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LSG failure

What to do when the sleeve fails?

Failure linked to BMI and age
single-anastomosis duodeno-ileal bypass with sleeve gastrectomy as effective as RYGB
Andrés Sánchez-Pernaute

Safe, effective and durable are words often associated with laparoscopic sleeve gastrectomy. However, when the procedure does fail, what can a surgeon do to rectify the situation.

According to Professor Andrés Sánchez-Pernaute, Hospital Clínico San Carlos, in Madrid, Spain, there are several options available for both obese and super-obese patients which result in adequate excess weight loss.

The Hospital Clínico San Carlos, in Madrid, Spain, currently performs approximately 150 bariatric procedures annually. The most common procedure is gastric bypass (around 60 cases per year), followed by biliopancreatic diversion with duodenal switch and sleeve gastrectomy (around 45 cases per year).

“Our indications for sleeve whether to perform a two-stage or stand-alone procedure are dependent on several factors including BMI, co-morbidities, age, weight loss, as well as considering medical or surgical considerations,” said Sánchez-Pernaute. “Approximately 50% of cases are stand-alone and 45% the first step of a two stage procedure. The remaining 5% cases are ‘run away’ cases, that is, cases in which intraoperative problems or findings indicate the performance of a sleeve gastrectomy.”

Failure

In regard to patient outcomes, the different results are explained by the heterogeneous population receiving treatment. For example, the re-operation rates for stand-alone procedures are 5%, compared with 27% for two-stage procedure.

“Operating on different patients and getting different results because of different failures, means we need to be able to offer different solutions,” Sánchez-Pernaute.

In his own institution, Sánchez-Pernaute explained that the key factors influencing weight loss is whether a patient’s BMI is over or under 50 and whether they are older or younger than 40.

Ten percent of sleeve patients fail who are under 40 years of age and have a  BMI under 50. However, 40% of sleeve patients fail if they are aged over 40 with a BMI over 50.

“The results show patients aged over 40 with a BMI over 50 could not be most appropriate population and the sleeve could be an insufficient operation. Therefore, we need to find another solution.”

Solutions

Sánchez-Pernaute said that as 36% of gastric bypass patients with a BMI over 50 fail to reach a 50% excess weight loss beyond five years, it is questionable to convert a failed sleeve into another procedure that is going to offer the same rate of failures as the sleeve. He questioned whether converting a failed sleeve into a gastric bypass is really an improvement over a re-sleeve or a plication.

Therefore, after sleeve failure in a patient with a BMI over 50, the procedure of choice is a malabsorptive procedure, such as the single-anastomosis (one loop) duodeno-ileal bypass with sleeve gastrectomy (SADI-S).

The procedure has previously obtained good results, however, would a one-loop DS (SADI) work similarly as a second step after a sleeve in a patient with an initial BMI over 50?

To answer the question, Sánchez-Pernaute and colleagues established a prospective, randomised clinical trial in which patients with BMI over 50 received initially a sleeve gastrectomy as a first step. If the patient’s weight stabilised or if they regained weight, they were randomised to receive a standard Roux-en-Y duodenal switch or SADI. The patient characteristics are shown in Table 1.

Gender

8 male, 9   female

Age

40 ys (20 -   68)

Initial   weight

165 kg (128   - 216)

Initial BMI

60.2 kg/m2   (53.4 - 76.1)

T2DM

4/17   (23.5%)

HTA

11/17 (65%)

Table 1: Patient characteristics

At a mean follow-up of 18 months, the results of the sleeve showed a mean weight of 122kg (94-183) and a mean BMI of 44 (36-54). The outcomes following standard Roux-en-Y duodenal switch or SADI are shown in Table 2.

 

DS

SADI

p

Initial BMI

57

63

0.04

Min. BMI   Sleeve

41

48

0.01

% pts >   50% EWL

50%

28%

0.3

% pts BMI   > 40

14%

62%

0.05

Mean op   time

230m

138m

0.007

Table 2: Patient characteristics at the second step

There were no intraoperative or postoperative complications in any of the groups

With regards to excess weight loss (%), no significant differences were observed between both groups. Excess weight loss (%) is shown in Table 3.

Time

DS

SADI

p

3 months

54

52

0.8

6 months

66

62

0.6

9 months

74

67

0.4

12 months

82

74

0.3

18 months

85

77

0.3

24 months

80

71

0.4

% of WL

52

52.6

 

Table 3: Excess weight loss (%)

Conclusion

In conclusion, he said that biliopancreatic diversion is an adequate operation in the super-morbid patient after a failed sleeve gastrectomy, and a single-anastomosis duodeno-ileal bypass is at least as effective as standard Roux-en-Y duodenal switch as a second step in the super-morbid patient.

“When the sleeve fails in the younger and less heavy patients, we suggest to re-sleeve or plicate, but for the heavier patient, divert the duodenum in one loop.”

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