bariatric and metabolic unit desenzano del garda fabrizio bellini

Bariatric and Metabolic Unit Desenzano del Garda

Fabrizio Bellini

REDO SURGERY

LA CONVERSIONE DA BAND A BY PASS

"single step"

SICOB 2013, Cagliari

Redo bariatric surgery


Long term complications

Gastric pouch dilatation/slippage Intragastric band migration

Restrictive Procedures: long-term break down up to 40%

Failure

Insufficient weight loss Weight regain

Poor quality of life Psychological intolerance, frequent vomiting, GERD




Reasonable morbidity and mortality

Aim• Achieve sufficient weight loss• Treat complications• Allow good quality of life

Technical troubles• Adhesions from previous surgery• Staple line insufficiency, disruption

Gastric Band Brake Down


BAND Complication

Good weight loss Poor weight loss

ConversionGBP / BPD

Good quality of life

ConversionGBP / BPD

Re L AGB(except band migration)

Poor quality of life

Rescue procedure choice

Sleeve gastrectomy(has though been

reported as a potential revisional procedure)




Andrew A. Gumbs, MD; Alfons Pomp, Michel Gagner, MD

Obesity Surgery, 17, 2007

Revisional Bariatric Surgery for Inadequate Weight Loss



70 patients, one session in 47 cases Mostly pouch dilatation and insufficient weight

loss (94 %) 3 conversions Morbidity 14,3 %, early reoperations 5,7 % No mortality BMI 32,2 after 18 months

Mognol et al, Obes Surg 2004; 14: 1349




218 patients (15 % of all bariatric procedures) Mortality: 0,9 % Serious morbidity: 26 % 94 % conversion to RYGBP Insufficient weight loss: 81 patients 46 % EWL, 78 %

satisfaction rate Complications/side-effects: 95 patients 88 resolved, 79

satisfaction rateNesset EM et al. SOARD 2007; 3: 25-30




47 patients (62 % for insufficient weight loss)

26 laparoscopic (4 conversions), 21 open No mortality, 19 % morbidity EWL > 50 % in 47 % of patients

Van Wageningen B, et al. Obes Surg 2006; 16: 137




62 patients, 30 re-banding, 32 conversions to RYGBP Two periods, different indications, short follow-up Both techniques are safe Further weight loss with RYGBP, not with re-banding

Weber M, et al. Ann Surg 2003; 238: 827



33 patients with pouch dilatation after GB (6,7 %) 16 repositioning / re-banding 9 band removal 8 conversions to RYGBP

Patients often gain weight (10 / 16) and are dissatisfied after re-banding

All patients converted to RYGBP lost further weight and were extremely satisfied (better food tolerance, no vomiting)

Lanthaler M, et al. Obes Surg 2006; 16: 484



Actual and maximal weight loss after first procedure and initial weight before the first procedure

Type of complication if present: barium swallow, EGDS

Quality of life:o Psychological toleranceoDigestive tolerance :

Alimentary comfortFrequency of nausea and vomitingGastro - oesophagal reflux

Surgical team skill Patients wish

How to approach revisional surgery :



Get the old operative report Be sure that patients are aware of

increased risks and lower likelihood of success.

Obtain Upper GI contrast study to determine staple line integrity and location of GE Junction.

Endoscopy

GENERAL PRINCIPLES



Completely comfortable with performing primary procedure (100 cases).

Higher complication rate. Lower success rate. Unusual findings.

GENERAL PRINCIPLES



Nbr LEAK Morbidity Mortality

GAGNER . M 2002 27 0 % 22 % 0 %

WEBER . M 2003 62 1.6 % 8 % 0 %

WANG . W 2004 29 3.4 % 17 % 3.4 %

MOGNOL . Ph 2004 70 0 % 14.3 % 0 %

SUTER . M 2004 49 6 % 20 % 0 %

COHEN . R 2005 62 0 % 0 % 0 %

VAN WAGENINSEN 2006 26 4 % 23 % 0 %

Literature laparoscopic revision



Michel Gagner, Paolo Gentileschi, John de Csepel, Subhash Kini,

Obesity Surgery, 12, 2002

Retrospective study

• Morbidity : 22%

• Mortality : 0%

• Conversion : 3.7%• 2° revision : 14.8%

• Operative time

• Hospital stay



Gastro-gastric stitches dissection

TECHNICAL FEATURES



“Smaller pouch”in case of slippage.

TECHNICAL FEATURES



Avoid fibrotic tissue!!

TECHNICAL FEATURES



Technology enables surgeons to use staplers in a broader range of tissue thicknesses than before!

• Largest Staple Height• Thickest Tissue Ever



3mm 0,75 GREY 0.21mm

2,0 mm

3mm 1mm WHITE 0.21mm

2.5mm

3mm 1.5mm BLUE 0.21mm

3.8mm

3mm 2mm GREEN 0.23mm

4.8mm

Purple

THE PRECISE STAPLE HIGH



Trocars Position

1. Optivew: 10 m

2. Liver retractor:10

3. Surgeon: 10 mm

4. First aid: 10 mm

1

2

3

3

4


BILIOPANCREATIC LIMB

60 cmALIMENTARY LIMB

200 cm

SIMPLIFIED LAPAROSCOPIC

GASTRIC BYPASS



35 patients (2,69%) 33 one step 2 two steps - 1 previously removed in pregnancy for slippage

- 1 gastric perforation during band removal

930 Gastric Bands

Rescue Gastric By Pass • EWL < 25%• BMI > 40



1 YR WEIGHT LOSS AFTER LRYGB FOR LAGB FAILURE(35 PTS)

49,2

44,9

32,3

30

35

40

45

50

55

Heliogast Rescue By Pass 12 months

MeanBMI

Bariatric and Metabolic UnitOspedale di Desenzano del Garda



Pre BMI Post BMI Time of Follow Up

Mognol 45 32 18m

Sanchez 40 27.6 12m

Perathoner 37.4 28.5 12m

Perathoner 35.5 27.3 12m

Weber 42.0 31.8 10.5m

Westling 33.0 28 12m

Spivak 42.4 30.7 15.7m

Topart 43.1 33.3 18m

VanWageningen 45.8 37.7 12m

BAND → RYGB



0

24,9

6375

01020304050607080

Heliogast Rescue By Pass 12 months 24 months

EWL%

Bariatric and Metabolic UnitOspedale di Desenzano del Garda

2 YRS EWL% AFTER LRYGB FOR LAGB FAILURE(35 PTS)



Conclusion

All restrictive procedure are theoretically

associated with long term failure and/or

mechanical complications

A lifelong multidisciplinary management and

surveillance for these patients appears

compulsory

Bariatric revisional surgery is a major concern

RYGBP is a very good rescue procedure after

failure of restrictive procedure



In our experience excellent results in term of:

Morbidity and mortality: 0%

Weight loss :EWL%>70

The laparoscopic conversion of failed gastric bands to Gastric Bypass in “one step” is reported in literature to be safe in high volume centres.

Conclusion

Thank You.

bariatric and metabolic unit desenzano del garda fabrizio bellini

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