LAUSR

Dear editor We greatly appreciate the great interest and thoughtful comments on our paper by the authors of the letter to the editor concerning: Clinical Outcomes of Sleeve Gastrectomy Versus Roux-En-Y Gastric Bypass After Failed Adjustable Gastric Banding. We hope our reply will satisfy you. We fully agreed with the comment that this enthusiasm for laparoscopic adjustable gastric banding (LAGB) was tempered by the realization of the high incidence of late complications and high explantation rate for poor weight loss [1]. In addition, based on the most recent data provided by ASMBS (American Society for Metabolic and Bariatric Surgery), LAGB, which accounted for 35.4% of all weight loss and metabolic procedures in 2011, was only second to RYGB (36.7%). The proportion of LAGB decreased year by year in the following years and LAGB accounted for only 2.77% by 2017 [2]. These available evidences indicated that LAGB is not one of the commonest performed procedures anymore. However, there are enormous numbers of patients who have bands, and who may require revision surgery. This is an important point we want to make and it is the clinical significance of our meta-analysis. As far as our meta-analysis is concerned, insufficient weight loss is still the main cause of revisional surgery after failed LAGB. According to the analysis, 57.2% of the patients who underwent revisional surgery were due to insufficient weight loss. Moreover, the proportion for conversion of failed LAGB to Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) for the cause of insufficient weight loss was 62.19% and 64.25%, respectively. Therefore, we can still conclude that insufficient weight loss is the main cause of revisional surgery at present, and this trend is consistent with previous articles and continues in 2019. In our meta-analysis, there is no available data for us to analyze and compare the effectiveness of revisional surgery for the patients with different reasons such as insufficient weight loss, band-related, and other postoperative complications. Which revisional procedure was the most suitable operation according to the reasons for conversion of failed LAGB to RYGB or SG is hard to conclude. Based on the literatures you recommend [3, 4], there is a possibility of postoperative bowel obstruction in the patients who received RYGB, whether the mesentery is closed or not. In our meta-analysis, there were only two articles with available information about mesentery. In the article conducted by Moon et al., all hiatal hernias were suture closed when present and the mesentery was left intact. There was one patient who was found to have internal herniation at the mesenteric defect 31 months after conversion [5]. The mesenteric defects of all the patients in the article conducted by Angrisani were closed [6]. These two literatures in the included studies showed that the proportion of mesenteric closure was 100%. In addition, both one-stage and two-stage procedures were performed for the patients in eight studies [7–14]. In five studies, all patients were treated with one-stage operations [6, 15–17], while in one study; two-stage surgery was performed in all patients [18]. The patients reported in the included studies were treated with one-step procedure and two-step procedure was 75.06% (641 patients) and 24.94% (213 patients), respectively. In addition, 90% (324 patients) of patients underwent RYGB as revisional surgery took a one-step procedure, while the rest took a two-step procedure. Moreover, 70.94% (288 patients) of patients underwent SG as revisional surgery took a one-step procedure, while the rest took a twostep procedure. Because the purpose of our meta-analysis was not to discuss the clinical outcomes of one-stage and two* Maomin Song [email protected]