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Revision: "Exit Strategy"Surgical treatment of obesity often fails. Consideration of any surgical treatment of obesity should also include an evaluation of the operation's "Exit Strategy," i.e. how the operation can be revised or reversed and what are the revision's associated risks and complications. Revision rates of up to 20-40% are reported with some forms of weight loss surgery because of excessive weight loss, severe unresponsive anemia, persistent nausea and vomiting, unsatisfactory weight loss resulting from staple line disruption, pouch dilatation, and/or stomal enlargement and other problems. Studies show that the morbidity and mortality are higher for revision than primary surgery . In a series reported by Sugerman and Wolper 46% of 122 gastroplasties for morbid obesity failed. They stated that "Conversion of a failed gastroplasty to a Roux-Y gastric bypass is a difficult procedure that carried a significantly higher complication rate." Lovig et. al. reported a five year follow-up of 174 morbidly obese patients with gastric banding performed between 1981 and 1985. In their series 48 patients (28%) had 60 late complications requiring 26 reoperations (14.9%). In a series of 170 patients undergoing Biliopancreatic Diversion followed for 7 years the re-operation rate because of these side-effects was 7%. Even newer types of surgery such as the silicone band types of surgery have revision rates of up to 10%. Miller and Hell performed 102 adjustable silicone gastric bandings and 54 Swedish adjustable gastric bandings. They report that the late complications that required reoperation were two pouch dilatations (1.3%), three band leakages (2%), one band migration (0.6%), and one late infection of the port (0.6%). Band removal was necessary in one patient because of an esophageal motility disorder. The overall reoperation rate was 7%. These revision rates are more than 10 times higher than the 0.6% rate in the Mini-Gastric Bypass. In a series of 391 patients undergoing laparoscopic adjustable silicone gastric banding reported by Abu-Abeid and Szold a total of 26 (6.4%) reoperations were performed . In a series of 40 Lap-Band patients reported by Angrisani et. al. 8 of 40 patients who underwent laparoscopic adjustable silicone gastric banding experienced proximal gastric pouch dilation (18%) or band dislocation (3%). Debanding was performed in 3 patients with pouch dilation (8%), while in 4 the pouch dilation was successfully treated with deflation of the band. Two patients (5%) were treated with band repositioning. In a study by O'Brien et. al. prolapse of the stomach through the band occurred in 27 of 302 patients (9%). These reported rates of revision are much higher than the revision rate in this series of Mini-Gastric Bypass patients (revision rate of 0.6%). It appears that the Mini-Gastric Bypass has a revision rate that seems much lower than that reported for other forms of weight loss surgery. In addition, the reports of greatly increased risks after revision of other forms of weight loss surgery do not appear to be present in the Mini-Gastric Bypass. Revisions of the MGB were easily performed in an hour or less. Unfortunately, the presently available surgical approaches have been fraught with such severe short and long-term complications that many physicians and surgeons prefer to avoid bariatric surgery entirely [i]. An ideal weight loss surgery should be effective, easy to perform and safe. It should have an simple and effective "Exit Strategy", that is, it should be easy to modify or reverse for inadequate weight loss, weight regain, excessive weight loss or other complications. [i] Cowan GS Jr, Smalley MD, Defibaugh N, Cowan KB, Hiler ML, Sehnert W, James S., Obesity Stereotypes Among Physicians, Medical and College Students, Bariatric Surgery Patients and Families., Obes Surg. 1991 Jun;1(2):171-176 |
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