from lapband to sleeve

Question
I have had the lap band twice.  The first time was March 05' and then July 07'.  It was removed and replaced due to slippage.  The second band never worked because it was either too tight or not tight enough and I would get reflux.  So, we stopped filling. With first surgery, I lost around 50 lbs and heavily exercised as I have continued to do since 2003.  Currently, my weight continues to yo yo at 15 lbs.  

I have been approved for the sleeve by my insurance company.  What are the risks of the taking the band out and performing the sleeve at the same time?  If it is not done in one surgery, how much time should lapse between removing the band and performing the sleeve?  I know that my surgeon does the stapling with sutures as well to protect against leaks.  What would you suggest happen in this situation?  Thanks much.

Answer
Hi:

Honestly, your surgeon will not be able to tell you if he can convert you to a Sleeve at the same time until he gets in there and sees what damage the Lap Band has done.  For most people, they can be converted at the same time--but for others, they need about six weeks to three months healing time.  It will have to be your surgeon's decision.

Stapling with suturing over the staple line does help with leaks, that's true.  Your bigger concern will be that you are used to restriction, and adjustable restriction--that gets tighter as time goes by.... yet with the Sleeve the reverse is true.  You'll have the most restriction immediately after surgery, but your sleeve will continue to stretch over time... even if your surgeon uses a 32 or 34F bougie.

You are facing your second revision... are you sure the Sleeve is the right choice? In general, if you have not been successful with a restrictive-only operation, you are better off with a malabsorption operation.  I understand the appeal of the Sleeve.  A normal stomach! :)  You can eat whatever you want.  No fills.  But, the Sleeve to Band revisions usually are less successful than Virgin sleeves.. with weight loss around 41% EWL.  About 20% less than virgin Sleeves.   I really think you should look at the Duodenal Switch and RNY before you go ahead with surgery to avoid yet another revision in your future.  If you are OK with losing only about 40% of your excess weight, then go ahead with the Sleeve.  But if you truly won't be happy unless you have 60% or more weight loss, then you need to think malabsorption.  The DS would give you a functioning stomach like the Sleeve with malabsorption and excellent weight loss.  As with the Sleeve (and DS and RNY), you'll need supplements as well as regular bloodwork for life... but you would need that with the Sleeve too. (Vit B12 sublingual, Vit D, Cal, Mg, Iron...minimum for Sleeve.)

Here are two different studies which showed similar results with Lap-Band to Sleeve revisions.  You will find people on the boards who've had different results--but sadly, they tend to be the exceptions.  Just from a logical standpoint--if you adjustable restriction doesn't work, non-adjustable restriction isn't going to offer you better results...even with the ghrelin effect.

Surg Obes Relat Dis. 2009 Sep 15. [Epub ahead of print]
Sleeve gastrectomy as revisional procedure for failed gastric banding or gastroplasty.

Foletto M, Prevedello L, Bernante P, Luca B, Vettor R, Francini-Pesenti F, Scarda A, Brocadello F, Motter M, Famengo S, Nitti D.

Bariatric Unit, Azienda Ospedaliera Universita' di Padova, Padova, Italy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is considered an effective multipurpose operation for morbid obesity, although long-term results are still lacking. Also, the best procedure to be offered in the case of failed restrictive procedures is still debated. We here reported our results of LSG as a revisional procedure for inadequate weight loss and/or complications after adjustable gastric banding or gastroplasty. METHODS: Since April 2005, 57 patients (20 men and 37 women), with a mean age of 49.9  /- 11.9 years, underwent revisional LSG, 52 after laparoscopic adjustable gastric banding/adjustable gastric banding and 5 after vertical banded gastroplasty at our institution. The mean interval from the primary procedure to LSG was 7.54  /- 4.8 years. The LSG was created using a 34F bougie with an endostapler, after removing the laparoscopic adjustable gastric band or the anterior portion of the band in those who had undergone vertical banded gastroplasty. An upper gastrointestinal contrast study was performed within 3 days after surgery and, if the findings were negative, a soft diet was promptly started. RESULTS: A total of 41 patients had undergone concurrent band removal and LSG and 16 had undergone band removal followed by an interval LSG. Three cases required conversion to open surgery because of a large incisional hernia. The mean operative time was 120 minutes (range 90-180). One patient died of multiple organ failure from septic shock. Three patients (5.7%) developed a perigastric hematoma, 3 (5.7%) had leaks, and 1 had mid-gastric short stenosis. The median hospital stay was 5 days. The mean body mass index at revisional LSG was 45.7  /- 10.8 kg/m(2) and had decreased to 39  /- 8.5 kg/m(2) after 2 years, with a mean percentage of the estimated excess body mass index lost of 41.6%  /- 24.4%. Two patients required a duodenal switch for insufficient weight loss. CONCLUSION: LSG seems to be effective as revisional procedure for failed LAGB/vertical banded gastroplasty, although with greater complication rates than the primary procedures. Larger series and longer follow-up are needed to confirm these promising results.

Obes Surg. 2009 Sep;19(9):1216-20. Epub 2009 Jun 27.
Laparoscopic sleeve gastrectomy as revisional procedure for failed gastric banding and vertical banded gastroplasty.

Iannelli A, Schneck AS, Ragot E, Liagre A, Anduze Y, Msika S, Gugenheim J.

Service de Chirurgie Digestive et Transplantation H閜atique, H魀ital Archet 2, 151 Route Saint Antoine de Ginestiere, BP 3079, 06202 Nice, France. [email protected]

BACKGROUND: The problem of revision of failed gastric banding (GB) and vertical banded gastroplasty (VBG) procedures has become a common situation in bariatric surgery. Laparoscopic sleeve gastrectomy (LSG) has been recently used to revise failed restrictive procedures. The objective of this study is to evaluate the results of LSG as revisional procedure for failed GB and VBG. METHODS: A prospective held database was questioned regarding patients' demographic, indication for revision, conversion to open surgery, morbidity, percentage of excess weight loss (%EWL), evolution of comorbidities, and need for a second procedure after LSG. RESULTS: Forty-one patients, 34 women and seven men with a mean age of 42 years (range 19 to 63 year

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