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      Laparoscopic vertical sleeve gastrectomy after open gastric banding in a patient with situs inversus totalis

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      Journal of Minimal Access Surgery
      Medknow Publications & Media Pvt Ltd

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          Abstract

          Dear Sir, I read with interest the recent unusual case, “Laparoscopic vertical sleeve gastrectomy after open gastric banding in a patient with Situs Inversus Totalis a case report and review of literature”, written by Gary B DeutschG.[1] I congratulate the author for his excellent work. I would like to comment on some of issues regarding selection of revisional procedure. Unfortunately, revisional surgery is required in 20-30% of cases of Laparoscopic adjustable gastric banding (LAGB) given the failure of this first procedure to produce meaningful weight loss. The availability of different surgical options for treatment of failed gastric banding makes the question of which operation is best. Several revisional strategies have been proposed, but there is no consensus regarding the best surgical option. Revision of failed gastric banding can be converted into four different bariatric procedures like laparoscopic sleeve gastrectomy [LSG], laparoscopic Roux-en-Y gastric bypass [LRYGB], and laparoscopic biliopancreatic diversion with or without duodenal switch [BPPDS]. But these surgical procedures are not equivalent alternatives as mentioned by author. Each procedure has its advantages and disadvantages with regards to safety, perioperative and long term morbidity, weight loss efficacy, and improvement of comorbidities. Roux-en-Y gastric bypass is a commonly chosen revision technique. The weight loss success rate after roux-en-Y gastric bypass revision surgery is generally excellent. Over the past few years laparoscopic sleeve gastrectomy is being done in few centers because it has a lower potential for complications. Revisional surgery to a duodenal switch is a complex operation and carries a high potential for major complications. Nonetheless, it can be accomplished safely with good long-term results. Review of literature shows that the mean excess weight loss (EWL) after revision surgery for failed gastric banding was 22.0%, 57.8% , 47.1% for the LSG, LRYGB, and BPDDS group, respectively. The EWL reached 78.4% (35) in the BPPDS group after two years follow up.[2] Diabetes resolution was greatest for subjects undergoing biliopancreatic diversion [95%] followed by gastric bypass [80%] and 63% resolution seen after laparoscopic sleeve gastrectomy.[3] Weight loss associated with LRYGBP significantly improves the symptoms of sleep apnea and improvement of obstructive sleep apnea symptoms occur as early as 1 month postoperatively.[4] Failed restrictive procedure, such as gastric banding, should be replaced by another, not purely restrictive, procedure. The laparoscopic conversion to a gastric bypass leads to a moderate restrictive procedure in combination with malabsorptive mechanisms and with suppression of gastrointestinal hormones, such as plasma ghrelin.[5] Conversion to a malabsorptive bariatric procedure may be the better option for this patient as she had body mass index of 42 kg/m2 and had many co morbidities like, hypertension, noninsulin-dependent diabetes mellitus, hypothyroidism, and obstructive sleep apnea. Stable weight loss and resolution of co morbidities appear promising after malabsorptive bariatric procedure. However, the choice of operation can be done after in- depth discussion between patients and surgeons with regard to perioperative and late complication data, long term weight loss, variability of weight loss, as well as data regarding the rate for remission of co morbidities between these procedures.

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          Laparoscopic Roux-en-Y gastric bypass, but not rebanding, should be proposed as rescue procedure for patients with failed laparoscopic gastric banding.

          To define whether laparoscopic rebanding or Roux-en-Y gastric bypass represents the best approach for failed laparoscopic gastric banding in patients with morbid obesity. Countless laparoscopic gastric bandings have been implanted during the recent years worldwide. Despite excellent short-term results, long-term failures and complications have been reported in more than 20% of patients. Which rescue procedures should be used remains controversial. Therefore, we analyzed our experience with the use of laparoscopic rebanding versus laparoscopic Roux-en-Y gastric bypass after failed gastric banding. Using a prospectively collected database, we analyzed the feasibility, safety, and effectiveness of laparoscopic rebanding versus laparoscopic conversion to Roux-en-Y gastric bypass after failed laparoscopic gastric banding. RESULTS A total of 62 consecutive patients were treated in our institution between May 1995 and December 2002 for failed primary laparoscopic gastric banding, including 30 laparoscopic rebandings and 32 laparoscopic conversions to Roux-en-Y gastric bypass. Rebandings were preferably done during the initial period of the study and Roux-en-Y gastric bypass in the last period. Both groups were comparable before the initial banding procedures. At the time of redo surgery, patients receiving a gastric bypass had more esophageal dysmotility (47% vs. 7%, P = 0.002) and higher body mass index (BMI) than those elected for rebanding procedures (BMI 42.0 vs. 38.4 kg/m2, P = 0.015). Feasibility and safety: Each procedure was performed laparoscopically. Mean operating time was 215 minutes for gastric bypass and 173 minutes for rebanding (P = 0.03). Early complications occurred in one case in the rebanding group and in 2 cases in the bypass group; all underwent a laparoscopic reexploration without the need for open surgery. There was no mortality in this series. Effectiveness: BMI in the gastric bypass group decreased from 42.0 to 31.8 kg/m2 (P = 0.02) within 1 year of surgery, while it remained unchanged in the rebanding group. Laparoscopic conversion to a gastric bypass as well as laparoscopic rebanding are feasible and safe. Conversion to gastric bypass offers a significant advantage in terms of further weight loss after surgery. Therefore, this procedure should be considered as the rescue therapy of choice after a failed laparoscopic gastric banding.
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            Resolution of obstructive sleep apnea after laparoscopic gastric bypass.

            Obstructive sleep apnea is a common condition in patients undergoing bariatric surgery. The aim of this study was to determine the clinical outcome of a cohort of morbidly obese patients with documented sleep apnea who underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP). 56 morbidly obese patients with documented sleep apnea by polysomnography underwent LRYGBP. There were 36 females with mean age 46 years and mean BMI 49 kg/m2. The Epworth sleepiness scale (ESS) scores and the number of patients requiring the use of continuous positive airway pressure (CPAP) therapy were recorded preoperatively and at 3-month intervals. The mean length of sleep apnea condition was 44 +/- 55 months. Preoperative polysomnography scores were classified as severe in 50% of patients, moderate in 30%, and mild in 20%. 29 of 56 (52%) patients required CPAP therapy preoperatively. The mean excess body weight loss was 73 +/- 3% at 12 months. The mean ESS score decreased from 13.7 preoperatively to 5.3 at 1 month postoperatively (P<0.05) and maintained below the threshold level (<7) for the entire 12 months of follow-up. Of the 29 patients requiring preoperative CPAP, only 4 (14%) patients required CPAP at 3 months postoperatively and none required CPAP at 9 months. Weight loss associated with LRYGBP significantly improves the symptoms of sleep apnea and is effective in discontinuation in the clinical use of CPAP therapy. Improvement of obstructive sleep apnea symptoms occur as early as 1 month postoperatively.
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              Laparoscopic vertical sleeve gastrectomy after open gastric banding in a patient with situs inversus totalis

              While several equivalent alternatives are available in the bariatric algorithm, more recently the laparoscopic sleeve gastrectomy (SG) has been gaining traction as an effective means of weight loss in patients with morbid obesity. We present the case of a 39-year-old woman with situs inversus totalis, who was taken to the operating room for laparoscopic SG. The patient had previously undergone a failed open gastric banding procedure 20 months earlier. Awareness of the inherited condition before performing the operation allows for advanced planning and preparation. Subsequent modifications to the standard trocar placement help make the procedure more technically feasible. To our knowledge, this is the first published report of a laparoscopic SG after open gastric banding in a patient with situs inversus totalis. After encountering the initial disorientation, we believe experienced laparoscopic surgeons can perform this procedure successfully and safely.
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                Author and article information

                Journal
                J Minim Access Surg
                J Minim Access Surg
                JMAS
                Journal of Minimal Access Surgery
                Medknow Publications & Media Pvt Ltd (India )
                0972-9941
                1998-3921
                Jul-Sep 2013
                : 9
                : 3
                : 145-146
                Affiliations
                [1]Department of Surgery, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
                Author notes
                Address for correspondence: Dr. K. Sugunakara Rao, Department of Surgery, King George Hospital, Visakhapatnam, Andhra Pradesh, India. E-mail: suggukodi@ 123456yahoo.co.in
                Article
                JMAS-9-145
                10.4103/0972-9941.115385
                3764662
                24019697
                f584f88d-d597-4f03-927c-97a162a9c8e3
                Copyright: © Journal of Minimal Access Surgery

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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                Surgery

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