Revisional bariatric surgery appears to be associated with a higher risk of complications than the initial procedure, according to a report in the February issue of Archives of Surgery, one of the JAMA/Archives journals.
Surgical treatment is currently the only effective approach for long-term weight loss in the severely obese, according to background information in the article. "During the last decade, there has been a marked increase in the number of bariatric operations performed annually, which coincides with the increased acceptance and demand of these procedures worldwide," the authors write. "The evolution of bariatric surgery has also led to a rapidly increasing demand for revisional bariatric procedures following the discontinuation of surgical techniques favored in the past that had unsuccessful weight loss results or other complications in the long term." Rates of second bariatric operations are reported to be anywhere from 5 percent to 56 percent.
Charalambos Spyropoulos, M.D., and colleagues at the University Hospital of Patras, Rion, Greece, studied 56 patients (average age 39.6, average body mass index 46.9) who underwent revisional bariatric surgery at one institution between 1995 and 2008. The patients had three primary reasons for undergoing revisions: 39 had unsatisfactory weight loss after their initial procedure, 15 had severe nutritional complications such as protein malnutrition and two had intolerable adverse effects, including blocking or narrowing of the digestive tract.
The participants were followed for an average of 102 months. None died, but 19 patients (33.9 percent) had serious complications within 30 to 90 days, including internal leakage from the surgical site, acute kidney failure and pneumonia. Late complications (after more than 90 days) were experienced by 13 patients (23.2 percent) and included development of a hernia at the incision site, narrowing of the passageway between the stomach and intestine and low levels of albumin in the blood.
Patients who had revision surgery due to inadequate weight loss experienced a significant decrease in body mass index (BMI), from an average of 55.4 to an average of 35, and an average loss of 68.9 percent of excess body weight. Among those with nutritional complications, total resolution of all clinical signs and symptoms of protein malnutrition were resolved, and although they regained a small amount of weight they reported being satisfied by the final outcome. The two patients with intolerable complications after their initial procedure also experienced favorable outcomes after revision.
"The accelerated growth of bariatric surgery during the last decade has led to a proportional increase of bariatric revisions worldwide. As improvements in technique and instrumentation take place in this surgical field, along with the novel compelling application of bariatric surgery in the treatment of severe metabolic disorders, it is very likely that revision rates of both failed operations of the past and currently popular procedures will increase considerably in the near future," the authors conclude. "New concepts and improved techniques by well-trained surgeons in properly organized institutions coupled with cautious patient selection represent the cornerstone for achieving favorable results and for extending patients' longevity."
(Arch Surg. 2010;145:173-177. Available pre-embargo to the media at www.jamamedia.org.)
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