Need for bariatric revision varies by primary operation

By Reuters Staff

NEW YORK (Reuters Health) - 2/1/2019

Bariatric reoperations are more common after banding and vertical banded gastroplasty (VBG) than after gastric bypass (GBP), according to long-term follow-up of participants in the Swedish Obese Subjects (SOS) study.

"The 26 years of follow-up of the SOS may be a wakeup call regarding the choice of the primary operation," writes Dr. Richardo Cohen, from The Center for Obesity and Diabetes at Oswaldo Cruz German Hospital in Sao Paulo, Brazil, in an editorial published online with the study January 2 in JAMA Surgery.

The analysis by Dr. Stephan Hjorth of the University of Gothenburg and colleagues focused on 2,010 adults who underwent bariatric surgery, including 376 who had gastric banding (18.7%), 1,365 who had VBG (67.9%) and 266 who had GBP (13.2%).

Median follow-up time was 19 years. During this time, 559 patients (27.8%) underwent revisional surgery for the first time, including 354 conversions to other bariatric procedures (17.6%), 114 corrective surgeries (5.6%) and 91 reversals to normal anatomy (4.5%).

Most revisional surgeries (conversions, corrective surgery and reversals) happened in those who had banding (40.7%) or VBG (28.3%) as their index surgery. The revisional-surgery rate was only 7.5% with GBP as the primary surgery.

Patients who had banding and VBG primarily underwent conversion to GBP or reversal surgery.

Corrective surgery was equally common regardless of the index surgery, occurring in 5.3% of patients who had VBG, 6.1% of those had banding and 7.1% of those how had GBP.

The reasons for revisional surgery included inadequate weight loss, band-associated complications (migration, stenosis, and slippage), staple-line disruptions and postsurgical morbidity, and varied depending on the index surgery.

Most corrective surgeries occurred within the first 10 years, whereas conversions and reversals occurred over the entire follow-up period.

"A limitation of this study is that most of the index operations were done with techniques that are now largely abandoned (e.g., banding and VBG) in favor of GBP (and recently also gastric sleeve). This notwithstanding, the size of the study and the access to detailed, high-quality, high-resolution prospective data remains a strength for long-term outcome analysis," Dr. Hjorth and colleagues point out in their article.

"Although the SOS study started in the 1990s and operative techniques have evolved, it brings answers about bariatric revisional surgery and raises thoughts regarding choosing the best index bariatric procedure," Dr. Cohen adds in his editorial.

"One-anastomosis gastric bypass is gaining popularity throughout the world, but alkaline reflux is often disregarded as a complication that leads to high rates of revisions. Sleeve gastrectomy is widely performed, and the rate of reported revisions because of acid reflux and weight recidivism is growing. Revisional surgery carries a higher complication rate than the primary procedure, but if needed, it should not be denied. Maybe a wiser movement is to start with the right choice and curb the need for reoperations," concludes Dr. Cohen.

The study had no commercial funding and the authors have disclosed no conflicts of interest. Dr. Cohen reports grant support from Ethicon-JJ and serving on the scientific advisory board of GI Dynamics.

SOURCE: JAMA Surg 2019.

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