Perioperative outcomes of revisional laparoscopic gastric bypass after failed adjustable gastric banding and after vertical banded gastroplasty: experience with 107 cases and subgroup analysis.

BACKGROUND: A growing number of revision procedures are to be expected in bariatric surgery after failed restrictive procedures such as failed adjustable gastric banding (AGB) or vertical banded gastroplasty (VBG). Conversion to revisional laparoscopic Roux-en-Y gastric bypass (ReLRYGBP) has been advocated as the procedure of choice. METHODS: The results of ReLRYGBP were reviewed in a retrospective chart review. A subgroup analysis compared perioperative results after VBG and after AGB. A second subgroup analysis compared perioperative results of ReLRYGBP immediately after AGB removal and after a delay as a two-step procedure. RESULTS: Between 2003 and 2009, ReLRYGBP was performed for 107 patients. Of these 107 operations, 21 were performed after failed VBG and 86 after failed AGB. The mean body mass index (BMI) was 42 kg/m(2). The causes of failure were mainly insufficient weight loss or reflux disease-related symptoms. During a median follow-up period of 44 months, there was no mortality, and morbidity was 34 %, including late complications. Major early complications occurred in 11 % of the cases (n = 12). Conversions and major early complications occurred significantly more frequently after VBG than after AGB (p < 0.05). In 59 % of the cases (n = 50), ReLRYGBP was performed as a single-stage procedure immediately after removal of AGB and in 41 % of the cases (n = 36) as a delayed two-step procedure. The outcomes did not differ significantly (p > 0.5). CONCLUSIONS: The perioperative outcomes of ReLRYGBP are worse after VBG than after AGB. The ReLRYGBP operation can be performed safely as a one-step procedure after AGB removal.

Management of the 'normal' appendix during surgery for right fossa syndrome: proposed clinical algorithm.

The management of the normal appearing appendix during laparoscopy for right fossa syndrome remains a matter of debate when no other cause is found. Recent data suggest that the appendix modulates both the normal brain-gut axis and the pathophysiology of inflammatory bowel disease by neuro-immunological pathways. Recurrence of symptoms caused by acute appendicitis is uncommon when the appendix is left in place. The decision to remove a normal appendix should therefore not be taken lightly, but after consideration of the patient's age, medical history and expectations as well as the timing and specificity of the presenting symptoms. An overview of the relevant literature is provided with an algorithm to aid in clinical decision making.