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Bariatric surgical procedures are now well established as effective in achieving major weight loss in the severely obese. In particular, gastric stapling procedures have been in common usage now for over 35 years and considerable data on their benefits and their hazards are now available. They are highly effective in achieving strong weight loss in the first 2 years after operation and several systematic reviews have documented this impressive effect.1

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However, there are failures. There are patients who fail to lose sufficient weight to solve the problems caused by their obesity. There are patients who have an initial successful outcome only to find there is a progressive regain of weight after 2 or 3 years. And there are patients who suffer side effects and complications of the gastric stapling procedure that leads to the need for its reversal or revision.

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In this chapter we look at the prevalence of failed gastric stapling, including gastric bypass and gastroplasty and the option of conversion to laparoscopic adjustable gastric banding (LAGB). We will review the appropriate selection of patients and their preoperative assessment, review the surgical options for these patients, and seek to determine what is a realistic expectation of outcomes.

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Gastric bypass is commonly regarded as the most effective form of gastric stapling and yet nearly 50% of the RYGBP patients will have lost less than 50% of the excess weight at 5 years after surgery. In a systematic review which looked at the medium-term (3–10 years) outcomes after all current bariatric procedures, the published reports of RYGBP patients showed mean excess weight loss of 58%, 45%, 55%, and 53% at 5, 6, 7, and 10 years after surgery. The patient doing poorly is most likely to cease attending follow-up clinics and generally by 5 years less than 50% of patients are still attending follow-up. Rarely do published reports gave figures for loss to follow-up. The true %EWL for all patients is therefore almost certainly below the published figures.

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Multiple randomized controlled trials have shown that gastroplasty patients do less well than do RYGBP patients2,3 and this group of operations is now becoming of historic interest only. Nevertheless, there are many tens of thousands of patients who were treated by gastroplasty in the 1980s and 1990s and who are now seeking relief of their symptoms of maladaptive eating or better weight loss or both. It could therefore be estimated that, on the basis of 30,000 bariatric procedures in the United States alone per year during the last two decades of the twentieth century and an expectation of less than 50% of them have achieved loss of half of their excess weight, there are likely to be 300,000 patients from that era in that country alone who would benefit by better weight loss.

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However, the principal reason for revisional surgery is not failure of weight loss but the presence of complications. ...

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