FROM COMPLEX EVOLVING TO SIMPLE: CURRENT REVISIONAL AND ENDOSCOPIC PROCEDURES FOLLOWING BARIATRIC SURGERY

Abstract

Background: Roux-en-Y gastric bypass (RYGB) is a standard therapy in bariatric surgery. Sleeve gastrectomy and gastric banding, although with good results in the literature, are showing higher rates of treatment failure to reduce obesity-associated morbidity and body weight. Other problems after bariatric may occur, as band erosion, gastroesophageal reflux disease and might be refractory to medication. Therefore, a laparoscopic conversion to a RYGB can be an effective alternative, as long as specific indications for revision are fulfilled.

Objective: The objective of this study was to analyse own and literature data on revisional bariatric procedures to evaluate best alternatives to current practice.

Methods: Institutional experience and systematic review from the literature on revisional bariatric surgery.

Results: Endoscopic procedures are recently applied to ameliorate failure and complications of bariatric procedures. Therapy failure following RYGB occurs in up to 20%. Transoral outlet reduction is currently an alternative method to reduce the gastrojejunal anastomosis. The diameter and volume of sleeve gastrectomy can enlarge as well, which can be reduced by endoscopic full-thickness sutures longitudinally. Dumping syndrome and severe hypoglycemic episodes (neuroglycopenia) can be present in patients following RYGB. The hypoglycemic episodes have to be evaluated and usually can be treated conventionally. To avoid partial pancreatectomy or conversion to normal anatomy, a new laparoscopic approach with remnant gastric resection and jejunal interposition can be applied in non-responders alternatively. Hypoglycemic episodes are ameliorated while weight loss is sustained.

Conclusion: Revisional and endoscopic procedures following bariatric surgery in patients with collateral symptomatic or treatment failure can be applied. Conventional non-surgical approaches should have been applied intensively before a revisional surgery will be indicated. Former complex surgical revisional procedures are evolving to less complicated endoscopic solutions.

FIGURE 1. Conversion from laparoscopic sleeve gastrectomy (LSG) to RYGB: A) schematic illustration of the conversion where LSG is cut horizontally with a linear stapler, preserving the blood vessels and, in some cases, reduction of the pouch is indicated, for dilated sleeves; B) linear stapler is set horizontally to delineate the pouch formal RYGB is performed; C) the afferent loop of the performed gastrojejunal anastomosis is cut by a linear stapler to form the Y-Roux.

FIGURE 2. Conversion of a laparoscopic adjustable gastric band to RYGB: A) schematic illustration of the conversion where the linear stapler is set proximally to the scarred tissue of the former band, when possible; B) adhesions and scars to gastric wall are solved; C) the pouch is performed through a horizontal and a vertical stapler, and formal RYGB is performed.

FIGURE 3. Conversion from vertical stapled gastroplasty (Mason) to Roux-en-Y-gastric bypass: A) schematic illustration of the conversion with the stapling line to perform the pouch is horizontally set, without crossing the previous vertical gastroplasty; B) adhesions in the region of the gastroplasty are solved, to identify the ring, a 45 mm stapler is set horizontally and a further stapler (60 mm) is also set vertically (medial or at the Mason gastroplasty) to allow distal flow, if the former pouch is not resected; the ring can be or not extracted, depending on the position of the new pouch; C) construction of the pouch using 45 stapler and the pouch is anastomosed to the alimentary limb, and a formal RYGB is performed.

FIGURE 4. Conversion from RYGB to jejunal interposition with subtotal gastrectomy - Branco switch: A) schematic illustration of the conversion for therapy of severe hypoglycemia after RYGB; the primary objective is transforming the RYGB and restoring the continuity to the duodenum through a jejunal interposition and subtotal gastrectomy; B) performing a pylorus-preserving gastrectomy at 2-4 cm of remaining antrum and, finally, the alimentary limb is resected at 20 cm from the gastrojejunal anastomosis till the Y-Roux anastomosis; C) the 20 cm remaining alimentary limb becomes a handsewn anastomosis to the rest of the antrum and the Y-Roux is closed by a stapler to finalize the resection of the alimentary limb.

FIGURE 5. Endoscopic revision of RYGB: A) the transoral reduction of the gastrojejunal anastomose after RYGB (transoral outlet reduction/TORE) is performed endoscopically, using a special full-thickness suture device (Apollo Overstich(r), Austin, TX, USA); B) a special overtube is inserted to prevent esophageal damage; C) the enlarged gastrojejunal anastomosis (around 5 cm) is prepared for sutures using Argon beamer; D) the dilated outlet anastomosis is effectively reduced to less than 9 mm through Overstich(r) sutures.

FIGURE 6. Endoscopic sleeve gastroplasty (ESG): A) novel indications for primary endoscopic sleeve gastroplication, as a first step in high risk patients for preparation for a surgical second step in 9-12 months; BMI=72 (315 kg) with respiratory insufficiency and tracheostomy; B) as a primary procedure in patients with giant hernia and adhesions; in this patient, laparoscopic SG was aborted due to adhesions, and ESG was indicated; C) the performance of ESG as a primary bariatric procedure is set through consecutive full-thickness sutures from the incisura angularis to proximal; the sutures are interrupted, so the gastric secretion and food can have free transit between the gastroplasty; D) postinterventional radiologic study after ESG.