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

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.