Reply to “Simultaneous Gastric Band Removal and Sleeve Gastrectomy Complication Rate. Letter”

Abstract

It was with great interest that we read Dr Campanile and Dr Silecchia’s comments on our article “Simultaneous gastric band removal and sleeve gastrectomy: a comparison with front-line sleeve gastrectomy”, and we thank them for their interest. The article may not have been clear enough in some respects, and we hope that the information below will clarify matters. In our center, we use a 34-French bougie to guide the staple line for primary and secondary sleeve gastrectomy since the weight loss results are better [1]. Most cases of revisional surgery after a primary bariatric procedure are indicated by insufficient weight loss (as in our series) [2, 3], and so any revisional surgery must maximize the likelihood of weight loss. In the series described in our present article, we did not reinforce the gastric staple line because a report published during the study period found that there was no significant decrease in the gastric fistula rate when using this technique [4]. We agree with Dr Campanile and Dr Silecchia that reinforcement does indeed appear to reduce the postoperative gastric fistula rate [5, 6]; however, the data they cite were obtained very recently, i.e., after our series of Roux-enY gastric bypass (RGB) + laparoscopic sleeve gastrectomy (LSG) procedures. In order to identify at-risk situations in which simultaneous RGB + LSG cannot be performed, we always perform gastroscopy 1 month before RGB and LSG (e.g., to check for intragastric migration of the gastric band). If migration has occurred or if we discover a gastric fistula during the gastric banding removal procedure, we do not perform an LSG in the same procedure as RGB. The gastric fistula rate in our present publication concerned patients having undergone surgery up until May 2009 and, indeed, was relatively high in both the RGB + LSG and LSG groups. Nevertheless, our results should be compared with those of other series published during the same period, in which the gastric fistula rate after primary LSG ranged from 3 to 4 %. These other published series had much the same sample size as in our report and thus corresponded to similar levels of surgical experience [7, 8]. Actually, our current results for the gastric fistula rate are also similar to other series which, for the 800 primary LSGs in our surgical center, we have noted a gastric fistula rate of 2.3 % (and just 1.9 % for patients having undergone surgery in the last 2 years). The latest meta-analysis (published in 2012) reported a gastric fistula rate of 2.2 % [5]. With respect to the conclusion “the performance of RGB + LSG [...] does not increase postoperative morbidity,” based on our experience with a series of 46 patients, there were two gastric fistulas (concerning the fifth and 20th patients to have undergone surgery). None of the last 26 patients in our series presented a postoperative gastric fistula. Our impression was that (as with primary LSG [9]) there is a learning curve for RGB + LSG, which is an operation with distinct characteristics. We agree that performing RGB + LSG in the same procedure can be difficult; the poor results in the literature data suggest that most surgical teams do not have enough experience of this technique. None of the series contained more than 26 patients. Since the publication of our series concerning 46 patients, we have performed a further 26 RGB + LSG procedures. Out of our total of 72 RGB + LSG procedures, we recorded only two gastric fistulas L. Rebibo : P. Verhaeghe :A. Dhahri : J.-M. Regimbeau Department of Digestive Surgery, Amiens University Medical Center, Amiens, France