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The Sleeve and Reproductive Potential
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The Sleeve as a Revisional Procedure
Camilo Boza Wilson and Andrés San Martin
1 Introduction
Bariatric surgery (BS) has widely shown its effectiveness in weight loss and
improving comorbidities. According to ASMBC [1], in 2011 BS went from
158,000 to 252,000 cases in 2018. Revisional Surgery (RS) in the same period
went from 6 to 15.4%. This increase also implies an increase in the number of
failures and hence the need for RS. Long-term studies show that all primary techniques have a variable percentage of failures.
Sleeve gastrectomy (SG) is the most commonly performed primary bariatric procedure around the world. It is the technique that contributes with most of
the cases in terms of weight regain, GERD and complications, and therefore that
contributes the most to the number of RS. In 2016 it was the first time that RS
numbers were shown worldwide, where 50,977 surgeries were reported. The percentages range from 1 to 11% of the total performed interventions, depending on
the region (North America, Europe and Latin America respectively). Of the total
numbers of RS 63% of these were due to insufficient weight loss or low response
in comorbidities and 26% due to complications and 11% for both [2].
C. B. Wilson (*)
Department of Digestive Surgery, Clinica Las Condes, Santiago, Chile
e-mail: bozauc@mac.com
A. S. Martin
Médico Cirujano, Fellow Cirugía Bariátrica Clínica las Condes, Santiago, Chile
e-mail: andresesanmartin@gmail.com
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_12
95
C. B. Wilson and A. S. Martin96
2 General Considerations
As a general rule we should know that any RS is complex, technically demanding
and associated with greater operating risks and complications than primary procedures [3–6]. When performed by experienced surgeons, the rate of complications
is close to 13% [7]. When the team is assessing a RS should look at the causes of
primary failure, presence of uncontrolled comorbidities, new symptoms that could
have originated or worsen after the primary procedure (GERD, Dumping, anemia,
micronutrient deficit) [8, 9], For this purpose all patients must be addressed by the
multidisciplinary team.
The patient candidate for revision surgery must be carefully studied, in search
of the causes of primary failure. Anatomy must be assessed with an endoscopy,
radiologic studies, CT scan volumetry. Patients should also undergo laboratory
analysis and in some cases Ph-impedance studies. For example, Re-Sleeve was
generally proposed for patients with an excessively high residual gastric volume,
as assessed by gastric CT volumetry) and/or with gastric pouch dilatation (as
assessed by barium swallow) [10–12]. Keep in mind that GERD symptoms associated with Barret's esophagus are a contraindication for Re-Sleeve [13]. In addition
to the above, patients must be assessed considering these procedures are technically complex in part due to the presence of adhesions, previous surgeries such,
cholecystectomy or other bariatric procedures. Special attention should be noted in
those with previous open surgery or abdominoplasty that increases difficulty.
3 Choice of Technique Based on Evidence
Evidence on RS is increasing, IFSO SURVEY presented RS as the current challenge of bariatric surgery. When BS fails, we have more than one RS alternative. In 2018 a survey was conducted with 460 bariatric surgeons from 27
countries about preferences in RS: For revision after LAGB, the RYGB (75.5%,
n = 345) emerged as the most common option followed by SG (56.9%, n = 260)
and one anastomosis gastric bypass (OAGB) (37.2%, n = 170). For the revision
after SG, RYGB (77.7%, n = 355) was the preferred option followed by OAGB
(42.45%, n = 194) and Re-Sleeve (22.32%, n = 102) [14].
Sleeve gastrectomy (SG) as RS has been described after multiple interventions, such
as gastric band (LAGB), after Sleeve Gastrectomy; RYGB or endoscopic procedures.
4 Laparoscopic Adjustable Gastric Banding (LAGB)
to Sleeve Gastrectomy (SG)
LAGB has been associated with high failure rates requiring RS [15–18]. Although
band placement does not create a permanent anatomic alteration, it does not leave
the stomach region undamaged. Erosion, scar tissue, pouch dilation, and adhesions
The Sleeve as a Revisional Procedure
97
make the area more complex and vulnerable during further interventions; this
makes revisional surgery technically demanding [19, 20].
Recently SG has gained increased popularity as a revisional procedure after
failed LAGB [21, 22]. In a systematic review and meta-analysis of Dimitrios E.
Magouliotis et al. comparing RYGB versus SG after LAGB, they presented indications for conversion. The most frequent cause was insufficient weight loss (68%),
band slippage/erosion (13.7%), gastric pouch dilation (3.6%) and intractable GE
reflux (2.68%). Similar results are seen in other series. His team concluded that
both techniques have no differences in clinical outcomes, hospital stay, complications, or excess weight loss (EWL) after a year. They found a better EWL at
2 years for RYGB [23]. Similarly, Jacobs et al. concludes that the SG has lower
morbidity and mortality rates than converting to a RYGB with comparable weight
loss. Average EWL was 60% at 26 months [24]. In his Sistematic review Alistair J.
Sharples describes that the pooled morbidity and mortality rates for LAGB conversions are comparable to those reported for primary bariatric surgery. When comparing the EWL at 24 months, they showed 59.5% for conversion to RYGB and
61.8% after SG [7].
5 Sleeve Gastrectomy to Re-sleeve
Patients who have undergone SG but have experienced weight loss failure (insufficient weight loss or weight regain) or have developed certain complications can
be treated surgically by a second intervention, such as Re-Sleeve. It is necessary
to know the scope and causes of SG failures, as well as indications and results
of revisions after SG. The most accepted indications for performing a Re-Sleeve
are weight loss failure, if the barium swallow shows an upper gastric pouch dilation or a big, unresected fundus or if in the CT scan volumetry exceedes 250 cc.
When deciding which RS to perform, the Re-Sleeve seems to be technically easier, than others, without anastomosis. With low conversion rates to open surgery
and acceptable complication rates. Although it is still too early to conclude on
its long-term efficacy [25, 26]. Al Sabah et al. presented a series with 24 patients
undergoing Re-Sleeve compared to 12 patients undergoing RYGB after sleeve failure. Failure of SG was defined by a percentage of excessive weight loss (EWL%)
of less than 50% after 1 year. All 24 patients underwent Re-Sleeve due to insufficient weight loss and dilation of gastric sleeve. Without intra-operative or postoperative complications, they achieved a mean EWL% of 57% after Re-Sleeve
at 12 months vs 61% after revisional RYGB. They concluded that the results of
re-sleeve and revisional RYGB for poor weight loss are feasible with good outcomes and comparable results after a 1-year follow-up [27]. Similar results were
presented by Antonopulos C. et al. in 2019 comparing SG failure results, getting
similar results in weight loss during the first year of follow-up in both techniques
[28]. Kamal K. et al. review compared the results of the Re-Sleeve versus primary SG, where only 2 out of 7 studies showed a better weight loss in primary
surgery, while in the rest it finds no differences [29]. Previously in 2015 Nedelcu
C. B. Wilson and A. S. Martin98
et al., presented their series with 61 patients undergoing Re-Sleeve. All cases were
completed by laparoscopy with no intraoperative complications. They found an
EWL of 58.5% with 20 months of follow-up. Concluding that Re-Sleeve is a valid
option for SG primary failure [30].
Compared with the malabsorptive procedures, Re-Sleeve offers several advantages, including increasing the restriction and decreasing the gastric output; lessening dumping syndrome by preserving the pylorus; decreasing risk of anemia,
osteoporosis, and protein and vitamin deficiency (excepting B12 and thiamine
level); and requiring shorter operative times. However, long term efficacy is still in
debate specially in patients with higher BMI’s [31].
6 RYGB to SG
The failure of a primary RYGB represents a great challenge for the multidisciplinary tema, due to the surgical difficulty and the few surgical options currently
available. Himpens eta al presented a series with nine patients who presented poor
weight loss (EWL < 10%) after primary RYGB. In these cases the bypass was
reversed and converted to a SG, followed on a next stage to a duodenal switch
in 3 patients. Two of them (28.6%) had a leak at the gastro-gastric anastomosis
[10]. A few years before, the same group presented a small series with 4 patients
converted from RYGB to SG, concluding that it is feasible and safe. The risk
of gastric fistula is an important issue for this option (25% in this series). They
reported a better weight loss, which leaves the patient in better condition to perform a second stage [32]. It could also be an option to consider when patients
develops a sever malnutririon or the sleeve is as a first step for a planned biliopancreatic diversion with duodenal switch (BPD-DS) [33] or part of a conversion to
Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) [34].
7 SG After Endoscopic Procedures
Currently, there are multiple endoscopic procedures to treat obesity. Some of
which produce changes in the gastric anatomy and others only a temporary occupation of the stomach such as the intragastric balloon. These techniques are also
not exempt from therapeutic failures or complications. The SG as revision surgery
could be an alternative in these failures. Although at the moment there are few
publications about its feasibility. Al Sabah et al. presented a case report of sleeve
gastrectomy after primary obesity surgery endolumenal (POSE). The patient lost
20 kg after 6 months the revision [35]. Alqahtani et al. presented a series of 20
patients undergoing a conversion from Endoscopic Sleeve Gastrectomy (ESG)
to LSG from a total of 1665 (1.2%) undergoing primary ESG. Patients who did
not lose sufficient weight (defined as <5% of total weight) after at least three
months from ESG, and those who experienced weight regain, were evaluated and
The Sleeve as a Revisional Procedure
99
considered for revisional options. They presented no mortality, reoperations or
readmissions in any of the 20 patients after the conversion [36, 37].
8 Conclusion
All patients who are candidates for RS should be thoroughly evaluated. SG as RS
is an efficient and reasonable option. It has improvements in comorbidities, weight
loss and rate of complications similar to other techniques such as RYGB. The biggest drawback of this is the presence of GERD, hiatus hernia or barrett's esophagus where other options should be considered.
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101
Converting Endoscopic Bariatric Procedures to LSG: POSE, Endosleeve, and Balloon
Salman Al-Sabah and Eliana Al Haddad
1 Introduction
Bariatric surgery has now provided a new option for overweight patients that have
attempted conventional weight loss methods and failed. With more studies being
performed covering health and the detriments that come with increasing BMI’s,
the different emerging methods of weight loss have caught the attention of physicians, researchers, and patients alike, trying to provide the best option catered
to each person individually. A systematic review and meta-analysis conducted by
Gloy et al. [1] was able to demonstrate that bariatric surgery is a more effective
method than non-surgical treatments for obesity, as well as the co-morbid conditions that come along with it. Therefore, more and more patients and physicians
are starting to turn to bariatric surgeries, not only for the treatment of obesity, but
also for the management of these co-morbid conditions.
Currently, multiple endoscopic procedures exist that are sought after due to
the fact that they can be considered as ‘less invasive’ bariatric procedures. These
include the Primary Obesity Surgery, Endolumenal (POSE) procedure, the endosleeve, and the balloon. However, long-term success rates of these procedures,
especially in patients with higher BMI’s, have shown to be lower than their surgical ‘invasive’ counterparts.
S. Al-Sabah (*)
Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
e-mail: salman.k.alsabah@gmail.com
E. Al Haddad
Columbia University Medical Center, New York, NY, USA
e-mail: Eliana.h91@gmail.com
E. Al Haddad
Amiri Hospital, Kuwait City, Kuwait
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_13
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