LOS ANGELES – Revisional surgery after failed adjustable gastric banding (AGB) is associated with an increased risk of adverse events and resource utilization, according to Dr. Steven Poplawski, medical director for Barix Clinics in Ypsilanti, Mich.
His conclusion is based on safety outcomes at 30 days for 55,237 patients who underwent primary bariatric surgery and 1,417 patients who underwent AGB revision between June 2006 and July 2015 in the Michigan Bariatric Surgery Collaborative. Patients were excluded from the retrospective evaluation if they had urgent/emergent procedures or more than one previous bariatric operation.
Dr. Steven Poplawski
The primary bariatric surgery was Roux-en-Y gastric bypass (RYGB) in 43%, sleeve gastrectomy in 37%, AGB in 19%, and biliopancreatic diversion with duodenal switch (BPD/DS) in 1%.
The patients turned to AGB revision for the same reasons that have prompted its dramatic decline in utilization: weight loss failure (38%), band complications (33%), or both (29%). AGB revisional procedures were sleeve gastrectomy in 54%, RYGB in 35%, AGB in 9%, and BPD/DS in 2%.
Patients undergoing band-to-RYGB conversions had significantly more serious complications, compared with primary RYGB procedures (10.2% vs. 4.4%; P less than .0001), reoperations (5.1% vs. 2.3%; P = .0001), and hospital readmissions (10% vs. 7.3%; P = .0064), and a nonsignificant trend toward more leaks (1.3% vs. 0.7%; P = .13), Dr. Poplawski reported.
Patients undergoing band-to-sleeve conversions had significantly more serious complications when compared with primary sleeve gastrectomy (5% vs. 1.8%; P less than .0001), reoperations (3.3% vs. 1%; P less than .0001), and leaks (1.5% vs. 0.5%; P = .0001), and a nonsignificant trend toward more readmissions (7.7% vs. 4.6%; P = .0685).
Outcomes were not reported for the smaller number of patients undergoing AGB-to-AGB or AGB-to-BPD/DS conversions.
A secondary analysis was performed examining a one-stage versus a two-stage procedure in 525 patients undergoing revisional surgery for weight loss failure only. The only safety outcome to show a significant difference at 30 days was hospital readmissions in the RYGB-conversion group, favoring the one-stage over the two-stage procedure (7.1% vs. 11.5%; P = .0164).
“Clearly, the benefit of a one-stage procedure versus a two-stage procedure is unclear in the way it was studied here,” Dr. Poplawski said at Obesity Week 2015, presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
“You can read in some reports that [surgeons] do all [of these procedures as] two-stage because they think it’s safer, but I don’t know that there’s much support for that here. I think it’s reasonable to get most of them done in one stage because there’s also two hospitalizations, two periods of convalescence, and when we talk about the complications of the two-stage operation we aren’t even including the costs to remove the initial band, which are not insignificant,” he noted.
Dr. Raul Rosenthal of the Cleveland Clinic in Weston, Fla., who comoderated the session, said the takeaway message is that “reoperative surgery pays a price. No matter how you look at it, one stage, two stages, with bands or sleeve, you’re going to get in trouble.”