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PROSS outcomes: Re-redo bariatric surgery is effective but carries significant risk of complications

Although Re-redo bariatric surgery is an effective treatment for obesity it carries a significant risk of complications, according to the outcomes from the multi-centre Polish Revision Obesity Surgery Study (PROSS).

Figure 1: Changes in patients’ BMI

The study authors stated that approximately 7% of all bariatric procedures are revisional and in the US, it is the third most common type of bariatric surgery. The most common reasons for revisional surgery include weight regain, inadequate weight loss and the need to control obesity-associated diseases, as well as less frequent factors such as gastroesophageal reflux disease (GERD), marginal ulcers, malnourishment and fistulas.

The complication rates associated with bariatric surgery range from 10 to 17%. However, with a higher risk of complications and a scarcity of general guidelines, it is never an easy decision to qualify a patient for a third or subsequent bariatric operation. The aim of this study was to evaluate patients who underwent re-redo bariatric surgery in terms of weight loss effectiveness and complications from 12 referral bariatric centres in Poland.

The study 20 patients (13 females) who underwent elective re-redo bariatric surgery because of weight regain or insufficient weight loss. The mean maximal BMI in the past was 49.4kg/m2 and the mean BMI before primary bariatric procedure (PBS) was 47.5 kg/m2. Type 2 diabetes (T2D) was present in 7/20 patients (35%) and 13/20 patients (65%) had hypertension (HT). The median time interval between PBS and Redo treatments was four (2–6.5) years, and the median time interval between Redo and Re-Redo surgery was three (1–4.5) years. The mean follow-up after Re-Redo surgery was 35.3 months. Compared with Redo group, Re-Redo patients were more likely to have hypertension.

Regarding their initial procedures, 16 patients had adjustable gastric banding (AGB), three had sleeve gastrectomy (SG) and one patient had Mason’s vertical banded gastroplasty. For their Redo surgery patients underwent SG (seven patients), Roux-en-Y gastric bypass (RYGB) (four), re-sleeve gastrectomy (three), replacement of adjustable gastric band (three) and gastric band removal (three).

Re-redo bariatric surgery included SG (six), RYGB (five), OAGB (three) and single anastomosis sleeve-ileal bypass (SASI) (two). The following procedures were performed only once: biliopancreatic diversion with duodenal switch (BPD-DS), AGB after RYGB, biliopancreatic limb lengthening after RYGB, gastrojejunal re-anastomosis with biliopancreatic limb lengthening after RYGB.

Among the reasons for Redo surgery were insufficient weight loss i.e. < 50% excess weight loss (EWL) (six patients), weight regain (four) and band slippage and/or erosion (ten). Of these patients, 15 underwent Re-Redo surgery because of weight regain and five due to insufficient weight loss < 50% EWL.

The mean percentages of excess body mass index loss (%EBMIL) were consecutively: 62.0±32.7% after PBS, 38.3±23.1% before re-redo, and 72.1 ± 20.8% after re-redo surgery. The mean percentage of total weight loss (%TWL) were: 29.5±16.3% after PBS, 19.5±13.8% before re-redo and 34.2±11.1% after re-redo surgery. %TWL and %EBMIL regarding BMI before and after re-redo was 17.4±12.4% and 51.6±35.9% consecutively (Figure 1).

The mean BMI before redo surgery was 40.0±8.7kg/m2. The mean BMI before re-redo surgery was 38.8±4.9kg/m2. The mean final BMI after re-redo was 31.9±5.3 kg/m2. Complications after Re-Redo surgery occurred in three of 20 patients (15%). None of them required further surgical intervention. Among these complications were:

  • Vomiting more than once a week a patient who had SG as PBS, reSG as Redo because of weight regain and OAGB as Re-Redo because of insufficient weight loss (< 50%EWL).

  • Esophagitis and nutritional deficiencies a patient who had AGB as PBS, band removal with simultaneous SG as Redo because of gastric band intolerance (nausea, pain after eating) and RYGB as Re-Redo because of weight regain and also GERD.

  • Persistent abdominal pain complaints, episode of biliary colic, GERD a patient who had AGB as PBS, gastric band removal as Redo because of band dysfunction along with GERD-associated symptoms and SG as Re-Redo because of weight regain.

From our group, five of 20 patients experienced complications after the first redo surgery. This is a similar complication rate compared to all the patients who underwent redo surgery included in PROSS, which was 27.8% (222/799); the most common complications included GERD - 117 (14.64%) patients, followed by vomiting in 42 (5.26%) cases, band malfunction in 20 (2.5%) patients, gastrointestinal obstruction in 20 (2.5%) patients, malnutrition in nine (1.12%) patients, gastrointestinal leakage in five (0.63%) patients and anaemia in four (0.5%) patients.

“Re-redo bariatric surgery is an effective treatment that should be considered in patients with weight regain or unsatisfactory weight loss after previous bariatric surgeries, but it comes with a considerable risk of complications,” the authors conclude. “It's important to evaluate each patient on a case-by-case basis and not deny them assistance solely based on their previous bariatric treatment. Referral centers should be the optimal choice for performing re-redo bariatric surgery due to its higher complexity and the potential for complications.

The findings were featured in the paper, ‘The outcomes of Re-Redo bariatric surgery—results from multicenter Polish Revision Obesity Surgery Study (PROSS)’, published in Scientific Reports. To access this paper, please click here

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