritoneal Vacuum Trial will be a single-center, randomized controlled trial. Adults will be intraoperatively allocated to TAC with either the ABThera or Barker's vacuum pack after the decision has been made by the attending surgeon to perform a damage control laparotomy. The study will use variable block size randomization. On study days 1, 2, 3, 7, and 28, blood will be collected. Whenever possible, peritoneal fluid will also be collected at these time points from the patient's abdomen or TAC device. Luminex technology will be used to quantify the concentrations of 65 mediators relevant to the inflammatory response in peritoneal fluid and plasma. The primary endpoint is the difference in the plasma concentration of the pro-inflammatory cytokine IL-6 at 24 and 48 h after TAC dressing application. Secondary endpoints include the differential effects of these dressings on the systemic concentration of other pro-inflammatory cytokines, collective peritoneal and systemic inflammatory mediator profiles, postoperative fluid balance, intra-abdominal pressure, and several patient-important outcomes, including organ dysfunction measures and mortality. DISCUSSION: Results from this study will improve understanding of the effect of active negative pressure peritoneal therapy after damage control laparotomy on the inflammatory response. It will also gather necessary pilot information needed to inform design of a multicenter trial comparing clinical outcomes among patients randomized to TAC with the ABThera versus Barker's vacuum pack. TRIAL REGISTRATION: ClinicalTrials.gov identifier http://www.clicaltrials.gov/ct2/show/NCT01355094.