Revisional Bariatric SurgeryIndications and potential benefits.

William Bakhos,MD

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-Feb;3(1):25-30 Mayo Clinic College of Medicine, Rochester, Minnesota

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-Feb;3(1):25-30

Mayo Clinic College of Medicine, Rochester, Minnesota

Hallowell PT et al.Am J Surg. 2009 Mar;197(3):391-6.

Case western,OH

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.

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.

• 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 Mar;197(3):391-6. Case western,cleveland,OH

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-Feb;5(1):27-30. Epub 2008 Oct 30. Advanced Bariatric Center, Fresno, California

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 Feb;22(2):448-53. University Hospital, Zurich, Switzerland.

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 Sep;71(9):738-43.

Cedars Sinai Medical Center, Los Angeles, CA

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 <.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.

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-Feb;5(1):38-42. Fountain Valley, California.

Revision of LAGB for Pouch dilatation/overrestriction.

• 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 Sep;18(9):1104-8.

Monash University, Melbourne, Australia

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 Aug;22(8):1746-50. CCF Weston,Fl.

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 Aug;22(8):1746-50. CCF Weston,Fl

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-Dec;3(6):611-8. Epub 2007 Oct 23 Cornell University, New York Presbyterian Hospital, New York.

Resection of long tip of the Alimentary limb (Candy cane)

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-Jun;3(3):408-10. Albert Einstein Healthcare Network, Philadelphia, Pennsylvania

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-Feb;3(1):37-41 5 centers from VA and NC

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-Feb;3(1):37-41

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 Jan;18(1):43-6. Université de Nice-Sophia-Antipolis, Nice, 06107, France.

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 Sep;201(3):366-74. University of South Florida College of Medicine, Tampa, FL.

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 Sep;201(3):366-74.

University of South Florida College of Medicine, Tampa, FL.

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.

Thank You