Reoperative surgery for nonresponders and complicated sleeve gastrectomy operations in patients with severe obesity. An international expert panel consensus statement to define best practice guidelines

Abstract

Background: Laparoscopic sleeve gastrectomy (SG) has rapidly become the most commonly performed bariatric procedure in the United States as well as other countries, with approximately 120,000 procedures being performed annually in the United States. Reoperative interventions after SG have become more prevalent in the past few years since the initial development of SG as a primary operation. Given the expected rapid growth of these reinterventions, an expert consensus conference was held with some of the most experienced bariatric surgeons in the world to better understand, discuss, and provide consensus on the reasons, indications, contraindications, and surgical options for nonresponders and complicated SG operations.

Objectives: Provide consensus-based best practice guidelines regarding the performance of reinterventions after failed or complicated SG in patients with obesity, using expert opinion by organizing a consensus meeting of experts and evaluating the current literature.

Setting: The meeting was held in Boca Raton, Florida on February 18, 2017.

Methods: The panel of 32 expert bariatric surgeons representing 12 countries and major regions of the world and all 6 populated continents identified 54 questions for consensus. Questions encompassed patient selection, indications, contraindications, surgical technique, prevention and management of weight regain, and short- and long-term complications after SG. Responses were calculated and defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement). The current available literature was extensively reviewed for each topic in question and proposed to the panel.

Results: Full consensus was obtained for the essential aspects of indications and contraindications, surgical technique, management, and prevention of complications. Consensus was achieved for 35 of 54 key questions. Highlights include consensus recommendations regarding technique in reoperation, management of GERD and Barrett's esophagus after SG, and surgical options for poor initial weight loss. No consensus was reached on topics, such as management of chronic proximal fistula after SG.

Conclusions: This first international expert meeting provides 35 statements and recommendations for a clinical consensus guideline regarding standardization of indications, contraindications, surgical options, and surgical techniques when reoperating on patients who underwent a failed or complicated SG. To our knowledge, the present consensus report represents the first document that defines best practice guidelines for the performance of reinterventions after failed or complicated SG.

Keywords: Consensus; Reintervention; Reoperative surgery; Revision; Sleeve gastrectomy.