Transcript Revisional Bariatric Surgery

Revisional Bariatric Surgery
Indications and potential benefits.
William Bakhos,MD
Introduction
Revision of a Bariatric Procedure may be
indicated in case of
1-Complications affecting quality of life and resistant to
adequate medical/conservative therapy
2-Failure to lose or maintain adequate weight loss by a
bariatric procedure.
3-Protein/Calorie malnutrition.
Sarr MG.Surg Obes Relat Dis. 2007 Jan-Feb;3(1):25-30
Mayo Clinic College of Medicine, Rochester, Minnesota
Introduction
• Revisional surgery, although technically
challenging, can/may produce desirable
outcomes if performed on the right patient
in the right timing.
Sarr MG.Surg Obes Relat Dis. 2007 Jan-Feb;3(1):25-30
Mayo Clinic College of Medicine, Rochester, Minnesota
Hallowell PT et al.Am J Surg. 2009 Mar;197(3):391-6.
Case western,OH
Introduction
• Reoperations can be both technically challenging and
high risk because these patients may present with
uncorrected serious co-morbidities.
• Furthermore, patients may have extensive abdominal
adhesions, ulcers, inflammation, bowel obstructions,
metabolic disturbances, and other severe physiological
problems attributed to the initial surgeries.
• These difficulties contribute to high postoperative
complications and and thus lead to undesirable
outcomes following revisions.
Introduction
• The clinical efficacy of revisional operations for
failure remains unclear because critical
evaluations for the success of revisions is
limited.
• Currently, guidelines and standards for
reoperative approach are unavailable.
• Multiple approaches have been taken to revise
failed bariatric procedures and have yielded
comparable results.
• 46 of 1,038 bariatric patients underwent revisional
surgery.
• Twenty of 46 had a primary Roux-en-Y gastric bypass.
• The most common indication for revisions is inadequate
weight loss secondary to gastrogastric fistula (15/20).
• Leaks occurred more frequently following revisional
surgeries (11% vs 1.2%), but intensive care unit (ICU)
utilization was less (11% vs 4.4%) and mortality was
lower (0% vs 0.3%) with bariatric revision surgery.
Hallowell PT et al.Am J Surg. 2009 Mar;197(3):391-6.
Case western,cleveland,OH
Lengthening of alimentary limb for
symptomatic bile reflux
• A total of 16 patients were diagnosed with bile reflux and underwent
revisional surgery.
• The onset of symptoms occurred at 58.3 +/- 22.2 months after
RYGB. All patients complained of pain, 13 (81.3%) had vomiting,
and 7 (43.8%) had dysphagia.
• Endoscopy was performed in all patients and confirmed the
presence of bile in all patients and detected marginal ulceration in 5
(31.3%) and gastritis in 8 (50.0%).
• At revisional surgery, the mean alimentary limb length was 37.7 +/12.4 cm (range 20-62 cm),It was lengthened to 100 cm.
• At a mean follow-up of 14.9 months after revision, all patients had
reported resolution of their symptoms.
Swartz DE et al.Surg Obes Relat Dis. 2009 Jan-Feb;5(1):27-30. Epub 2008 Oct 30.
Advanced Bariatric Center, Fresno, California
Revisions of LAGB (for inadequate weight loss)
• Between January 1997 and November 2002, 74
consecutive patients underwent either laparoscopic
gastric rebanding (n = 44) or LRYGB (n = 30) after failed
LAGB.
• The median follow-up was 36 months (range, 24-60
months).
• RESULTS: Patients who underwent LRYGB had a
significantly better weight loss than patients with a
rebanding operation (mean -6.1 versus +1.5 BMI points).
Müller MK et al .Surg Endosc. 2008 Feb;22(2):448-53.
University Hospital, Zurich, Switzerland.
Revisions of LAGB (for complications)
• Series of 270 consecutive patients who had LAGB.
• Device-related reoperations were performed in 26
(10%) patients.
• Slippage
8 Leaking tube/port 6
• Erosion
1 Flipped port
2
• Dilated pouch
5
port infection
5
• Leaking silicone 1
Lyass S et al.Am Surg. 2005 Sep;71(9):738-43.
Cedars Sinai Medical Center, Los Angeles, CA
Conversion from LAGB to RYGB
• A total of 259 patients underwent LRYGB from 2003 to
2007, 58 after failed gastric banding and 201 as primary
surgery.
• Revisional LRYGB required a significantly longer
operative time (128.3 +/- 25.9 minutes versus 89.0 +/14.7 minutes, P <.0001) and the morbidity was greater
(8.6% versus 5.5%), but no patient died in the
postoperative period after revision.
• The 1-year percentage of excess weight loss was
comparable between the 2 groups (66.1% +/- 26.8% and
70.4% +/- 18.9%)
Topart P et al.Surg Obes Relat Dis. 2008 Aug 19.
Clinique de l'Anjou, Angers, France.
AGB on top of RYGB.
• 8 patients.
• The mean weight loss at 1 year of follow-up was 17.03
kg (range 0.2-42), with a mean percentage of excess
weight loss of 24.29% (range 0.2-49.2%).
• The mean weight loss of the 5 patients with 2 years of
follow-up was 36.4 kg (range 20-58), with a mean
percentage of excess weight loss of 48.7% (range 21.898.1%).
• One patient with 3 years of follow-up had a weight loss
of 56 kg and a percentage of excess weight loss of
66.2%. requiring evacuation. No band erosions or band
slippages occurred, and no major complications
developed.
Chin PL et al.Surg Obes Relat Dis. 2009 Jan-Feb;5(1):38-42. Fountain Valley, California.
Revision of LAGB for Pouch dilatation/overrestriction
.
• Series of 425 LAGB all performed by the pars flaccida
approach from June 2003 to October 2007.
• There were no posterior prolapses, 2 anterior prolapses,
and 17 cases of symmetrical pouch dilatation (SPD)
(revision rate 4.4%).
• All revisions were completed laparoscopically with no
mortality, no significant complications, and a median
hospital stay of 1 day. The median weight loss following
revisional surgery was not significantly different from the
background cohort.
Brown WA et al.Obes Surg. 2008 Sep;18(9):1104-8.
Monash University, Melbourne, Australia
Anastomotic ulcers/strictures (RYGB)
• 1012 patients who underwent LRYGB from January
2001 to May 2004.
• Stomas less than 10 mm in diameter, or those not
allowing passage of the scope were considered
significant strictures and were treated with balloon
dilations.
• Sixty-one patients (46 females and 15 males) were
found to have anastomotic strictures, corresponding to
an incidence of 6%. In total, 134 upper endoscopies
were performed, with 128 dilatations.
Ukleja A, Rosenthal R et al. Surg Endosc. 2008 Aug;22(8):1746-50.
CCF Weston,Fl.
Anastomotic ulcers/strictures (RYGB)
• The number of dilations per patient was as follows: a
single dilation in 28% of patients, two dilations in 33%,
three dilations in 26%, four dilations in 11.5%, and five
dilations in 1.5% of patients.
• All the patients responded to dilation without need for
formal surgical revision.
• However, after balloon dilatation three patients (4.9%),
all females, had bowel perforation and had exploration
+/- primary repair without revision.
Ukleja A, Rosenthal R et al. Surg Endosc. 2008 Aug;22(8):1746-50.
CCF Weston,Fl
RYGB to BPD-DS
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Twelve patients were analysed,mean BMI 41.
No patient died and no leaks developed.
One patient required laparotomy.
4 developed stricture at the gastrogastrostomy.
The patients lost a dramatic amount of weight after
conversion to BPD-DS, with a mean body mass index
and excess weight loss of 31 kg/m(2) and 63%,
respectively, at 11 months postoperatively.
• All co-morbidities resolved completely with the weight
loss.
Gagner,M et al.Surg Obes Relat Dis. 2007 Nov-Dec;3(6):611-8. Epub 2007 Oct 23
Cornell University, New York Presbyterian Hospital, New York.
Resection of long tip of the Alimentary limb
(Candy cane)
Resection of long tip of the Alimentary limb
(Candy cane)
• 3 patients.
• The symptoms included regurgitation of food in 2
patients, reflux in 2, significant weight regain in 1,
postprandial pain that was relieved after vomiting in 2,
persistent nausea in 2, and epigastric fullness in 2
patients.
• The resected length of bowel ranged from 8 to 15 cm.
• All had very good outcome.
Dallal RM and Cottam DSurg Obes Relat Dis. 2007 May-Jun;3(3):408-10.
Albert Einstein Healthcare Network, Philadelphia, Pennsylvania
MGB to RYGB.
• The databases of 5 medical centers
• A total of 32 patients were identified who presented with
complications after undergoing an MGB procedure and required or
require revisional surgery.
• The complications included
Gastrojejunostomy leak
3
Malabsorption/malnutrition 8
Bile reflux
20 Weight gain
2
Intractable marginal ulcer 5
• 21 required conversion to RYGB ,5 have planned revisions in the
future. 2 treated with Braun enteroenterostomies and 4 required 1 or
more abdominal explorations.
Johnson WH, Fernanadez AZ, Farrell TM, Macdonald KG, Grant JP, McMahon RL, Pryor AD,
Wolfe LG, DeMaria EJSurg Obes Relat Dis. 2007 Jan-Feb;3(1):37-41
5 centers from VA and NC
MGB to RYGB
• MGB does require revision in some patients
and that conversion to RYGB is a common
form of revision.
• A national registry to record the
complications and number of revisions is
proposed to gain insight into the need for
revision after MGB and other nontraditional
bariatric procedures.
johnson WH, Fernanadez AZ, Farrell TM, Macdonald KG, Grant JP, McMahon RL, Pryor AD,
Wolfe LG, DeMaria EJ.Surg Obes Relat Dis. 2007 Jan-Feb;3(1):37-41
VBG to RYGB
.
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(Lap)
18 patients, mean BMI at 37.6 .
Indications for revisional surgery were insufficient weight loss (11
patients), stoma stenosis (4 patients), and acid reflux (3 patients).
There was one conversion
No early postoperative mortality, and 4 (22.2%) developed
immediate post-op complications (GJ leak 1; stenosis of the GJ 2;
liver abscess 1).
One patient died 6 months after conversion because of a bleeding
anastomotic ulcer (late mortality 5.5%).
2 patients (11.5%) developed late complications (incisional hernia 1;
internal hernia 1). At a mean follow-up of 23, 4 months BMI is on
average 29.8 kg/m(2) (range 22.7-37).
Iannelli A et al. Obes Surg. 2008 Jan;18(1):43-6.
Université de Nice-Sophia-Antipolis, Nice, 06107, France.
VBG to RYGB (Open)
• 28 conversions from VBG to RYGB.
• Preoperative BMI was 40 (range 20 to 58),
• Indications for revision were band-related complications
(13 patients), staple-line disruption (9 patients), and
inadequate weight loss (6 patients).
• Median operative time was 185 minutes (range 105 to
465 minutes).
• Median postoperative BMI was 32 (range 20 to 41) at a
follow-up of 16 months (range 1 to 32 months).
Gonzalez R, Murr MM et alJ Am Coll Surg. 2005 Sep;201(3):366-74.
University of South Florida College of Medicine, Tampa, FL.
VBG to RYGB (Open)
• Early postoperative complications (within 30
days after operation) occurred in 9 patients
(32%).
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•
Anastomotic leak
Wound infection
DVT
UGI bleeding
5
2
1
1
(18%)
(7%)
(4%)
(4%)
Gonzalez R, Murr MM et alJ Am Coll Surg. 2005 Sep;201(3):366-74.
University of South Florida College of Medicine, Tampa, FL.
RYGB with significant mal-absorption
• Severe diarrhea,protein deficiency and
swelling resistant to pancreatic enzymes and
max anti-diarrheal agents.
• Long alimentary limb by operative report.
• 3 patients.
• 2 significantly improved.
Thank You