Removal Of Adjustable Gastric Band Research Articles

Uncommon Complication of a Biliary Leak After Adjustable Gastric Band Removal: A Case Report

Uncommon Complication of a Biliary Leak After Adjustable Gastric Band Removal: A Case Report

Gastric remnant perforation after single anastomosis gastric bypass

Introduction: Acute perforation of gastric remnants after single anastomosis gastric bypass are scarcely reported in the literature. The leak of gastrointestinal contents into the abdomen increases morbidity and if not promptly recognized can lead to mortality from sepsis. Case Report: A 42-year-old male developed abdominal pain and fever after laparoscopic removal of adjustable gastric band, hiatus hernia repair, and single anastomosis gastric bypass. Computed tomography showed evidence of viscus perforation, bowel obstruction, and intra-abdominal infection. Operative findings suggested bowel obstruction of the afferent small bowel loop led to perforation at the gastric remnant staple line which was repaired primarily. Conclusion: Patients presenting with early sepsis after single anastomosis gastric bypass should be investigated with computed tomography. Gastrointestinal leaks should be promptly addressed with surgical washout, primary repair, and suture reinforcement.

Controlling intraoperative laparoscopy-induced pneumothorax using a novel technique

Pneumothorax (PTX) is defined as an abnormal accumulation of gas in the pleural space. There is a potential development of PTX during laparoscopy since gas insufflation is used. Management options are available to control PTX intraoperatively, and herein we describe a new technique that can be implemented with unique features. A 32-year-old patient with morbid obesity was scheduled for laparoscopic adjustable gastric band (AGB) removal and laparoscopic sleeve gastrectomy (LSG). During the removal of AGB, a hiatal hernia was noticed. Dissection of the hernia led to PTX. Images were collected from the procedure video to describe our technique in controlling laparoscopy-induced PTX. Upon noticing PTX, actions were taken promptly using our technique. The anesthesia team was alerted, the abdomen was deflated, and the table was positioned to Trendelenburg. The PTX was controlled using a 14fr feeding tube advanced through the dissected esophageal hiatus, with the external end submerged under saline. The procedure was completed with no complications. Our technique in controlling laparoscopy-induced PTX is effective in certain situations. The technique assures completing the procedure without hindrance with minimal morbidity.

Safety and short-term outcomes of sleeve gastrectomy and Roux-en-Y gastric bypass following removal of adjustable gastric banding

Background: The practice of bariatric surgery was studied using the German Bariatric Surgery Registry (GBSR). The focus of the study was to evaluate whether revision sleeve gastrectomy (R-SG) or Roux-en-Y Gastric Bypass (R-RYGB) has a major benefit in terms of perioperative risk in patients after failed Adjustable Gastric Banding (AGB). Methods: The data collection includes patients who underwent SG or RYGB as revision surgery after failed AGB between 2005 and 2019. Outcome criteria were perioperative complications, comorbidities, 30-day mortality, and operative time. Results: The study analyzed data from 1395 patients after revision SG and RYGB. 907 patients after R-RYGB, and 488 after R-SG. Intraoperative and overall postoperative complication rates were not significantly different between the two groups (p=0.321 and 0.621). The specific postoperative complication rate was significantly lower in R-SG than in R-RYGB (p=0.049). The mean operative time differed significantly between the two groups in favor of R-SG (160.3 min vs. 128.3 min; p<0.001). There was no significant difference in 30-day mortality between the two groups (p=0.952). Conclusion: The study shows that R-SG and R-RYGB are safe and feasible as revision procedures and have acceptable complication and mortality rates. However, in our study, we cannot make a recommendation in favor of any of the surgical methods. Proper patient selection is essential to avoid possible adverse effects. Concerning the long-term results, further studies with higher methodological quality are necessary.

Safety and short-term outcomes of sleeve gastrectomy and Roux-en-Y gastric bypass following removal of adjustable gastric banding

Safety and short-term outcomes of sleeve gastrectomy and Roux-en-Y gastric bypass following removal of adjustable gastric banding

Resection of Fibrous Pseudocapsule in a Patient with Secondary Achalasia and Persistent Symptoms After Removal of Adjustable Gastric Band: Case Report and Review of the Literature

Background: Secondary achalasia in the setting of an adjustable gastric band is a known, but rare complication. Most of the symptoms usually resolve after deflating or removing the gastric band, bu...

Removal of Gastric Band Does Not Always Lead to Significant Weight Gain

Background: Reported outcomes after removal of adjustable gastric band (AGB) are very limited, yet, important to direct patient and surgeon decision-making. The aim of this study was to investigate the medium-term weight changes in patients who underwent AGB removal without an additional bariatric procedure. Methods: In this retrospective study, we analyzed data of 25 patients who had undergone AGB removal without an additional bariatric surgery (2009–2016). Results: The reasons for the AGB removal included gastroesophageal reflux disease (n = 10, 40%), band slippage (n = 5, 20%), band prolapse (n = 5, 20%), band erosion (n = 4, 16%), and planned incisional hernia requiring mesh implantation (n = 1, 4%). At a median follow-up time of 2 years (interquartile range [IQR] 1–4) after laparoscopic AGB removal, the median weight and body mass index changes were +7.3 kg (IQR, −2 and +18) and +1.9 kg/m2 (IQR, −1 and +6), respectively. Forty-eight percent (n = 12) did not gain more than 3 kg of body weight after removal of their gastric band. All patients experienced resolution of their AGB-related symptoms. Conclusion: Recognizing that weight regain is not necessarily inevitable for all patients after gastric band removal may assist in decision-making.

Surgical Management of Adjustable Gastric Band Failures and Literature Review: Algorithm for Removal and Conversion

Adjustable gastric band (AGB) failures frequently require conversion to sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB); the ideal conversional procedure is not established. We report on management of AGB failures at a university hospital along with literature review and proposed treatment algorithm. From October 2012 to January 2017, 32 patients underwent laparoscopic AGB removal with conversion to SG (n = 23) or RYGB (n = 9). Patient characteristics and outcomes were abstracted from medical records and a quality improvement database. Twenty-three patients (71.9%) were female with mean age of 43 ± 10.6 years and mean BMI of 42.7 ± 5.9 kg/m2; 62.5% (n = 20) had 2-staged conversion while 37.5% (n = 12) had 1-stage conversion to SG/RYGB. GERD significantly increased likelihood of conversion to RYGB vs. SG (44.4% vs. 0, p = 0.03). Preoperative diagnostics included upper gastrointestinal series (n = 15,46.7%), esophagogastroduodenoscopy (n = 32,100%), and high-resolution esophageal manometry (HRM) (n = 11,34.4%). Overall complication rate was 9.4% (n = 3). AGB-to-SG patients had mean % total body weight loss of 17.0% ± 5.9 compared to 28.3% ± 15 in AGB-to-RYGB, and mean follow-up of 11.7 ± 12.9 months compared to 18.9 ± 14.4 months. Validated criteria for conversional procedure selection following AGB failure do not exist; appropriate procedure selection requires thorough workup. Future research may elucidate the role of HRM in the diagnostic armamentarium.

The fate of laparoscopic adjustable gastric band removal

Long-term complications and lack of weight loss have caused a surge in laparoscopic adjustable gastric band (LAGB) removal. This study reviews the trend of LAGB removal and examines outcomes of patients undergoing subsequent revision bariatric surgery at a single tertiary care centre in Canada. All LAGB removals performed between January 2008 and December 2016 were reviewed. A subset of patients who underwent revision surgery was then analyzed for patient demographics, weight, body mass index and postoperative complications. During the study period, 211 patients underwent LAGB removal (87.7% female). Most bands were inserted out of province. Reasons for band removal included dysphagia, band slip and weight recidivism. Fifty-nine patients (28%) underwent revision surgery at a mean of 12.8 ± 9.3 (range 0–55) months after LAGB removal. Mean age was 47 ± 9.7 (range 26–63) years, and mean pre-LAGB weight was 131.0 ± 30.0 kg. Following LAGB, the mean weight decreased to 120.5 ± 26.4 kg, but most regained weight after removal to a mean prerevision weight of 125.1 ± 27.0 kg. The lowest mean weight was achieved 12 months after revision surgery (98.7 ± 30.2 kg). The mean percent total weight loss was not significantly different after revision laparoscopic Roux-en-Y gastric bypass compared with revision laparoscopic sleeve gastrectomy (22.8 ± 9.6% v.17.5 ± 6.5%, p = 0.179). The overall revision surgery 30-day complication rate was 18.6% and increased to 23.7% long-term. No deaths occurred. The number of LAGB removals is increasing. Revision bariatric surgery leads to improved weight loss; however, revision surgery is associated with complications.

Conversion of Adjustable Gastric Banding to Stapling Bariatric Procedures: Single- or Two-stage Approach.

The aim of this study was to compare the safety of single- versus two-stage conversion of adjustable gastric band (AGB) to gastric bypass (RYGB) or sleeve gastrectomy (SG). AGB patients often present for conversion to RYGB or SG. The impact of single- or two-stage approach of such conversion remains unclear. A statewide database was used to identify all patients who underwent AGB removal and concurrent (single-stage) or interval (two-stage) RYGB or SG. Propensity score matching schemes were constructed to account for differences in baseline comorbidities and demographics, allowing for matched pairs available for comparisons. A total of 4330 patients underwent AGB conversion. Complications, readmissions, and ED visits were noted in 394 (9.1%), 278 (6.42%), and 589 (13.6%) patients, respectively. Three hundred sixty-seven matched pairs underwent RYGB; single-stage patients experienced shorter length of stay (LOS) (median difference -1 d, P < 0.0001), less complications [risk difference (RD): -8.4%, 95% confidence interval (CI), -13.4% to -3.5%], readmissions (RD: -5.2%, 95% CI, -9.6% to -0.8%), and ED visits (RD: -5.7%, 95% CI, -11.3% to -0.2%). Eight hundred seventy-five matched pairs underwent SG; single-stage patients experienced improved outcomes in all measures examined. For single-stage procedures (809 pairs), RYGB was associated with longer LOS, and more complications (RD: 3.3%, 95% CI, 0.9%-5.8%), with similar readmissions, and ED visits. AGB conversion procedures have low morbidity. Single-stage conversion is associated with lower morbidity compared with the two-stage approach. Conversion to SG seems to be safer than RYGB.

Postoperative Opioid Prescribing Practices and Evidence-Based Guidelines in Bariatric Surgery

Excessive opioid prescribing creates risk for abuse and adverse effects, but must be balanced against individualized pain control. Minimal literature exists to guide providers in the postoperative bariatric surgical setting. We compare opioid prescribing practice for minimally invasive bariatric surgery in a university hospital with self-reported patient use and satisfaction. This data is used to create practice guidelines for postoperative prescriptions. A 10-question survey was administered at the first postoperative office visit. All patients at this visit were eligible. None declined or excluded. We analyzed 115 patients for 3 procedures: laparoscopic sleeve gastrectomy (LSG; n = 53), laparoscopic roux-en-Y gastric bypass (LRYGB; n = 50), and laparoscopic adjustable gastric band removal (LAGBR; n = 12). Outcomes included number of pills prescribed (verified), proportion used, duration of use, satisfaction with pain control, and non-narcotic analgesic use. An average of 27 ± 10 pills were dispensed for LSG, average 4.1days of use; 28 ± 7 pills for LRYGB, 4.6days; and16 ± 9 pills for LAGBR, 2.6days. Fifty to 74% retained more than half or all of their opioids at 2weeks. Fifty-four percent utilized non-narcotic analgesics. Overall, 91.3% reported adequate pain control. For each procedure, average number of pills used was calculated with representative values for "less than half left" (75% of average number of pills prescribed) and "more than half left" (25% of average number of pills prescribed). For LSG, an average of 9 pills were used; LRYGB 14 pills, and LAGBR 7 pills. Opioids are overprescribed following most common surgical procedures, but only one study has evaluated patterns after bariatric surgery. Our survey-based tool examines prescribing, utilization and satisfaction following common minimally invasive bariatric procedures. Opioid prescriptions were variable, and excessive for most patients. We now recommend prescribing no more than 15 pills after these operations.

A133 - Postoperative opioid prescribing practices and evidence-based guidelines in bariatric surgery

Excessive opioid prescribing creates risk for abuse and adverse effects, but must be balanced against individualized pain control. Minimal literature exists to guide providers in the postoperative bariatric surgical setting. We compare opioid prescribing practice for minimally invasive bariatric surgery in a university hospital with self-reported patient use and satisfaction. This data is used to create practice guidelines for postoperative prescriptions. A 10-question survey was administered at the first postoperative office visit. All patients at this visit were eligible. None declined or excluded. We analyzed 115 patients for 3 procedures: laparoscopic sleeve gastrectomy (LSG; n = 53), laparoscopic roux-en-Y gastric bypass (LRYGB; n = 50), and laparoscopic adjustable gastric band removal (LAGBR; n = 12). Outcomes included number of pills prescribed (verified), proportion used, duration of use, satisfaction with pain control, and non-narcotic analgesic use. An average of 27 ± 10 pills were dispensed for LSG, average 4.1 days of use; 28 ± 7 pills for LRYGB, 4.6 days; and16 ± 9 pills for LAGBR, 2.6 days. Fifty to 74% retained more than half or all of their opioids at 2 weeks. Fifty-four percent utilized non-narcotic analgesics. Overall, 91.3% reported adequate pain control. For each procedure, average number of pills used was calculated with representative values for “less than half left” (75% of average number of pills prescribed) and “more than half left” (25% of average number of pills prescribed). For LSG, an average of 9 pills were used; LRYGB 14 pills, and LAGBR 7 pills. Opioids are overprescribed following most common surgical procedures, but only one study has evaluated patterns after bariatric surgery. Our survey-based tool examines prescribing, utilization and satisfaction following common minimally invasive bariatric procedures. Opioid prescriptions were variable, and excessive for most patients. We now recommend prescribing no more than 15 pills after these operations.

Laparoscopic Removal of Adjustable Gastric Band as an Isolated Procedure: Indications and Early Surgical Outcomes

Background: Adjustable gastric band (AGB) is one of the earlier bariatric procedures that frequently require revision due to either failure of complications. Objectives: To evaluate the indications and outcomes of laparoscopic removal of AGB as an isolated surgical procedure. Methods and Materials: A retrospective review of charts for all patients who underwent laparoscopic removal of AGB was carried out. Patients who had other types of surgeries done during the same operation were excluded. Data about the indications of band removal and the early surgical outcomes were collected. Results: Between January 2003 and October 2016, 1676 bariatric operations were done. Of those, 76 patients (4.5%) had laparoscopic removal of AGB and it was an isolated surgical procedure in 26 (34.2%) patients. The median age of this series was 39.5 years (19-67) and 73% were females. The indications for isolated LRAGB were; weight regain in 12 patients (46%), slippage of band in 9 patients (34.5%), band migration in 3 patients (11.5%) and infection of band in 2 patients (7.5%). There was no conversion to open surgery and no mortality associated with the procedure. The procedures were done electively in all except 2 patients who had acute gastric obstruction secondary to band slippage. Twenty-one patients had short (<48 hours) hospital stay while 5 patients, 2 with obstruction and 3 with infected bands, required longer hospital stay. Conclusions: Isolated Laparoscopic removal of AGB is safe and requires short hospital stay in majority of patients. The commonest indication was weight regain however complications were also frequent. This makes AGB not a preferred option as weight reduction procedure.

Safety and Outcome of Laparoscopic Sleeve Gastrectomy Following Removal of Adjustable Gastric Banding: Lessons from 109 Patients in a Single Center and Review of the Literature.

Although considered a common bariatric procedure, laparoscopic adjustable gastric banding (LAGB) is associated with high rates of weight loss failure and long-term complications. The purpose of this study was to re-assess the safety and outcome of conversion of failed LAGB to laparoscopic sleeve gastrectomy (LSG). One hundred and nine patients underwent conversion from LAGB to LSG (78 females, mean age 43±11.3years, mean BMI 42.4±7.4kg/m2). Patient demographics, obesity-related co-morbidities, BMI before and after the procedure, post-operative complications, and length of hospital stay were documented. All cases were completed laproscopically, with 88% (n=96) performed in a single stage. Fourteen patients developed early post-operative complications (12.8%), including two leaks and three post-operative bleeding. There were no mortalities in this series. Average BMI at least 1-year following surgery was 33±5.3kg/m2 (excess weight loss (EWL)=53.7%). Our data suggests that conversion of failed LAGB to LSG is both safe and effective. Randomized controlled studies comparing conversion of a failed LAGB to sleeve gastrectomy versus other bariatric operations are necessary to clarify the optimal conversion procedure.

Redo Laparoscopic Gastric Bypass: One-Step or Two-Step Procedure?

The adjustable gastric band (AGB) is a bariatric procedure that used to be widely performed. However, AGB failure-signifying band-related complications or unsatisfactory weight loss, resulting in revision surgery (redo operations)-frequently occurs. Often this entails a conversion to a laparoscopic Roux-en-Y gastric bypass (LRYGB). This can be performed as a one-step or two-step (separate band removal) procedure. Data were collected from patients operated from 2012 to 2014 in a single bariatric centre. We compared 107 redo LRYGB after AGB failure with 1020 primary LRYGB. An analysis was performed of the one-step vs. two-step redo procedures. All redo procedures were performed by experienced bariatric surgeons. No difference in major complication rate was seen (2.8 vs. 2.3%, p = 0.73) between redo and primary LRYGB, and overall complication severity for redos was low (mainly Clavien-Dindo 1 or 2). Weight loss results were comparable for primary and redo procedures. The one-step and two-step redos were comparable regarding complication rates and readmissions. The operating time for the one-step redo LRYGB was 136 vs. 107.5min for the two-step (median, p < 0.001), excluding the operating time of separate AGB removal (mean 61min, range 36-110). Removal of a failed AGB and LRYGB in a one-step procedure is safe when performed by experienced bariatric surgeons. However, when erosion or perforation of the AGB occurs, we advise caution and would perform the redo LRYGB as a two-step procedure. Equal weights can be achieved at 1year post redo LRYGB as after primary LRYGB procedures.

Laparoscopic adjustable gastric band removal and outcome of subsequent revisional bariatric procedures: A retrospective review of 214 consecutive patients

BackgroundLaparoscopic adjustable gastric band (LAGB) removal is required in cases of slippage, erosion, infection, intolerance, or failure in weight loss. The aim of the study was to follow up the patients who underwent band removal and analyze the outcome of subsequent revisional bariatric procedures. Patients and methodsA retrospective review of consecutive patients who underwent LAGB removal during 3.5 years. All patients underwent a phone interview in early 2015. Patients were divided to three groups following band removal: without additional surgery, laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en Y gastric bypass (LRYGB), and Redo LAGB(Re-LAGB). Outcome of different revisional procedures was compared according to causes and symptoms before band removal, patient satisfaction, weight loss, quality of life (QOL) questionnaire, and the bariatric analysis and reporting outcome system II (BAROSII) score. ResultsOverall 214 patients (73.8% females) with mean age of 41.9 years were enrolled in the study. The mean time between LAGB placement and removal was 81.0 months. Mean % estimated weight loss (%EWL) was 29.6 at time of band removal. There was no difference between groups in patient age, gender, BMI before LAGB, and most co-morbidities. Patients with 1–5 outpatient visits preferred additional surgery. Patients suffering from vomiting from 1 to 10 times per week preferred revision as LSG or LRYGB. Patients with lower BAROS score underwent LSG or LRYGB. Most of the patients with band intolerance underwent conversion to another bariatric procedure, while patients with band erosion and infected band preferred Re-LAGB. Most of the patients without band gained weight. There was a significant improvement in %EWL (39.9 vs 29.6), QOL (1.08 vs 0.07), and BAROS(2.82 vs-0.11) in patients who underwent additional bariatric surgery before and after band removal irrespective of surgery type. ConclusionsPatient selection for different revisional bariatric procedures after LAGB removal is a main point for surgery success. This results in high patient satisfaction, EWL, and QOL. All options (Re-LAGB, LSG, LRYGB) are feasible and safe.

Sugammadex Allows Fast-Track Bariatric Surgery

Morbidly obese (MO) patients are at increased risk for postoperative anesthesia-related complications. We evaluated the role of sugammadex versus neostigmine in the quality of recovery from profound rocuronium-induced neuromuscular blockade (NMB) in patients with morbid obesity. We studied 40 female MO patients who received desflurane and remifentanil anesthesia for laparoscopic removal of adjustable gastric banding. NMB was achieved with rocuronium. At the end of the surgical procedure, complete reversal of NMB was obtained with sugammadex (SUG group, n = 20) or neostigmine plus atropine (NEO group, n = 20) in the presence of profound NMB. No difference in surgical time or anesthetic drugs was found between the groups. Anesthesia time was significantly greater in the NEO group than in the SUG group (95 ± 21 vs. 47.9 ± 6.4min, p < 0.0001), which was mainly due to a longer time to reach a train-of-four ratio (TOFR) ≥ 0.9 in the NEO group (48.6 ± 18 vs. 3.1 ± 1.3min, p < 0.0001) during reversal of profound NMB. Upon admission to the postanesthesia care unit, level of SpO2 (p = 0.018), TOFR (p < 0.0001), ability to swallow (p = 0.0027), and ability to get into bed independently (p = 0.022) were better in the SUG group than in the NEO group. Patients in the SUG group were discharged to the surgical ward earlier than patients in the NEO group were (p = 0.013). Sugammadex allowed a safer and faster recovery from profound rocuronium-induced NMB than neostigmine did in patients with MO. Sugammadex may play an important role in fast-track bariatric anesthesia.

Single-Access Laparoscopic Adjustable Gastric Band Removal: Technique and Initial Experience

Single-access laparoscopy (SAL) has gained significant interest in recent years. Potential benefits, beyond cosmetic outcomes, could be reduction of abdominal trauma, decreased risk of incisional hernia and diminished postoperative pain. Technique and initial experience in patients submitted to laparoscopic adjustable gastric band removal (LAGBR) through SAL is reported here. Between December 2009 and March 2012, 14 patients (9 females, 5 males) underwent LAGBR through SAL. Indications for operation were band intolerance (11), pouch dilatation (2) and insufficient weight loss (1). The mean age was 40.3 ± 9.1years (range 26-57), and the mean interval time between LAGB placement and removal was 94.7 ± 41.9months (range 37-157). The mean weight and the mean body mass index at the time of LAGBR were 89.3 ± 17.6kg (range 65-119) and 30.6 ± 4.5kg/m(2) (range 25.3-36.7), respectively. Technically, the previous port site scar was used as the single-access site to the abdominal cavity. An 11-mm reusable trocar was adopted for a 10-mm regular scope, besides curved reusable instruments. No patients required conversion to open surgery and none necessitated additional trocars. The mean laparoscopic time was 24.6 ± 7.9min (range 13-37), and the mean final scar length was 3.6 ± 0.3cm (range 3-4). Two patients experienced early postoperative complications. The mean hospital stay was 1.3 ± 1.1days (range 1-5). The mean follow-up time was of 18 ± 9.8months (range 3-30), and there were no late complications. LAGBR can be safely performed through SAL. Thanks to this technique, the laparoscopic working triangulation is established as well as the ergonomic positions of the surgeon. Due the use of only reusable material, the cost of this SAL remains similar to multiport laparoscopy.

Perioperative outcomes of revisional laparoscopic gastric bypass after failed adjustable gastric banding and after vertical banded gastroplasty: experience with 107 cases and subgroup analysis

A growing number of revision procedures are to be expected in bariatric surgery after failed restrictive procedures such as failed adjustable gastric banding (AGB) or vertical banded gastroplasty (VBG). Conversion to revisional laparoscopic Roux-en-Y gastric bypass (ReLRYGBP) has been advocated as the procedure of choice. The results of ReLRYGBP were reviewed in a retrospective chart review. A subgroup analysis compared perioperative results after VBG and after AGB. A second subgroup analysis compared perioperative results of ReLRYGBP immediately after AGB removal and after a delay as a two-step procedure. Between 2003 and 2009, ReLRYGBP was performed for 107 patients. Of these 107 operations, 21 were performed after failed VBG and 86 after failed AGB. The mean body mass index (BMI) was 42 kg/m(2). The causes of failure were mainly insufficient weight loss or reflux disease-related symptoms. During a median follow-up period of 44 months, there was no mortality, and morbidity was 34 %, including late complications. Major early complications occurred in 11 % of the cases (n = 12). Conversions and major early complications occurred significantly more frequently after VBG than after AGB (p < 0.05). In 59 % of the cases (n = 50), ReLRYGBP was performed as a single-stage procedure immediately after removal of AGB and in 41 % of the cases (n = 36) as a delayed two-step procedure. The outcomes did not differ significantly (p > 0.5). The perioperative outcomes of ReLRYGBP are worse after VBG than after AGB. The ReLRYGBP operation can be performed safely as a one-step procedure after AGB removal.