Outcomes of conversions in bariatric surgery mendoza 2011

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Outcomes of conversions in bariatric surgery mendoza 2011

  1. 1. Outcomes of Conversions in Bariatric Surgery Samer G. Mattar, MD, FRCS, FACS Associate Professor of Surgery Indiana University
  2. 2. Outline <ul><li>Incidence of Revisional and Reoperative Bariatric Surgery </li></ul><ul><li>Causes of failed primary operations </li></ul><ul><li>Evaluation of the patient with failed primary operation </li></ul><ul><li>Therapeutic options </li></ul><ul><li>Outcomes </li></ul>
  3. 3. Growth of Bariatric Surgery: 500% NEJM 350;11, 2004, March 11, 1075-1079
  4. 4. Bariatric Surgery Increase Total number of Roux-en-Y Gastric Bypasses Performed in the USA* *National Center for Health Statistics 1998 25000 1999 23000 2000 38000 2002 40000 2004 140000 2005 170000 2008 220,000
  5. 5. Bariatric Surgery Increase
  6. 6. Incidence of Revisional Bariatric Surgery <ul><li>Hard to predict. </li></ul><ul><li>Upwards of 25% of bariatric patients will undergo a revisional procedure </li></ul><ul><li>Gagner M, Gentileschi P, de Csepel J, et al. Laparoscopic reoperative bariatric surgery : experience from 27 consecutive patients. Obes Surg 2002; 12:254-260 </li></ul>
  7. 7. Incidence of Revisional Bariatric Surgery
  8. 8. Definitions <ul><li>Revisional Bariatric Surgery: </li></ul><ul><li>Operations to address failure of weight loss or weight regain </li></ul><ul><li>Reoperative Bariatric Surgery: </li></ul><ul><li>Operations that treat complications of bariatric surgery. </li></ul>
  9. 9. Definition of Failed Bariatric Surgery <ul><li>Weight loss < 50% EWL </li></ul><ul><li>Regain of > 15% of weight after reaching nadir </li></ul><ul><li>Inadequate resolution or improvement of co-morbidities </li></ul>
  10. 10. Causes of Failed Bariatric Surgery <ul><li>Inability to adapt to specific lifestyle. </li></ul><ul><li>Inability to maintain lifestyle changes. </li></ul><ul><li>Treatment with medications that increase appetite. </li></ul><ul><li>Anatomic factors (eg large pouch) </li></ul><ul><li>Lack of follow up. </li></ul>
  11. 11. Late Complications of Bariatric Surgery <ul><li>Persistent strictures </li></ul><ul><li>Persistent or perforating marginal ulcers </li></ul><ul><li>Gastro-gastric fistulas. </li></ul><ul><li>Small bowel obstruction </li></ul><ul><li>Band erosions </li></ul><ul><li>Slipped bands. </li></ul><ul><li>Malabsorption syndrome (nutritional deficiencies) </li></ul>
  12. 12. Evaluation of the failed patient <ul><li>Did the patient fail the operation or did the operation fail the patient? </li></ul>
  13. 13. Evaluation of the failed patient <ul><li>Did the patient fail the operation or did the operation fail the patient? </li></ul><ul><li>Or </li></ul><ul><li>Did the program fail the patient? </li></ul>
  14. 14. Evaluation of the failed patient <ul><li>Careful detailed history by physician, dietitian, and psychologist. </li></ul><ul><li>Review stressful factors, medications. </li></ul><ul><li>Food journal. </li></ul><ul><li>Close and frequent counseling. </li></ul><ul><li>Back on Track program. </li></ul><ul><li>Support groups </li></ul>
  15. 15. Evaluation of the failed patient <ul><li>Upper GI endoscopy to assess pouch size, anatomy, staple line breakdown. </li></ul><ul><li>Upper GI films to assess pouch size, band position, esophageal dilatation, hiatus hernia, etc. </li></ul><ul><li>These studies are essential for planning revisional surgery. </li></ul><ul><li>Review operative notes (if available). </li></ul>
  16. 16. Who should not be converted? <ul><li>Substance users. </li></ul><ul><li>Patients with GERD who have not had medical therapy. </li></ul><ul><li>Patients with maladaptive eating who fail to comply. </li></ul><ul><li>Patients who fail to comply with vitamin and nutritional counseling. </li></ul>
  17. 17. Revisional Surgery Options <ul><li>VBG RYGB </li></ul><ul><li>Sleeve RYGB </li></ul><ul><li>Gastric Band RYGB, Sleeve, DS </li></ul><ul><li>RYGB RYGB + Band </li></ul><ul><li>RYGB Modify malabsorption </li></ul>
  18. 18. VBG RYGB <ul><li>Most cases are done laparoscopically. </li></ul><ul><li>Sharply dissect liver from stomach. </li></ul><ul><li>Identify caudate lobe. </li></ul><ul><li>Access lesser sac. </li></ul><ul><li>Identify GEJ (use endoscopy) and band. </li></ul><ul><li>Lift fat pad to check for hiatus hernia. </li></ul><ul><li>Verify patent stomach (will fundus drain?) </li></ul><ul><li>Create pouch using 4.8mm staples. </li></ul><ul><li>Place drain and G-tube. </li></ul>
  19. 19. VBG RYGB <ul><li>105 patients </li></ul><ul><li>Indications: </li></ul><ul><li>- inadequate weight loss = 22 pts </li></ul><ul><li> -inadeq. Wt. loss + dysphagia = 83pts </li></ul><ul><li>Mean BMI decrease of 8 units </li></ul><ul><li>No deaths </li></ul><ul><li>Complication rate of 38% </li></ul><ul><li>One leak, 8 strictures, DVT in 3 </li></ul>Gagne et al SOARD Online first
  20. 20. Sleeve gastrectomy RYGB <ul><li>8 / 73 patients </li></ul><ul><li>GERD = 3; Weight regain = 5 </li></ul><ul><li>Interval 33 months </li></ul><ul><li>36F bougie </li></ul><ul><li>All patients had resolution of GERD </li></ul><ul><li>1 postoperative leak; treated with stent </li></ul>Langer FB, et al; Obes Surg; Online April 15, 2010
  21. 21. Failed LAGB Reband or Convert? <ul><li>Switzerland </li></ul><ul><li>74 failed LAGB patients </li></ul><ul><li>44 underwent rebanding </li></ul><ul><li>20 underwent LRYGB </li></ul><ul><li>Median follow up = 36 months </li></ul><ul><li>Change in BMI RYGB vs. Reband = 6.1 vs. + 1.5 </li></ul><ul><li>45% of Rebanded patients needed more surgery. </li></ul>Muller MK, et al; Surg Endosc (2008);22:448-53
  22. 22. Failed LAGB Reband or Convert? Dotted line = Re-banded patients Solid line = Patients converted to LRYGB p = 0.035 Muller MK, et al; Surg Endosc (2008);22:448-53
  23. 23. Gastric Band RYGB <ul><li>Massachusets study </li></ul><ul><li>350 LAGB patients </li></ul><ul><li>23 patients required conversion to RYGB </li></ul><ul><li>Interval = 29 months </li></ul><ul><li>Mean Follow up = 18 months </li></ul><ul><li>Pre-conversion EWL% = 23% </li></ul><ul><li>After conversion EWL% = 56% </li></ul>Moore R et al, SOARD 2009;5(4):439-43
  24. 24. Gastric Band RYGB <ul><li>Austria study </li></ul><ul><li>25 LAGB patients underwent band explantation and immediate conversion </li></ul><ul><li>10 for inadequate weight loss; 15 for weight regain </li></ul><ul><li>Follow up = 12 months </li></ul><ul><li>2 port site hernias, 1 stricture and 1 fistula </li></ul><ul><li>EWL% = 50 + 15% </li></ul>Langer FB, et al; Obes Surg 2008; 18(11):1381-6
  25. 25. Gastric Band Sleeve <ul><li>Padova, Italy </li></ul><ul><li>57 patients </li></ul><ul><li>52 had a LAGB, 5 had VBG </li></ul><ul><li>Time interval from primary = 7.5 years </li></ul><ul><li>34F bougie </li></ul><ul><li>41 patients had concurrent band removal and SG </li></ul>Foletto M et al; SOARD 2010;6(2):146-52
  26. 26. Gastric Band Sleeve <ul><li>Mean OR time = 120 minutes </li></ul><ul><li>1 death from septic shock </li></ul><ul><li>3 leaks (5.7%) (mostly in VBG patients) </li></ul><ul><li>1 mid-gastric stricture </li></ul><ul><li>Change in BMI = 45 to 39 </li></ul><ul><li>EWL% = 41% </li></ul><ul><li>EWL% is similar in primary and revision SG patients </li></ul>Foletto M et al; SOARD 2010;6(2):146-52
  27. 27. RYGB RYGB + Band <ul><li>22 patients </li></ul><ul><li>BMI = 44 </li></ul><ul><li>3 complications (13.5%) : 1 sbo, 1 band slip, 1 band erosion. </li></ul><ul><li>Follow up = 60 months </li></ul><ul><li>EWL% = 47% </li></ul>Bessler M et al; SOARD; 6(1):31-5
  28. 28. RYGB RYGB + Band Bessler M et al; SOARD; 6(1):31-5
  29. 29. RYGB Malabsorption <ul><li>Distal RYGB reserved for failed patients with intact anatomy. </li></ul><ul><li>The Bilio-pancreatic limb is anastomosed 50-75 cm from ileo-cecal valve </li></ul><ul><li>EWL% = >50% </li></ul>
  30. 30. RYGB Malabsorption <ul><li>But </li></ul><ul><li>Complications include: </li></ul><ul><li>Fat soluble vitamin deficiency </li></ul><ul><li>Liver dysfunction </li></ul><ul><li>Normocytic normochromic anemia </li></ul><ul><li>Protein calorie malnutrition </li></ul>
  31. 31. Revision to Duodenal Switch <ul><li>Interesting option. </li></ul><ul><li>Data is lacking. </li></ul><ul><li>Largest study had 46 patients with open DS. </li></ul><ul><li>All patients had resolution of comorbidities. </li></ul><ul><li>Follow up = 30 months </li></ul><ul><li>EWL% = 69% </li></ul><ul><li>No deaths </li></ul><ul><li>4 anastomotic leaks. </li></ul>Keshishian A et al; Obes Surg 2004;14(9):1187-92
  32. 32. Re-operative Bariatric Surgery <ul><li>384 secondary operations. </li></ul><ul><li>Excluded all adjustable gastric bands, and immediate postoperative complications. </li></ul><ul><li>151 conversions and reoperations. </li></ul>Patel, Szomstein, Rosenthal. Obes Surg Online first July 2010
  33. 33. Indications Patel, Szomstein, Rosenthal. Obes Surg Online first July 2010 Gastrogastric fistula 41% Ulcer, reflux, bleeding 30.5% Strictures and outlet obstructions 23 % Eroded anastomotic rings 8% Weight loss with malnutrition 7%
  34. 34. Re-Operative Procedures <ul><li>91% </li></ul><ul><li>of the re-operative procedures </li></ul><ul><li>were performed </li></ul><ul><li>laparoscopically </li></ul>Patel, Szomstein, Rosenthal. Obes Surg Online first July 2010
  35. 35. Outcomes * all patients required immediate operative intervention Patel, Szomstein, Rosenthal. Obes Surg Online first July 2010 Postoperative Complications n % Leaks 20 13.2 Wound infection 5 3.3 Intra-abdominal abscess 4 2.6 Trocar site hernia* 3 2.0 Gastrointestinal bleeding* 1 0.7
  36. 36. Outcomes <ul><li>Morbidity = 21.9% </li></ul><ul><li>n = 33 </li></ul><ul><li>Mortality = 2.0% </li></ul><ul><li>n = 3 </li></ul>Patel, Szomstein, Rosenthal. Obes Surg Online first July 2010
  37. 37. Conclusions <ul><li>Revisional bariatric surgery is on the rise and will continue to increase. </li></ul><ul><li>Bariatric surgeons will face more revisions. </li></ul><ul><li>General surgeons should be familiar with conplications of bariatric surgery. </li></ul><ul><li>Choose your revision patients wisely. </li></ul><ul><li>Evaluate all failed patients with endoscopy and radiology. </li></ul>
  38. 38. Conclusions <ul><li>Review operative notes from primary operation or speak with first surgeon. </li></ul><ul><li>Prepare the failed patient by counseling a change in lifestyle and eating habits. </li></ul><ul><li>Offer a malabsorptive operation to a patient who failed a restrictive operation. </li></ul><ul><li>Expect a higher incidence of morbidity and take necessary precautions (drains, G-tube, etc). </li></ul>
  39. 39. Thank you!

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