Surgery for Obesity and Related Diseases 12 (2016) 1769–1777

Original article 5-year outcomes of 1-stage gastric band removal and sleeve gastrectomy Aayed R. Alqahtani, M.D., R.C.S.C.S., F.A.C.S.a,*, Mohamed O. Elahmedi, M.B.B.S.a, Awadh R. Al Qahtani, M.D., M.Sc., F.R.C.S.C.a, Ahmad Yousefan, M.D.b, Ahmed R. Al-Zuhair, M.B.B.S.a aDepartment of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia bDepartment of Surgery, New You Medical Center, Riyadh, Saudi Arabia Received January 27, 2016; accepted May 15, 2016

Abstract Background: No verdict has been reached on single-stage removal of gastric banding with sleeve gastrectomy. Objectives: To report 5-year outcomes of 1-stage gastric band removal and sleeve gastrectomy (Conversion-LSG) compared with primary laparoscopic sleeve gastrectomy (Prim-LSG). Setting: Large single-surgeon prospective database. Methods: Two patient groups were included: Conversion-LSG as the study group and Prim- LSG for comparison. Preconversion characteristics, conversion indication, weight loss, and complications were compared. The surgical protocol was reviewed, focusing on key technical recommendations. Results: Atotalof209Conversion-LSGand3268 Prim-LSG patients, aged 32.9 Ϯ 9.8 and 31.8 Ϯ 10.7 years respectively (P .2), were studied. No significant differences in age, body ¼ mass index (BMI), or gender distribution existed. Conversion-LSG Baseline BMI was 47 Ϯ 12 kg/m2.Patientsspent6.2Ϯ 2.6 years with the band before Conversion-LSG. BMI at 1, 2, 3, 4, and 5 years was 37 Ϯ 8, 31 Ϯ 9, 29 Ϯ 11, 30 Ϯ 9, and 30 Ϯ 11 kg/m2,respectively.Nosig- nificant difference in BMI change between the 2 groups existed. In the Conversion-LSG group, 1patienthadasuccessfullystentedleak but developed a gastrobronchial fistula 1 year later. In the Prim-LSG group, 3 leak cases were reported and managed successfully through endoscopic stenting, 1 patient had pulmonary embolism that responded to standard treatment, and 3 patients had postoperative bleeding. No other major complications occurred, and there was no mortality in either group. Additionally, no Conversion-LSG patients required further bariatric intervention. Conclusion: Employing the surgical technique described in this paper, conversion-LSG is as well tolerated and effective as primary sleeve gastrectomy. (Surg Obes Relat Dis 2016;12:1769–1777.) r 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Keywords: One-stage; Sleeve gastrectomy; Gastric band; Concomitant; Single-stage; Revision; Band removal

Opinions on how to treat failed gastric banding are not uniform [1]. One of the valid options is conversion to sleeve gastrectomy (SG). However, the surgical community is *Correspondence: Aayed R. Alqahtani, M.D., F.R.C.S.C., F.A.C.S., Obesity Chair, Department of Surgery, College of Medicine, King Saud presently debating whether to perform SG at the time of the University, 1 Baabda, Riyadh, 11472, Saudi Arabia. band removal (1-stage/single-step) or at a later date E-mail: [email protected] (2-stage) [2]. Outcomes in the literature vary widely and, http://dx.doi.org/10.1016/j.soard.2016.05.017 1550-7289/r 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved. 1770 A. R. Alqahtani et al. / Surgery for Obesity and Related Diseases 12 (2016) 1769–1777 citing safety concerns, many authors recommend against port serves as the camera trocar, and 4 additional trocars are 1-stage conversion [3]. In this study, we critically review placed under laparoscopic view (Video 1; Segment 1). those concerns by reporting the largest single-surgeon experience with 1-stage conversion of failed gastric banding Adhesolysis and band exposure to SG. Additionally, we highlight the technical aspects and discuss surgical challenges that could have led to dissimilar Abdominal adhesions that interfere with the surgical field results in the literature. are released as necessary. The anterior part of the band, which usually has adhesions to the liver and the diaphragm, Methods is freed from both organs (Video 1; Segment 2). The assistant lifts the liver to keep the adhesions under Relevant data were abstracted from our database for all tension and maintain adhesolysis under direct vision. It patients who underwent 1-stage gastric band removal with is preferable to perform this step early unless the concomitant SG between September 2007 and September conditions of the field do not allow for it, in which case 2015 by a single surgeon (ARA). In this study, we report it can be done after releasing the gastrogastric tunnel. weight characteristics before gastric banding, nadir weight Using a hook or scissors, the total circumference of the loss results while on the band, preconversion characteristics, band is exposed by releasing the adhesions and the indication for conversion, postoperative weight loss, com- gastrogastric tunnel all the way to the left crus, staying plications, and follow-up rate. Body mass index (BMI), on the band surface while applying traction to both sides BMI change, percent excess weight loss, and percent total of the stomach to delineate the plane of the gastrogastric weight loss were calculated. Data from patients who tunnel. The band serves as a guide to the gastrogastric underwent primary SG by the same surgeon were included tunnel and the lateral aspect at the angle of His, and for for comparison of complications and weight loss. Addition- this reason it is best left in place until this stage. The fi ally, the surgical protocol is reviewed, focusing on speci c release of the last part of the gastrogastric tunnel toward technical recommendations for achieving a desirable safety the left crus is facilitated by retracting the stomach at 2 fi fi and ef cacy pro le. Variables were compared using the points, one using the left hand of the surgeon at a point t test or Fisher’s exact test where appropriate. Ethical just below the band, pulling in the direction of the liver. approval has been obtained from the institutional review The assisting surgeon flips the whole stomach to the board for this study. right side toward the pylorus. This exposure improves access, allowing for the release of the adhesions at the Preoperative assessment left crus over the band and complete release of the gastrogastric tunnel (Video 1;Segment3). In addition to routine preoperative assessment for the Occasionally, this step requires removing the band before readiness to surgery, patients underwent an upper gastro- its completion, as obtaining adequate exposure can be intestinal series to assess the anatomy and the status of the difficult with the band in place. band and the pouch above the band. Based on clinical presentation and contrast study findings, upper GI endos- copy may be performed. Band transection and fibrous capsulotomy The band is transected. The tube connecting it to the Surgical technique subcutaneous port is cut at a distance of a few centimeters The surgical technique is summarized in the following before it enters the abdominal wall. The band is then steps: (1) positioning and field preparation, (2) adhesolysis stationed above the right lobe of the liver to be removed at and band exposure, (3) band transection and fibrous the end of the procedure (Video 1; Segment 4). The capsule capsulotomy, (4) SG, and (5) gastric remnant and band surrounding the stomach at the band site is next transected and port extraction. vertically at that level just anterior to the left crus. The transected parts of the capsule are separated from the tissue beneath in both lateral and medial directions (Video 1; Positioning and field preparation Segment 5). First, the location of the gastric band port is determined After a few millimeters of separation, the surgeon by palpation and its location is marked. The patient is observes the release of the gastric pouch above the positioned in the reverse Trendelenburg French position. capsule, which is often surprisingly large. It is at this Insufflation of the abdominal cavity is performed to a stage when it will be clear how much of the stomach was pressure of 15 mm Hg using a 10-mm optic port, which trapped above the capsule. Continuing the release of the is inserted above the umbilicus (occasionally using a Veress capsule medially and laterally straightens the stomach needle in right upper quadrant to avoid adhesions). This and returns it to normal anatomic position (Video 1; 1-Stage Band Conversion to Sleeve Gastrectomy / Surgery for Obesity and Related Diseases 12 (2016) 1769–1777 1771

Fig. 1. Mean postoperative body mass index (BMI) comparing 1-step conversion from gastric banding to sleeve gastrectomy with primary sleeve gastrectomy. LSG Laparoscopic sleeve gastrectomy. ¼

Segment 6). It is important to release the capsule from Afterwards, the staple line is carefully examined and the medial aspect to prevent any tethering or kinking reinforcement is performed only at sites where all 3 staple caused by this part of the capsule during or after the rows at each side are not aligned, or if clips are deformed sleeve resection. (Video 1; Segment 8). Intraoperative testing for leak is only performed upon suspicion.

Sleeve gastrectomy Gastric remnant and band and port extractions Full straightening of the stomach is performed all the way from the hiatus to the pylorus, ensuring no tethering or The resected part of the stomach is extracted from the adhesions prevent the stomach from assuming a straight- abdomen through the 10-mm trocar incision after minimal ened and untwisted position. An orogastric calibration tube widening using Kelly forceps. The band, which has been (36-Fr) is then passed all the way to the duodenum. placed at a known location above the liver, is then extracted Stapling starts 2 cm from the pylorus using an Echelon using a Kelly forceps introduced through the same incision Flex™ Endopaths Stapler (Ethicon, Cincinnati, OH) used to extract the stomach. No intra-abdominal drain or loaded with black cartridge (4.4 mm) for the first reload nasogastric tube is placed. An incision is made over the and then following with black or green (4.1 mm) for the old scar of the subcutaneous port, which is then freed next reloads. Occasionally, gold (3.8 mm) and blue (3.5 from tissue attachment using electrocautery and extracted. mm) loads are used at the fundus if it is judged to be thin as a result of the capsule release performed earlier (Video 1; Segment 7). Table 2 Baseline characteristics of patients who underwent single-stage conversion of gastric banding to sleeve gastrectomy compared to those who underwent LSG as the primary procedure Table 1 Primary indication for conversion of gastric banding to sleeve gastrectomy Mean Ϯ Standard Deviation P value Primary indication for Conversion-LSG, n 209 n (%) Conversion-LSG Primary LSG ¼ Weight regain 116 (55.5) Age 32.9 Ϯ 9.8 31.8 Ϯ 10.7 .15 Band slippage 47 (22.5) M:F Ratio 1:2.1 1:1.9 .67 Poor weight loss 34 (16.3) BMI 46.9 Ϯ 11.7 47.3 Ϯ 10.9 .59 Device failure 12 (5.7) n 209 3268 -

Conversion-LSG single-stage conversion of gastric banding to sleeve Conversion-LSG single-stage conversion of gastric banding to sleeve ¼ ¼ gastrectomy. gastrectomy; LSG laparoscopic sleeve gastrectomy. ¼ 1772 A. R. Alqahtani et al. / Surgery for Obesity and Related Diseases 12 (2016) 1769–1777

Table 3 Adiposity variables after sleeve gastrectomy as a primary procedure versus 1-step conversion from gastric banding Mean Ϯ Standard Deviation

Age Group Conversion-LSG (n) Prim-LSG (n) P value

BMI, kg/m2 Baseline 46.9 Ϯ 11.7 (209) 47.3 Ϯ 10.9 (3268) .61 2 wk 45.6 Ϯ 12.7 (209) 44 Ϯ 11.4 (3261) .51 3 mo 40.7 Ϯ 10 (199) 40.9 Ϯ 10.3 (3108) .80 6 mo 37.1 Ϯ 10.2 (146) 37.9 Ϯ 10.4 (2873) .37 1yr 34 Ϯ 8.1 (184) 32.6 Ϯ 9.4 (2508) .11 2 yr 31.5 Ϯ 9.5 (125) 29.4 Ϯ 9.6 (1660) .052 3 yr 29.1 Ϯ 10.8 (87) 28.9 Ϯ 10.2 (976) .90 4 yr 29.6 Ϯ 8.7 (59) 29.3 Ϯ 9.6 (526) .86 5 yr 30.4 Ϯ 10.7 (40) 30.1 Ϯ 8.9 (256) .88 BMI Change, kg/m2 Baseline 2wk –4.3 Ϯ 3.8 –4.0 Ϯ 3.1 .2 3mo –7.8 Ϯ 5.1 –7.5 Ϯ 4.8 .40 6mo –10.8 Ϯ 6 –10.4 Ϯ 5.5 .40 1yr –13.7 Ϯ 5.8 –14.7 Ϯ 6 .08 2yr –16.1 Ϯ 5.9 –16.9 Ϯ 6.2 .80 3yr –20.6 Ϯ 6.3 –19.4 Ϯ 6 .16 4yr –19.4 Ϯ 5.9 –18.9 Ϯ 6.2 .66 5yr –18.5 Ϯ 7.8 –18.6 Ϯ 7.7 .95 Total Weight Loss, % Baseline 2 wk 3.8 Ϯ .7 3.6 Ϯ 1.6 .07 3 mo 13.2 Ϯ 3.7 13.4 Ϯ 3.5 .44 6 mo 20.8 Ϯ 5.1 20.3 Ϯ 5 .24 1 yr 28.5 Ϯ 7.6 30.0 Ϯ 8.5 .06 2 yr 32.8 Ϯ 8.8 35.4 Ϯ 10.5 .03 3yr 38 Ϯ 11.5 38.9 Ϯ 13 .63 4 yr 36.9 Ϯ 13.7 37.1 Ϯ 13.5 .94 5 yr 35.2 Ϯ 10.4 36.4 Ϯ 12 .65 Excess Weight Loss, % Baseline 2 wk 5.9 Ϯ 1.6 6.0 Ϯ 1.4 3 mo 29.8 Ϯ 6.9 30.5 Ϯ 5.6 .09 6 mo 44.5 Ϯ 12.4 43.7 Ϯ 8.1 .26 1 yr 60.5 Ϯ 14 62.4 Ϯ 11.7 .1 2 yr 70.4 Ϯ 21.3 73.9 Ϯ 18.4 .10 3 yr 81.3 Ϯ 25.2 79.1 Ϯ 22.4 .50 4 yr 79.2 Ϯ 23.4 83.6 Ϯ 27.1 .37 5 yr 75.1 Ϯ 26.5 80.4 Ϯ 25.5 .35

BMI body mass index; Conversion-LSG 1-step conversion of gastric banding to sleeve gastrectomy; Prim-LSG primary sleeve gastrectomy. ¼ ¼ ¼

Postoperative testing for leak is not performed unless weight loss results are described in Table 3. Mean nadir BMI clinically suspected. was 27.5 Ϯ 9.9 kg/m2. Mean post-nadir BMI regain was 4.1 Ϯ 2.5 kg/m2 (range: 0–8.5). Results The database yielded 209 patients with 1-stage conversion Table 4 Postoperative complications observed after single-stage conversion of of gastric banding to SG. The mean age was 32.9 Ϯ 9.8 gastric banding to sleeve gastrectomy compared to sleeve gastrectomy as years, and 68% of patients in the study group were females. a primary procedure 2 Nadir BMI while on the band averaged 36.5 Ϯ 9.5 kg/m , Conversion-LSG Primary LSG P value and BMI at time of 1-stage conversion was 47 Ϯ 12 kg/m2 (Fig. 1). On average, patients spent 6.2 Ϯ 2.6 years (range: Complications, n (%) 2 (1.0) 9 (.3) .14 Pneumonia 1 2 .17 1.9–12.2 yr) with the gastric band before undergoing Leak, n 1 3 .22 revision. The most common primary indication for conver- Pulmonary embolism, n 0 1 .99 sion to SG was weight regain, suffered by 138 patients (66%; Bleeding from staple line, n 0 3 .99 Table 1). There were no significant differences between the Mortality, n 0 0 1.00 primary- and conversion-LSG groups in terms of baseline Conversion-LSG single-stage conversion of gastric banding to sleeve ¼ age, BMI, and gender distribution (Table 2). Postoperative gastrectomy; LSG laparoscopic sleeve gastrectomy. ¼ 1-Stage Band Conversion to Sleeve Gastrectomy / Surgery for Obesity and Related Diseases 12 (2016) 1769–1777 1773

One patient from the 1-stage group was readmitted 2 LSG, figures that are lower than currently published rates. weeks after surgery with a postoperative leak. He had Reasons for variation in published complication rates percutaneous drainage and multiple endoscopic stent place- include poor standardization [8], disparity of data from ment and reposition that eventually resulted in leak control low-volume centers [9], and surgeon learning curve [10], and complete healing. He then presented 1 year after among others. discharge and stent removal with a frequent cough that The surgical learning curve is a primary factor in was aggravated by food intake. CT scan and upper GI series predicting postoperative complication rates [11]. Flum revealed a fistulous tract communicating between the et al. evaluated short- and long-term mortality rates in superior aspect of the gastric fundus (the site of the pre- patients undergoing gastric bypass and found that risk of vious leak), crossing through the left hemidiaphragm to complications was directly linked to the number of sur- the left lower lobe of the lung, and reaching the lower- geries the surgeon has independently performed [12]. lobe basal segment bronchus. The patient underwent endo- Similarly, for primary SG, Zacharoulis et al. reported that scopic management of the fistula in form of fistula performing at least 68 procedures is needed to achieve brushing, closure of the fistula using endoscopic clips, optimal operative times and complication rates [13]. The and stenting. The stent was removed 8 weeks later with German Bariatric Surgery Registry (GBSR), an online complete closure. Radiological evaluation 11 months database with voluntary data registration, reported results later confirmed maintenance of complete closure. No 1- with primary SG over 3 overlapping periods. In the early stage conversion patient developed a stricture or post- period (2006–2007), 144 LSG patients were included. The operative bleeding. Additionally, none of the 1-stage average number of LSG cases performed per hospital was conversion patients required further bariatric interven- 8.5, and only 3 hospitals performed 410 SGs per year. In tion (Table 4). this period, 10 patients (7%) had a postoperative leak [7]. For patients who had primary SG, there were 3 cases of A later report (2006–2011) compared 5400 cases of postoperative leak. For 2 patients, percutaneous drainage primary SG with 174 conversion cases. The results con- and an endoscopic stent were placed, and the other patient cluded that the leak rate after single-stage conversion was underwent reoperation, drainage, and stenting. One patient not significantly higher than that after primary LSG. presented to the emergency room with pulmonary embolism However, there were no leaks reported in the 37 cases that responded well to standard treatment, and 3 patients where 2-stage conversion was performed, which led the had postoperative bleeding that required blood transfusion. authors to conclude that 1-stage conversion carries a higher One of these patients was reoperated on to control bleeding risk of postoperative leak [14]. The more recent report from the staple line at the antrum. There was no mortality in included data up to 2012, and while there were more 1- either group. stage conversion cases (43 patients underwent 1-stage For 2 of the 1-stage conversion patients, it was intra- conversion in 2012), there were no more leak cases [15]. operatively discovered that the band had migrated inside the Together with the major difference in the complication rate stomach. In 1 of the 2 cases, the migration occurred laterally after primary LSG between the period 2006–2007 and and the defect was included in the removed part of stomach. 2006–2012, and the lack of leaks after single-stage con- In the other case, medial migration was discovered and the version in 2012, the data suggest that surgeons in the procedure was converted into a 2-step procedure, where the registry experienced a learning curve in the initial period removal of gastric band was performed followed by SG 3 that similarly affected outcomes with 1-stage conversion months later. and with primary SG. Moreover, a substantial variation in hospital volume exists in GBSR [7], a factor that has been – Discussion well correlated with surgical outcomes [9,16 20].Aswith GBSR data, the American College of Surgeons National Up to 60% of patients with gastric bands develop Surgical Quality Improvement Program (ACS NSQIP) data complications necessitating revision [4]. While a number show that 1-stage conversion has similar tolerability to of previous studies concluded against single-step conver- primary SG [21]. sion of failed gastric banding to SG, our results find that this Another primary reason for the variation in outcomes method is well tolerated and effective. Of the 209 patients after 1-stage conversion of gastric banding to SG is the fact comprising the study group, only 1 was readmitted (.5%), that not all gastric sleeves are created equal. Since the and there was no mortality. Within the first 3 years of advent of this procedure, different surgeons have been surgery, 480% of the excess weight was lost in both adopting different surgical techniques. Bougie size, distance primary and revision LSG groups. from the pylorus, distance from the angle of His, cartridge Published complication rates for 1-stage revision of staple height, oversewing, and reinforcement of the staple gastric banding to SG vary greatly, and range from .3% line all differ [8,22]. This lack of standardization extends to to 15% [5–7]. Our overall complication rates in this study the situation when SG is a revisional procedure [23]. In our were 1.4% for 1-stage conversion and .27% for primary experience while mentoring surgeons on single-step 1774 A. R. Alqahtani et al. / Surgery for Obesity and Related Diseases 12 (2016) 1769–1777 conversion of gastric band to SG, we observed surgeons intra-abdominal complications, prolonged hospital stay, dissecting up to the fibrous capsule and performing the and higher hospital costs significantly [26].Indeed,ACS SG just below that point without releasing the capsule. NSQIP data show that adhesions independently increase Others performed partial release but stapled on the the odds of superficial and deep or organ-space surgical remaining capsule without considering the difference in site infections, prolonged postoperative hospital stay, tissue thickness. Some surgeons also released the capsule operative time (20 min on average), and inadvertent partially and left part of the pouch above the resected area, enterotomies. These risks cannot be overlooked, espe- which would create a high-pressure zone in that area and cially since mortality in adhesolysis complicated by bowel ultimately contribute to the high leak rates and suboptimal injury is increased 5-fold. During band removal, extensive weight loss. adhesolysis might be required, tissue is manipulated, and In our approach, we initially leave the band in place and the gastrogastric tunnel is often released to remove the use it as a guide to release the wrap completely before band. All these steps would create further adhesions that removing the band. Next, we release the capsule starting could render the course of the future second-stage from the lateral aspect anterior to the left crus. Often, the bariatric procedure difficult and unpredictable. This fact pouch above the capsule is observed to be exceptionally is also evident in GBSR data, as 45% of patients who large. We then excise the capsule as necessary to had 2-stage conversion had intraoperative spleen injury minimize scar tissue at the staple line, and reduce any that required blood transfusion [14].Inouropinion,injury tethering affecting the alignment of the stomach so that to the spleen (and other inadvertent injuries) could be any capsule remnant is completely away from the staple avoided if the surgical view is not heavily obscured by line and not deforming the remaining stomach. Addition- adhesions. On the other hand, it is not mandatory to ally, it is important to make sure that the stapling is not on proceed with SG during a planned single-stage procedure part of the capsule, as this might cause a ring by the when band removal reveals tissue that is not healthy or remnant capsule with the staple line and stress the line eroded. proximal to that point. Also, the upper end of the staple Concerns exist about the degree and durability of weight line should be a few millimeters from the gastroesopha- loss observed when performing SG after gastric banding geal junction but should not leave a pouch at that level, [27]. In recent studies, average excess weight loss 1 year which would create a high-pressure zone and increase the after conversion of gastric banding to SG (1-stage or risk of a leak. 2-stage) ranged between 47% and 66% [23,28–32].In Using the proper staple height is also critical to the our study, the 1-stage conversion patients were able to success of the conversion. We start with a black cartridge reduce their weight by an average of 21 BMI points in the (4.4 mm; Ethicon) and then green (4.1 mm) in the first 3 years, translating to an excess weight loss of 81%. remaining; gold (3.8 mm) can be used when we feel the This observation is supportive of the notion that surgical tissue is thin after releasing the capsule, provided no technique affects postoperative weight loss. Having post- scar tissue is in the way of the staples. Blue cartridges nadir BMI gain of 4.1 Ϯ 2.5 kg/m2 in our group was (3.5 mm) can be used as well here with these conditions. equivalent to a mean %EWL of 75% at the fifth year visit. While some authors believe that stomach tissue is thicker This was comparable to our 5-year results in the primary around the site of the gastric band [24],webelievethat LSG group, and to published reports on long-term weight this excessive thickness is actually caused by the capsule. loss after LSG [33]. As discussed earlier, disrupting the capsule and surround- With evidence of the tolerability of 1-stage conversion of ing adhesions is highly important to ensure that undue gastric banding to SG through the technique described in pressure is not put on the staple line as a result of kinking this paper, we believe that dividing the procedure into 2 or stretching (Video 1;Segment9).Usingthetechnique stages is not justified. This is especially true since opting for we describe in this paper, only1%ofpatientsdeveloped a 2-stage approach carries the risk of unforeseeable com- postoperative complications. plications that are best avoided by performing removal of On the other hand, opting for a 2-stage technique the band with SG in 1 setting. subjects patients to repetitive abdominal surgery, which increases technical challenges and the risk of complica- — tions [25] consequences that 1-stage conversion aims to Conclusion avoid. In our experience, one of the major reasons that mean surgical time was increased from 33 Ϯ 9minutes Using the surgical technique specified on this paper, for primary SG to 64 Ϯ 12 minutes in our study was due 1-stage conversion of failed gastric banding to SG is as to adhesolysis. Adhesions are not only associated with well tolerated and effective as primary SG at 5 years increased surgical time but also increase the risk of sepsis, follow up. 1-Stage Band Conversion to Sleeve Gastrectomy / Surgery for Obesity and Related Diseases 12 (2016) 1769–1777 1775

Disclosures [12] Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: a population-based analysis. J Am Coll Surg 2004;199 The authors have no commercial associations that might (4):543–51. be a conflict of interest in relation to this article. [13] Zacharoulis D, Sioka E, Papamargaritis D, et al. Influence of the learning curve on safety and efficiency of laparoscopic sleeve gastrectomy. Obes Surg 2012;22(3):411–5. Acknowledgment [14] Stroh C, Benedix D, Weiner R, et al. Is a one-step sleeve gastrectomy The authors extend their appreciation to the Vice indicated as a revision procedure after gastric banding? Data analysis fi from a quality assurance study of the surgical treatment of obesity in Deanship of Research Chairs for nancially supporting Germany. Obes Surg 2014;24(1):9–14. this work through development and maintenance of the [15] Stroh C, Weiner R, Wolff S, Knoll C, Manger T. Revisional surgery prospective research database. The authors are grate- and reoperations in obesity and metabolic surgery: Data analysis of ful for the contribution of research assistance from the German bariatric surgery registry 2005-2012 [in German]. Chirurg Dr. Mohannad Bashir Elbashir. The authors also thank 2015;86(4):346–54. the participants who took part in the multidisciplinary [16] Torrente JE, Cooney RN, Rogers AM, Hollenbeak CS. Impor- tance of hospital versus surgeon volume in predicting outcomes program. for gastric bypass procedures. Surg Obes Relat Dis 2013;9 (2):247–52. Appendix [17] Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Supplementary data Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349(22):2117–27. Supplementary data associated with this article can be [18] Urbach DR. Pledging to eliminate low-volume surgery. N Engl J Med found in the online version at http://dx.doi.org/10.1016/j. 2015;373(15):1388–90. soard.2016.05.017. [19] Kelly JV, Hellinger FJ. Physician and hospital factors associated with mortality of surgical patients. Med Care 1986;24(9):785–800. [20] Luft HS, Bunker JP, Enthoven AC. Should operations be regional- ized? The empirical relation between surgical volume and mortality. References N Engl J Med 1979;301(25):1364–9. [21] Aminian A, Shoar S, Khorgami Z, Augustin T, Schauer PR, [1] Elnahas A, Graybiel K, Farrokhyar F, Gmora S, Anvari M, Brethauer SA. Safety of one-step conversion of gastric band to Hong D. Revisional surgery after failed laparoscopic adjustable sleeve: a comparative analysis of ACS-NSQIP data. Surg Obes Relat gastric banding: a systematic review. Surg Endosc 2013;27 Dis 2015;11(2):386–91. (3):740–5. [22] Gagner M, Buchwald JN. Comparison of laparoscopic sleeve [2] Rosenthal R. Sleeve gastrectomy as a revisional procedure. In: gastrectomy leak rates in four staple-line reinforcement options: a Brethauer SA, Schauer PR, Schirmer BD, editors. Minimally Invasive systematic review. Surg Obes Relat Dis 2014;10(4):713–23. Bariatric Surgery. New York: Springer; 2015. p. 173–7. [23] Gonzalez-Heredia R, Masrur M, Patton K, Bindal V, Sarvepalli S, [3] Schneck A-S, Lazzati A, Audureau E, et al. One or two steps for Elli E. Revisions after failed gastric band: sleeve gastrectomy and laparoscopic conversion of failed adjustable gastric banding to sleeve Roux-en-Y gastric bypass. Surg Endosc 2015;29(9):2533–7. gastrectomy: a nationwide French study on 3,357 morbidly obese [24] Angrisani L, Santonicola A, Formisano G, Hasani A, Lorenzo M. patients. Surg Obes Relat Dis. Epub 2015 Oct 21. Revisional surgery after LAGB. In: Agrawal S, editor. Obesity, [4] Shen X, Zhang X, Bi J, Yin K. Long-term complications requiring Bariatric and Metabolic Surgery. Cham: Springer International Pub- reoperations after laparoscopic adjustable gastric banding: a system- lishing; 2015. p. 403–11. atic review. Surg Obes Relat Dis 2015;11(4):956–64. [25] ten Broek RP, Issa Y, van Santbrink EJ, et al. Burden of adhesions in [5] Zellmer JD, Mathiason MA, Kallies KJ, Kothari SN. Is laparoscopic abdominal and pelvic surgery: systematic review and met-analysis. sleeve gastrectomy a lower risk bariatric procedure compared with BMJ 2013;347:f5588. laparoscopic Roux-en-Y gastric bypass? A meta-analysis. Am J Surg [26] van Goor H. Consequences and complications of peritoneal adhe- 2014;208(6):903–10; discussion 9–10. sions. Colorectal Dis 2007;9(Suppl 2):25–34. [6] Chang S, Stoll CT, Song J, Varela J, Eagon CJ, Colditz GA. The effectiveness and risks of bariatric surgery: An updated systematic [27] Noel P, Schneck AS, Nedelcu M, et al. Laparoscopic sleeve review and meta-analysis, 2003-2012. JAMA Surgery 2014;149 gastrectomy as a revisional procedure for failed gastric banding: (3):275–87. lessons from 300 consecutive cases. Surg Obes Relat Dis 2014;10 – [7] Stroh C, Birk D, Flade-Kuthe R, et al. A nationwide survey on (6):1116 22. bariatric surgery in Germany–results 2005-2007. Obes Surg 2009;19 [28] Khoursheed M, Al-Bader I, Mouzannar A, et al. Sleeve gastrectomy (1):105–12. or gastric bypass as revisional bariatric procedures: retrospective [8] Gagner M, Deitel M, Erickson AL, Crosby RD. Survey on evaluation of outcomes. Surg Endosc 2013;27(11):4277–83. laparoscopic sleeve gastrectomy (LSG) at the Fourth International [29] Sabbagh C, Verhaeghe P, Dhahri A, et al. Two-year results on Consensus Summit on Sleeve Gastrectomy. Obes Surg 2013;23 morbidity, weight loss and quality of life of sleeve gastrectomy as first (12):2013–7. procedure, sleeve gastrectomy after failure of gastric banding and [9] Birkmeyer NJ, Dimick JB, Share D, et al. Hospital complication rates gastric banding. Obes Surg 2010;20(6):679–84. with bariatric surgery in Michigan. JAMA 2010;304(4):435–42. [30] Goitein D, Feigin A, Segal-Lieberman G, Goitein O, Papa MZ, [10] Cook JA, Ramsay CR, Fayers P. Statistical evaluation of learning Zippel D. Laparoscopic sleeve gastrectomy as a revisional option after curve effects in surgical trials. Clin Trials 2004;1(5):421–7. gastric band failure. Surg Endosc 2011;25(8):2626–30. [11] Schauer P, Ikramuddin S, Hamad G, Gourash W. The learning curve [31] Rebibo L, Mensah E, Verhaeghe P, et al. Simultaneous gastric band for laparoscopic Roux-en-Y gastric bypass is 100 cases. Surg Endosc removal and sleeve gastrectomy: a comparison with front-line sleeve 2003;17(2):212–5. gastrectomy. Obes Surg 2012;22(9):1420–6.