Revision of failed restriction to RYGB
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Transcript Revision of failed restriction to RYGB
Mr Adam Skidmore FRACS
Assoc Professor Sim0n Woods FRACS
Upper GI and HPB Cabrini Medical centre, Melbourne
Introduction
Look at 29 patients who have had either a failed Gastric
Band – adjustable and fixed , VBG/HGR or Jejuno-ileal
bypass
Failure was either weight regain/non weight loss
Technical failure of the original operation
Other issues – gastroparesis, reflux and vomiting
Techniques for revision
Results of our experience
Sometimes surgery doesn't work
Revision is an option
2 surgeon series
29 cases of conversion of HGR/VBG, Gastric Band or
jejuno-ileal bypass to RYGB
Experienced in RYGB – open and Laparoscopic
Gastric Band Failure
Defined as either no weight loss at all or weight loss of
less than 10% EW
Variety of reasons
Maladaptive eating behavior
Technical issues with the band
Recurrent slip
Dilation of the pouch
Failure of VBG/HGR
Late failures - most 10years +
Maladaptive eating behaviour
Dilatation of the pouch – weight regain or reflux
Staple line dehiscence – weight regain
Reversal of stapling
Encouraged to reverse if severe maladaptive eating
Reversal is by removal of the sutures
6 months of normal diet and exercise prior to reversal
Methods of revision
All patients are fully evaluated by a multidisciplinary
team
Often have seen a Nutritional physician
Gastroscopy
Barium series
At least 2 pre operative consults with the surgeon
2 weeks of optifast BMI <50
4 weeks of optifast BMI>50
Slipped band
Dilated pouch with stenosis
Large hiatal hernia
Roux En Y Gastric Bypass
Preferred method of revision
Open approach
Often multiple previous surgeries
Midline laparotomy
Laparoscopic staplers/seamguard
Upper GI omnitract
Handsewn Gastrojejunostomy or orvil 25mm circular
stapler
Handsewn enteroenterostomy
Bariatric omnitract
Results
29 patients
Range of previous surgeries
Often multiple operations - open and laparoscopic
Mostly failure of weight loss
Significant amount of failures related to technical
issues
All successful completion to RYGB
3 underwent a partial gastric resection
2 underwent a partial liver resection
Results
Limited by follow up of 2-18 months
Average weight – 121 kg
170kg – 80 kg
20 females and 9 males
Weight loss average – 60% EW excluding patients
<6months
All had resolution of gastroparesis
Significant improvement in diabetes
All had resolution of reflux and vomiting
Complications
Leak – 2 gastrojejunostomy leaks
Bile leak – 1 bile leak treated by percutaneous drain
Wound infection – 2 wound infections requiring AB
and 1 requiring VAC dressing
Incisional hernia and internal herniation – 5
incisional hernias and 1 internal hernia
LOS and return to work
Average LOS – 5 days
Return to work – 3.5 weeks
TAKES AT LEAST 3 MONTHS TO RETURN TO
PREOPERATIVE QUALITY OF LIFE
Tips and pitfalls - stapling
Important to determine if stapling is dehisced or if
large pouch
If large pouch – must stay within the staple line – risk
of ischaemia
Sometimes better to perform a fundectomy excising
the fundus and staple line – easier to enter the lesser
sac away from adhesions
Fundectomy/mini sleeve can minimize splenic injury
Gastric band
If there is slippage – REMOVE THE BAND AND WAIT
If no slippage it is safe to perform in one surgery – MUST
REMOVE THE CAPSULE AND ALL SUTURES
GREEN LOADS +/- SEAMGUARD
Difficult Left lobe of Liver
Bleeding
Adhesions
Can remove part of the left lobe safely with the echilon
stapler
Less bleeding
Less Bile leak
Post operative
NGT – 24 hours
Gastrograffin swallow 24-48 hrs
Fluids after confirmation of no leak
Jackson pratt drain for 5 days
In very large patients useful to drain the subcutaneous
space
Vac dressings can be useful in very large patients with
wound infection
conclusions
Technically challenging
Access to ICU and Interventional radiology
Multidisciplinary support
Results can be as good as primary RYGB
Morbidity is higher