CME Author: Zeena Nackerdien
Study Authors: Stephan Hjorth, Ingmar Näslund, et al.
Target Audience and Goal Statement: Endocrinologists, gastroenterologists, surgeons, family doctors, and primary care physicians
The goal was to determine the incidence and type of revisional surgery after bariatric surgery in 26 years of follow-up of participants in the Swedish Obese Subjects (SOS) study.
- What was the long-term incidence of bariatric reoperations in patients who underwent bariatric surgery for morbid obesity?
- Could bariatric reoperation patterns be discerned from the findings?
Background, Synopsis, and Perspective
Overweight or obese people now number at least 2.1 billion (2013 estimate) compared with 857 million in 1980, according to the Global Burden of Disease Study. More than a third of Americans are now obese. Obesity is regarded as a disease by the American Academy of Family Physicians, which recommends screening of all adults for obesity and referral for those with a body mass index (BMI) ≥30 to intensive, multicomponent behavioral interventions. Bariatric surgery is currently the most effective option to treat obesity and its related health consequences — e.g., to attain metabolic control and effective prevention, remission, or delay of type 2 diabetes progression.
Guidelines from the American Heart Association, the American College of Cardiology, and the Obesity Society list two types of candidates for bariatric surgery:
- Adults with BMI ≥40
- Adults with BMI ≥35 who have obesity-related comorbid conditions and are motivated to lose weight but have not responded to behavioral treatment with or without pharmacotherapy; to achieve sufficient weight loss for target health goals
In addition, bariatric surgeries are contraindicated for some patients, including those with chronic obstructive pulmonary disease or respiratory dysfunction, poor cardiac reserve, nonadherence to medical treatment, and severe psychological disorders.
Previous research involving bariatric surgery mostly dealt with the outcomes of primary and secondary bariatric interventions; however, studies usually involved short-term to intermediate-term (i.e., <5 years) follow-up of smaller cohorts, and incidence figures varied widely as a function of cohort size, primary surgical procedure, and duration of follow-up.
Stephan Hjorth, PhD, of the University of Gothenburg in Sweden, and colleagues, noted in their new study that there was a gap in the literature with respect to long-term follow-up of one surgical cohort to determine which bariatric operation might be linked to a lower need for secondary interventions.
From 1987 to 2001, a total of 4,047 persons ages 37 to 60 were enrolled in the SOS study. Obese subjects (n=2,010) who underwent bariatric surgeries were contemporaneously matched with control patients (n=2,037) who received usual care.
Bariatric surgeries included in the analysis were gastric bypass procedures (GBP) (13% of the total), banding (19%), and vertical banded gastroplasty (VBG) (68%). Men had a BMI ≥34 and women had a BMI ≥38.
Prior follow-up analysis (2004-2012) showed mean changes in body weight after 20 years of -18% in the surgery group compared with -1% in the control group.
Hjorth and co-authors reported that of the 2,010 patients who underwent an index surgery, 1,365 had VBG (67.9%), 376 underwent banding (18.7%), and 266 had GBP (13.2%).
Bariatric reoperations were more common among persons who had banding (40.7%) and VBG (28.3%) versus those who had undergone GBP (7.5%), the researchers reported. Most corrections occurred within the first 10 years, whereas conversions and reversals occurred over the entire follow-up period. In patients who had banding and VBG, corrections were equally common (5.3%-7.1%) irrespective of index surgery, but indications differed between groups.
Conversions to GBP or reversals were mainly performed on patients who initially had banding and VBG procedures. The incidence of reversals was five times higher after banding than after VBG (40.7% vs 7.5% unadjusted hazard ratio, 5.19 [95% CI, 3.43-7.87]; P < .001).
For the VBG and banding subgroups, reoperations were linked to technical issues, morbidity, and weight. Patients who had GBP tended to have subsequent procedures because of bile reflux and esophagitis.
A limitation of the study, the team noted, was that most of the index operations were done with techniques that are now largely abandoned (e.g., banding and VBG), rather than GBP (and recently also gastric sleeve).
Source reference: JAMA Surgery, Jan. 2, 2019; DOI:10.1001/jamasurg.2018.5084
Study Highlights: Explanation of Findings
During 26 years of follow-up of 2010 eligible study subjects, nearly 28% underwent bariatric reoperations from 1987 to 2014. Corrective surgeries occurred primarily within the first decade. The incidence of secondary surgical procedures varied depending on the initial surgery and was highest in the group that underwent banding (40.7%) and lowest in the group that underwent GBP (7.5%).
The researchers reported that most first-time revisions in the banding subgroup were conversions (about 20% converted to a GBP), followed by reversals and corrections. Patients who underwent conversions in the surgery group were typically female (VBG) and younger (banding and VBG). Baseline BMI did not factor into decisions regarding secondary interventions.
Ricardo Cohen, MD, of Oswaldo Cruz German Hospital in Brazil, wrote in an accompanying commentary that prostheses-related or staple-related complications occurred with high frequencies following adjustable gastric banding and VBG procedures. In addition to being undesirable in terms of long-term weight loss, conversion from VBG into a Roux-en-Y GBP was associated with a 0.5% rate of death.
Published revisional surgery rates (with follow-up ≥5 years) varied from 10% to 56% among patients who had VBG, Cohen noted, adding that the SOS value of 28% for a similar patient cohort fell within the lower part of this range. Because of the higher rate of complications associated with VBG, this surgery was ultimately abandoned, and the editorialist predicted that adjustable gastric banding would have a similar fate.
When broken down by surgery type, the most common reason for a revisional surgery among those who had banding was band-associated problems, such as migration stenosis or slippage. Among banding patients, nausea and weight-related indications were also common reasons for revision. As for VBG patients, the most common indication for revisional surgery was staple-related disruptions, accounting for 10% of these patients. Nausea due to stenosis and collar migration were also common indications for revision.
Cohen also explained that loop GBP predominated at the advent of the SOS study and that alkaline reflux and esophageal problems were the main reasons for Roux-en-Y GBP as the optimal solution. Only five (2.3%) of the 200 patients who initially had a Roux-en-Y GBP required another bariatric surgery.
Compared with banding and VBG, GBP was associated with higher weight loss – a likely reason for the lower number of requests for conversions after the index procedure, Cohen said. He added that interestingly, a prior follow-up analysis at 12 years of the GBP subgroup also showed a lower incidence of diabetes, higher remission rates, and lower incidence rates of hypertension and dyslipidemia compared with the control group.
“Revisional surgery carries a higher complication rate than the primary procedure, but if needed, it should not be denied,” Cohen wrote, also noting the growing number of reported revisions with the recently popular sleeve gastrectomy. Ultimately, he said, “maybe a wiser movement is to start with the right choice and curb the need for reoperations.”
Kristen Monaco wrote the original story for MedPage Today