Revisional Bariatric Surgery Indications and potential benefits.

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Revisional Bariatric SurgeryIndications and
potential benefits.

• William Bakhos,MD

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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-Feb3(1)25-30
• Mayo Clinic College of Medicine,
  Rochester, Minnesota

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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-Feb3(1)25-30
• Mayo Clinic College of Medicine, Rochester,
  Minnesota
• Hallowell PT et al.Am J Surg. 2009
  Mar197(3)391-6.
• Case western,OH

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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.

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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.

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• 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
  Mar197(3)391-6.
• Case western,cleveland,OH

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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-Feb5(1)27-30. Epub 2008 Oct 30.
• Advanced Bariatric Center, Fresno,
  California

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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
  Feb22(2)448-53.
• University Hospital, Zurich, Switzerland.

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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
  Sep71(9)738-43.
• Cedars Sinai Medical Center, Los Angeles,
  CA

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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 lt.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.

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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 21.8-98.1).
• 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-Feb5(1)38-42. Fountain Valley, California.

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Revision of LAGB for Pouch dilatation/overrestrict
ion.

• 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
  Sep18(9)1104-8.
• Monash University, Melbourne, Australia

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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 Aug22(8)1746-50.
• CCF Weston,Fl.

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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 Aug22(8)1746-50.
• CCF Weston,Fl

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RYGB to BPD-DS

• 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-Dec3(6)611-8. Epub 2007 Oct 23
• Cornell University, New York Presbyterian
  Hospital, New York.

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Resection of long tip of the Alimentary limb
(Candy cane)
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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-Jun3(3)408-10.
• Albert Einstein Healthcare Network,
  Philadelphia, Pennsylvania

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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-Feb3(1)37-41
• 5 centers from VA and NC

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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-Feb3(1)37-41

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VBG to RYGB (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
  Jan18(1)43-6.
• Université de Nice-Sophia-Antipolis, Nice,
  06107, France.

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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 Sep201(3)366-74.
• University of South Florida College of
  Medicine, Tampa, FL.

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VBG to RYGB (Open)

• Early postoperative complications (within 30 days
  after operation) occurred in 9 patients (32).
• Anastomotic leak 5
  (18)
• Wound infection 2
  (7)
• DVT
  1 (4)
• UGI bleeding 1
  (4)
• Gonzalez R, Murr MM et alJ Am Coll Surg.
  2005 Sep201(3)366-74.
• University of South Florida College of
  Medicine, Tampa, FL.

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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.

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Thank You