Bariatric and Metabolic Unit Desenzano del Garda Fabrizio Bellini
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Bariatric and Metabolic Unit Desenzano del Garda
Fabrizio Bellini
REDO SURGERY
LA CONVERSIONE DA BAND A BY PASS
"single step"
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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
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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
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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)
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Andrew A. Gumbs, MD; Alfons Pomp, Michel Gagner, MD
Obesity Surgery, 17, 2007
Revisional Bariatric Surgery for Inadequate Weight Loss
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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
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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
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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
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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
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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
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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 :
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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
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Completely comfortable with performing primary procedure (100 cases).
Higher complication rate. Lower success rate. Unusual findings.
GENERAL PRINCIPLES
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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
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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
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Gastro-gastric stitches dissection
TECHNICAL FEATURES
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“Smaller pouch”in case of slippage.
TECHNICAL FEATURES
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Avoid fibrotic tissue!!
TECHNICAL FEATURES
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Technology enables surgeons to use staplers in a broader range of tissue thicknesses than before!
• Largest Staple Height• Thickest Tissue Ever
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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
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Trocars Position
1. Optivew: 10 m
2. Liver retractor:10
3. Surgeon: 10 mm
4. First aid: 10 mm
1
2
3
3
4
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BILIOPANCREATIC LIMB
60 cmALIMENTARY LIMB
200 cm
SIMPLIFIED LAPAROSCOPIC
GASTRIC BYPASS
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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
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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
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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
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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)
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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
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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.
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