Revisional surgery – re-sleeve or gastric bypass?

Both laparoscopic re-sleeve gastrectomy (LRSG) and laparoscopic Roux-en-Y gastric bypass (rLRYGB) are safe and effective for the management of failed primary sleeve gastrectomy, according to researchers from the Kuwait University and Al Amiri Hospital, Kuwait City, Kuwait, who have reported five-year outcomes comparing the two revisional procedures. Although patients undergoing LRSG had better weight loss better earlier on, by five years the weight loss was similar. The findings were reported in the paper, ‘Midterm results of revisional bariatric surgery postsleeve gastrectomy: resleeve versus bypass ‘, published in SOARD.

The authors stated that according to the literature the effectiveness and safety as revisional procedures are mixed, with differing outcomes on weight loss and/or higher morbidity rates after revisional surgery. Therefore, the researchers undertook the study to report on the midterm results of patients who had either LRSG or rLRYGB after an initial LSG in Kuwait between the 2008 and 2019. Patients were excluded if they did not undergo revision surgery for the management of their weight. Patients were followed at one-, three-, six- and 12-months post operation and yearly up to five years post initial SG.

In total, 2,858 patients had a SG from October 2008 to December 2018, and a subsequent 84 patients (3%) had either rLRYGB or LRSG. A majority (82.4%) of the 84 patients were female. Prior to initial surgery (LSG), the mean weight of the patients was 134.8 kg and the mean BMI 50.3 kg/m2. The initial mean weight loss was 37.3 kg (BMI 36.4 kg/m2).

The average time to revisional surgery was 4.1 years and the reasons for revisional surgery was weight regain (74.1%), inadequate weight loss (10.6%) or the development of a gastroesophageal reflux symptoms (GERD, 12.9%). In total, 55% of patients had rLRYGB with the remaining 45% having a LRSG.

The outcomes showed that LRSG patients had better weight loss results in terms of EWL after three -years post revision compared rLRYGB. At five years however, rLRYGB had a more sustained weight loss after five years post operation, while those who underwent LRSG began showing weight gain.

For example, the mean BMI showed a drop from 42.0 to 31.7 (p<0.001) one year post revisional surgery for the LRSG group and 42.7 to 34.5 (p<0.001) for the rLRYGB group, an excess weight loss (EWL) of 61.7% and 48.1%, respectively. However, at five years post revisional surgery, LRSG patients had an increase in BMI to 33.8 compared to rLRYGB patients who had a decrease BMI to 34.3.

The authors also reported a difference in resolution of co-morbidities between the procedures - 38% of rLRYGB patients reported resolution of hypertension compared to 25% of LRSG, while 50% of LRSG patients had resolution of T2DM compared to 22% of rLRYGB patients.

“When it comes to choosing the most appropriate revisional procedure, we propose that patients presenting with intractable GERD as their primary symptom to undergo rLRYGB, while those presenting with weight regain and pouch dilation to undergo LRSG,” the authors concluded. “Nevertheless, our data need to be further validated with longer-term and larger studies to aid future surgeons in choosing the revisional procedure on an individual basis appropriately and ensure the best results.