New Horizons in Gastric Surgery
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Webinar on endoluminal revisional bariatric surgery

Webinar on endoluminal revisional bariatric surgery

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New Horizons in Gastric Surgery Presentation Transcript

  • 1. New Horizons in Bariatric Surgery – endoluminal treatments for weight regain after gastric bypass: Elliot R Goodman MD Bariatric Surgery Service Beth Israel Medical Center New York, NY
  • 2. Background
    • 150,000-200,000 bariatric operations done a year
    • Weight loss of 67-75% EBWL in 80% of patients in 2 years
    • 14 year follow up study: 95% of patients maintained at least 50% EBWL
    Pories WJ, Swanson MS, MacDonald KG. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;222:339-350.
  • 3. Background
    • Estimated 10% - 20% will regain some weight at 5 and 10 years
    • Usually a nadir weight is reached at 2 years
    • Weight regain
      • Mean 10-20% weight gain above nadir weight
      • Many patients dropping below 50% of % EBWL after primary surgery
    • 12% incidence of revision after gastric bypass surgery for weight regain
    Gagner M., et al. Laparoscopic Reoperative Bariatric Surgery : Experience from 27 consecutive patients. Obes Surg, (12) 254-260, 2002.
  • 4. Weight loss trajectory after gastric bypass:
  • 5. Background
    • Review of Literature on Reoperative Bariatric Surgery
      • 838 patients - open reoperation
        • 118 major complications (14%)
        • 11 deaths (1.3%)
      • 64 patients - laparoscopic reoperation
        • 6 major complications (9%)
        • Average OR time 4.5 hours
    Jones KB. Revisional bariatric Surgery-potentially safe and effective. SOARDS 1 (2005) 599-603
  • 6. Background:
    • 2008 ASMBS Member Survey
      • What is the weight loss expectation for an endoluminal revisional procedure
      • 76% felt 10-20% EWL at 12 months with safety equivalent to that of a therapeutic endoscopy was acceptable
      • Brethauer SA, Pryor AD, Chand B et al Endoluminal procedures for bariatric patients: expectations among bariatric surgeons (2009) Surg Obes Relat Dis Mar-Apr;5 (2): 231-6
  • 7. Endoluminal Gastric Pouch Reduction (EGPR) StomaphyX TM
  • 8. Endoluminal Gastric Pouch Reduction
    • StomaphyX TM (EndoGastric Solutions, Redmond WA)
      • FDA approved in the United States for endoluminal tissue approximation
      • CE marked in Europe
      • Patients who want further weight loss
      • Patients with rapid gastric emptying or dumping syndrome associated with diarrhea
  • 9. Endoluminal Gastric Pouch Reduction
    • Procedure
      • Average 20-40 3-0 polypropylene fasteners per case
      • Start 1 cm proximal to stoma- 12-16 fasteners
      • 1-2 cm proximal to first row- another 12-16 fasteners
      • Additional fasteners until 1cm below GE junction reached
  • 10. Diagram for fasteners H H H H H H
  • 11. Endoluminal Gastric Pouch Reduction
  • 12. Endoluminal Gastric Pouch Reduction Pre anastomosis Post anastomosis
  • 13. Endoluminal Gastric Pouch Reduction Gastro-esophageal Junction
  • 14. Fluoroscopic evidence of stomal narrowing after EGPR with Stomaphyx: GJ stoma before EGPR Stoma after EGPR
  • 15. Serosa-to-serosa Fusion Full thickness tissue plication and serosa-to-serosa fusion seen in several animal models
  • 16. Beth Israel Medical Center results 2008-9 (N=64) 5 (2-10) Median time(years) after Gastric bypass surgery 31.3 Median BMI Post-GB(nadir) 31.3 Median BMI Post-Gastric Bypass (nadir) 48.7 Median BMI Pre-Gastric Bypass 65 Height (inches) 92% female / 8% male Female / Male 47.5 (24-66) Age (years)
  • 17. 7(12%) No follow up weight available 14(21%) No. Patients no weight loss 43(67%) No. Patients Weight loss 6(1-13) Median follow up(months) 37.75(25.1-55.2) Median BMI post Stomaphyx 39.85 (25.9-54.9) Median BMI before StomaphyX
  • 18. 23(10-40) Median # of fasteners 33%(0-67) Median reduction in gastric pouch length 50 (35-130) Median OR time 15.5(3.3-67) Median weight loss (lbs.) post StomaphyX
  • 19. RESULTS:
    • Dumping syndrome improved
    • GERD improved
  • 20. Endoluminal Gastric Pouch Reduction
    • 3 patients underwent repeat procedure due to unsatisfactory results.
    • Maximum weight loss: 67 lbs
    • Postprandial diarrhea/GERD resolved.
        • Slowed gastric emptying
        • Obliteration of the gastrocolic reflex
        • New valve created just distal to GE junction
  • 21. Latest data pooled from 3 large US centers (BIMC, OSU and Alvarado Hospital):
    • 124 patients underwent EGPR at three centers
    • 94% female mean age 49(+/-10)yrs mean pre-EGPR BMI 39(+/-8)
    • Mean 126lbs EWL after GB with 59lbs regained 7.1 (+/-3.7) yrs after GB
    • Followed for 6 months (+/-4 SD) after EGPR
  • 22. Latest data (con):
    • EGPR reduced pouch length by 50(+/-24)%
    • Mean number of plications 22(+/-9)
    • Mean weight loss 25lbs – 18% EWL or 43% RWL
    • Weight loss range - 23lbs gain to 183lbs loss
  • 23. Predictive factors:
    • Weight loss after EGPR significantly correlated with weight loss after initial GB (p=0.001)
    • Lower pre-EGPR BMI predicted better weight loss after EGPR (p=0.009)
  • 24. Endoluminal Gastric Pouch Reduction
    • Mechanism of Weight loss
    • Reduction in size of pouch
    • Reduction in size of stoma
    • Reduce compliance of pouch
    • Slowed gastric emptying
  • 25. The ROSE Procedure (by USGI):
  • 26. Stomal reduction with ROSE: Diameter 2.6cm Diameter 0.5cm
  • 27. Stoma/Pouch Reduction Achieved Cases Completed N=112/116 (97%) Mean Final Stomal Diameter 11.5 mm Mean % Stomal Reduction 50% Mean Final Pouch Length 3.3 cm Mean % Pouch Reduction per Case 44% Mean # Total Anchors per Case 5.9 Mean O.R. Time 87 min
  • 28. Results-6 Month Weight Loss *based on target BMI 25kg/m 2 6 Month Endpoint (N=96) Mean for Total Registry Max for Individual Subject Weight Loss (kg) 6.5kg 30kg %EWL* 18% 84% % Regained Weight Lost (RWL) 32% 300%
  • 29. Conclusions:
    • EGPR procedures are safe and can produce almost 50% loss of regained weight after 6-12 months
    • Long term durability still unknown
    • Pouch size reduction and stomal narrowing appears to treat dumping and GERD in most patients
    • Behavioral issues still play a major role in determining success after EGPR