Gastric restrictive procedures to treat obesity: reasons for failure and long-term evaluation of the results of operative revision.

BACKGROUND AND OBJECTIVE: Bariatric surgery has included a large number of operative procedures, some of which have become extinct and others, such as gastric restrictive procedures, which continue to be performed. While these operative procedures play an important role in the management of obesity, they are associated with significant failure rates. This study was performed to evaluate the results of operations performed on patients to revise failed gastric restrictive procedures.

METHODS: During the past 15 years operative revision of gastric restrictive procedures was performed on 65 patients. The demographic, operative, and postoperative information has been prospectively collected. The patients were divided into 20 non-obese patients who weighed less than 250 pounds (range 90-247 pounds) and 45 obese patients weighing more than 250 pounds (range 256-527 pounds). The primary indications for operation on the non-obese patients were intragastric foreign body, gastric fistula, gastroesophageal reflux, and non emptying gastric pouch. The obese patients underwent revision for gastroesophageal reflux and failure to maintain weight loss. The obese patients frequently had obesity associated health problems including sleep apnea (N = 5), hypertension (N = 6), diabetes (N = 5) and ventral hernia (N = 30). The operative procedures in the non-obese patients consisted of revision of a gastroplasty in two patients, conversion of a gastroplasty to a gastric bypass in 12 patients and revision of a gastric bypass in eight patients. In the obese patient group, eight patients underwent revision of a gastroplasty, 19 patients had a gastroplasty converted to a gastric bypass and 14 patients underwent revision of a gastric bypass. The mean +/- SEM length of follow-up was 57 +/- 8 months.

RESULTS: There were two postoperative deaths, one from a pulmonary embolus and one from unknown cause. There was no significant difference regarding the results of the various operations to revise gastric restrictive procedures on the weight of the non-obese patients at long-term follow-up. When obese patients underwent revision of a gastric bypass procedure, they lost 69 +/- 9 pounds which was significantly less than the 82 +/- 12 pounds lost by the patients who underwent revision of a gastroplasty. Conversion of gastroplasty operations to gastric bypass operations in obese patients resulted in the loss of 110 +/- 7 pounds at long-term follow-up.

CONCLUSIONS: Revision of gastric restrictive procedures can be performed with durable control of obesity; however, revision of gastric bypass restrictive procedures in obese patients produced the least benefit.