Diapositiva 1

REDO SURGERY
LA CONVERSIONE DA BAND A BY PASS
"single step"
Restrictive Procedures: long-term break down up to 40%
 Poor quality of life
 Psychological intolerance, frequent vomiting, GERD
 Failure
 Insufficient weight loss
 Weight regain
 Long term complications
 Gastric pouch dilatation/slippage
 Intragastric band migration
SICOB 2013, Cagliari
Gastric Band Brake Down
Aim
• Achieve sufficient weight loss
• Treat complications
• Allow good quality of life
Technical troubles
• Adhesions from previous surgery
• Staple line insufficiency, disruption
Reasonable morbidity and mortality
SICOB 2013, Cagliari
SICOB 2013, Cagliari
BAND Complication
Good weight loss
Good quality of life
Poor quality of life
Re L AGB
Conversion
GBP / BPD
(except band migration)
SICOB 2013, Cagliari
Poor weight loss
Conversion
GBP / BPD
Sleeve gastrectomy
(has though been reported as
a potential revisional
procedure)
Revisional Bariatric Surgery for Inadequate Weight Loss
Andrew A. Gumbs, MD; Alfons Pomp,
Michel Gagner, MD
Obesity Surgery, 17, 2007
SICOB 2013, Cagliari
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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
SICOB 2013, Cagliari
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 rate
SICOB 2013, Cagliari
Nesset 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
SICOB 2013, Cagliari
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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
SICOB 2013, Cagliari
 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 rebanding
 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
SICOB 2013, Cagliari
How to approach revisional surgery :
 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 tolerance
o Digestive tolerance :
 Alimentary comfort
 Frequency of nausea and vomiting
 Gastro - oesophagal reflux
 Surgical team skill
 Patients wish
SICOB 2013, Cagliari
GENERAL PRINCIPLES
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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
SICOB 2013, Cagliari
GENERAL PRINCIPLES
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Completely comfortable with
performing primary procedure (100
cases).
Higher complication rate.
Lower success rate.
Unusual findings.
SICOB 2013, Cagliari
Literature laparoscopic revision
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%
SICOB 2013, Cagliari
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
SICOB 2013, Cagliari
TECHNICAL FEATURES
Gastro-gastric stitches dissection
SICOB 2013, Cagliari
TECHNICAL FEATURES
“Smaller pouch”in case of slippage.
SICOB 2013, Cagliari
TECHNICAL FEATURES
Avoid fibrotic tissue!!
SICOB 2013, Cagliari
Technology enables surgeons to use staplers in a
broader range of tissue thicknesses than before!
• Largest Staple Height
• Thickest Tissue Ever
SICOB 2013, Cagliari
THE PRECISE STAPLE HIGH
SICOB 2013, Cagliari
Trocars Position
3
1. Optivew: 10 m
3
2. Liver retractor:10
3. Surgeon: 10 mm
2
4. First aid: 10 mm
SICOB 2013, Cagliari
1
4
SIMPLIFIED
LAPAROSCOPIC
GASTRIC BYPASS
BILIOPANCREATIC LIMB
ALIMENTARY LIMB
60 cm
200 cm
SICOB 2013, Cagliari
930 Gastric Bands
• EWL < 25%
• BMI > 40
Rescue Gastric By Pass
35 patients (2,69%)
 33 one step
 2 two steps
- 1 previously removed in pregnancy for slippage
- 1 gastric perforation during band removal
SICOB 2013, Cagliari
Bariatric and Metabolic Unit
Ospedale di Desenzano del Garda
1 YR WEIGHT LOSS AFTER LRYGB FOR LAGB FAILURE
(35 PTS)
55
50
Mean
BMI
49,2
44,9
45
40
35
32,3
30
Heliogast
Rescue By Pass
SICOB 2013, Cagliari
12 months
BAND → RYGB
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
Van
Wageningen
45.8
37.7
12m
SICOB 2013, Cagliari
Bariatric and Metabolic Unit
Ospedale di Desenzano del Garda
2 YRS EWL% AFTER LRYGB FOR LAGB FAILURE
(35 PTS)
80
70
60
EWL% 50
40
30
20
10
0
75
63
24,9
0
Heliogast
Rescue By Pass
SICOB 2013, Cagliari
12 months
24 months
Conclusion
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All restrictive procedure are theoretically associated with long
term failure and/or mechanical complications
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A lifelong multidisciplinary management and surveillance for these
patients appears compulsory
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Bariatric revisional surgery is a major concern
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RYGBP is a very good rescue procedure after failure of restrictive
procedure
SICOB 2013, Cagliari
Conclusion
The laparoscopic conversion of failed gastric bands to
Gastric Bypass in “one step” is reported in literature to
be safe in high volume centres.
In our experience excellent results in term of:
 Morbidity and mortality: 0%
 Weight loss :EWL%>70
SICOB 2013, Cagliari
Thank You.
SICOB 2013, Cagliari