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Combination Surgical TherapyBanding the BypassBypassing the Band
Matthew Kroh,MD
Assistant Professor of SurgeryCleveland Clinic
Center for Surgical Innovation, Technology, and EducationBariatric & Metabolic Institute
Disclosures
• Research support from and/or consultant:– Covidien– Ethicon Endo-Surgery– Davol/Bard
Introduction
• Number of failures & revisions increasing– Initial weight– Weight regain
• Must be part of inter-disciplinary evaluation including diet and exercise
Year
1992 1994 1996 1998 2000 2002 2004
# W
eigh
t Los
s O
pera
tions
/Yea
r
0
20000
40000
60000
80000
100000
120000
US Bariatric Surgery 1993-2004
Introduction
• Revisional bariatric surgery– More technically challenging – Higher complication rates
• Often open procedures• Increased laparoscopic experience
increasing successful outcomes
Indications
• Definitions of failure• Weight regain• Regain medical co-
morbdities• Failure to ameliorate
co-morbidities• Mechanical failure
– Operation– Device
Options for Failures
• Revisional procedures focus on:– Stoma size– Pouch size– Limb lengths
• Variables that can be surgically altered
Bypassing the Band
Reasons for Conversion
• Proportion of patients previously implanted requiring reoperation varies widely – (5-58%)
• Usually secondary to slippage or dilation• Revisions include replacement or re-
positioning of band• May convert to another procedure
– Most commonly sleeve gastrectomy or RYGB
Background
• Failure rates after banding are widely variable depending on criteria
• Different than RYGB• Include:
– Poor initial EWL– Long term weight regain– Slippage– Intolerance– Esophageal dilation– Infection– Gastric ischemia
AGB Failure
• Requires exclusion of band malposition or malfunction
• Conversion to RYGB described as 2- and 1-step procedures– Success of 1 step procedure enhanced with band
deflation in advance
• Conversion to RYGB more common procedure• Data improving, short and intermediate term
• 350 pts in 7 years underwent AGB
• 21 underwent conversion to RYGB
• Indications:– Poor weight loss, slippage, intolerance,
esophageal dilation, acute complications
• Average time to conversion 27 months
• 3 major complications (11%)– 1 leak, 1 j-j obstruction, 1 a-fib
• Follow-up 18 months
• Conclude safe and efficacious after failed LAGB
• 70 patients for failure – Inadequate weight loss
• Reinhold criteria (<25%)
– Slippage– Erosion
• Performed average 42 months after primary procedure
• Complication rate 14%, no mortality
Band to Bypass
• Several published series
• Overall low morbidity, mortality– Still significantly higher than primary
operations
• May be performed as staged procedure, especially for acute presentations
• Important to perform thorough pre-op evaluation
Re-operation After Primary Banding
• Not infrequent• Indications for re-operation should dictate plan• Repositioning or replacing AGB appears to be
good option for band related complications– Leakage, disconnection– Slippage? Up to 33% recurrence (Suter et al)
• Failure in terms of EWL and co-morbidities better treated with conversion– Most commonly RYGB
Banding the Bypass
Banding the Bypass- Simultaneous Procedures
• Usually in higher risk patients for failure– High BMI (Super-obese), Men
• Weight regain at 3-5 years• Greater experience with fixed rings
– Silastic, polypropylene– Concern for stenosis, erosion, infection
• Fobi, Capela and Capela– Large series of banded bypass pts, excellent
results
• Prospective study
• 90 pts, BMI >50
• Randomized intra-op to banded versus non-banded RYGB
• 1.5 x 7cm Marlex band, sutured around proximal pouch, 5.5 cm diameter
• 2 cm above G-J
• 36 month f/u
GI symptoms Complications
For Failure of Primary Operation
• Additional operation after RYGB
• Major complications for revision RYGB– Up to 50%
• Requires work-up– Anatomic
• Pouch dilation• Stoma dilation• Gatrogastric-fistula
– Exercise– Diet
Surgical Options
• Limb-lengthening procedures– Long-limb gastric bypass
• BPD with or without DS
• Revision of stoma– Surgical or endoscopic
• Revision of pouch– Surgical or endoscopic
Options
• Limb lengthening– Potentially severe metabolic problems
• BPD +/- DS – technically difficult– Excellent EWL, but malabsorption significant
• Endoscopic approaches– Promising– Durability, long term results
Surgical Options
• Banding the bypass
• Fixed versus adjustable bands– Interrupting propulsive wave with reduced
compliance versus outlet restriction
• Mainly silastic or polypropylene
Pre-operative Evaluation
• Operative notes• UGI• Endoscopy
– Hiatal hernia, G-G fistula, ulcer
– E-G junction– Length of pouch– Width of pouch– Size and
characteristics of G-J
Technique
• Laparoscopy versus open
• Knowledge of previous RYGB– Ante-colic, ante-gastric– Retro-colic, retro-gastric
• Recognize and repair hiatal hernia
• Identification of G-J– Intra-op endoscopy
Technique
• Identification of and mobilization of Angle of His
• Left pillar visualization
• Often requires dissection between remnant and pouch
Bessler et al, SOARD, (15) 1443-48.
Technique
• Pars flaccida approach
• Small retro-gastric tunnel
• Gastro-gastric plication– Remnant stomach– Large pouch– ? No plication
Outcomes
• Limited data
• Medical therapy still limited
• Short and medium term outcomes
• 6 pts s/p RYGB• Hyperphagia and weight
regain• BMI at reoperation 38,
initial BMI 36• Time interval 26 months
from 1st operation• Placement non-
adjustable silastic band (6.5-7cm)
• Results– No complications– F/U 14 months– Final BMI 26– EWL 70%– EWL before and after
revision statistically significant
• Hypothesize that fixed ring interrupts propulsive wave, delays emptying
• Different than restriction of AGB
Adjustable Band after Bypass
• Well documented safety• Excellent results as primary procedure
– 11 Pts, poor EWL or weight regain– Initial EWL 38%, after LAGB 59%– One flipped port, no other complications– Mean follow-up 13 months
• 23 patients failure RYGB– Persistent BMI after surgery >35– <50% EWL at 18 months
• Mean BMI at revision 45, initial BMI 53
• Majority laparoscopic
• Complications (13.5% re-operation rate)– 1 leak required removal – 1 slip, 1 port infection, 1 SBO from tubing
EWL at 5 Years
Advantages of AGB to RYGB
• Technically simpler– Especially after lap RYGB
• No anastomosis
• Unlikely additional metabolic sequelae
Conclusions
• Increasing number of failures after primary procedures
• Difficult group of patients requires thorough investigation as to etiology of failure
• Addition of AGB to RYGB for failure seems reasonable with short term data
• Long term outcomes required