Gastric pouch and gastric bypass


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Gastric pouch and gastric bypass

  1. 1. First International ConsensusConference on the Mini-Bypass / OneAnastomosis BypassParis 2012 October 18-19Email DrR@CLOS.Net
  2. 2. “Those who cannot remember thepast are condemned to repeat it.” George Santayana Bariatric Surgery: A History of Failure
  3. 3. 1454-1502: Bariatric Procedures Should Include Both Small Gastric Pouch and Gastric Bypass for Maximum EffectivenessBariatric Surgery: A History of Failure Dr. Rutledge Director Center for Laparoscopic Obesity Surgery Email: 702-714-0011
  4. 4. Bariatric Surgery: A History of Failure Jaw Wiring
  5. 5. Jaw wiring in treatment ofobesityLancet. 1977 Jun 11;1(8024):1221-2. Rodgers S, Burnet R, Goss A, Phillips P,Goldney R, Kimber C, Thomas D, Harding P, Wise P.17 patients with severe (median percentage above ideal weight 100%) and resistant obesity underwent jaw wiring.There were no major complications and patients tolerated the procedure and subsequent minor inconveniences.All patients lost weight at a rate (median 25-3 kg in six months) comparable with that of intestinal bypass surgery and one achieved and maintained her ideal weight.Two-thirds of the patients, however, regained some weight after the wires were removed.Jaw wiring is a simple effective procedure which can be carried out in most hospitals, and has a place in an integrated approach to obesity.
  6. 6. Maintenance of weight loss inobese patients after jaw wiringBr Med J (Clin Res Ed). 1981 March 14; 282(6267): 858–860.Maintenance of weight loss in obese patients after jaw wiringIn this study jaw wiring was used to limit food intake....patients were followed for 4-14 months after removal of jaw wires and regained a mean of only 5.6 kg of the 31.8 kg lost while their jaws were wired."This procedure compares favourably with other treatments for severe obesity."
  7. 7. Bariatric Surgery: A History of Failure Jaw Wiring BioEnterics Intragastric Balloon (BIB)
  8. 8. BioEnterics IntragastricBalloon (BIB)Int J Obes (Lond). 2006 Jan;30(1):129-33. BioEnterics Intragastric Balloon (BIB):a short-term, double-blind, randomised, controlled, crossover study on weightreduction in morbidly obese patients. Genco A, Cipriano M, Bacci V, Cuzzolaro M,Materia A, Raparelli L, Docimo C, Lorenzo M, Basso N. Department of Surgery ParideStefanini, University La Sapienza Medical School, Rome, Italy. alfredo.genco@uniroma1.itThe results of this study show thattreatment of obese patients withBioEnterics Intragastric Balloon is a safe and effective procedure.In association with appropriate diet it is significantly effective in weight reduction when compared to sham procedure plus diet.
  9. 9. BioEnterics IntragastricBalloon (BIB)Obes Surg. 2008 Dec;18(12):1611-7. Epub 2008 Jun 21. Evidence-based review ofthe Bioenterics intragastric balloon for weight loss. Dumonceau JM. Division ofGastroenterology and Hepatology, Geneva University Hospitals,Geneva, SwitzerlandReviewed clinical studies performed with the Bioenterics intragastric balloon (BIB) to promote weight loss.Thirty studies were included [18 prospective (5 randomized), 12 retrospective], totaling 4,877 patients.Only one of three controlled trials found a significantly higher weight loss with the BIB vs the sham procedureIn nonrandomized studies, weight loss with the BIB averaged 17.8 kg, BMI changes of 4.0-9.0 kg/m(2).
  10. 10. Bariatric Surgery: A History of Failure Jaw Wiring BioEnterics Intragastric Balloon (BIB) Vertical Banded Gastroplasty
  11. 11. High revision rates afterlaparoscopic vertical bandedgastroplastySurg Obes Relat Dis. 2009 Jan-Feb;5(1):94-8. Epub 2008 Jul 21.High revision rates after laparoscopic vertical banded gastroplasty. Marsk R, Jonas E, Gartzios H, Stockeld D, Granström L, Freedman J.Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.486 patientsThe median follow-up was 3 years104 patients, 21% required revision
  12. 12. Bariatric Surgery: A History of Failure Jaw Wiring BioEnterics Intragastric Balloon (BIB) Vertical Banded Gastroplasty Lap Band
  13. 13. Bariatric Surgery Failures: PubMed Search“failed gastric banding” >> 100 Articles1: Elnahas A, Graybiel K, Farrokhyar F, Gmora S, Anvari M, Hong D. 9: Burton PR, Brown WA. The mechanism of weight loss with laparoscopic Revisionalsurgery after failed laparoscopic adjustable gastric banding: a adjustable systematic gastric banding: induction of satiety not restriction. Int J Obes (Lond). 2011 review. Surg Endosc. 2012 Aug 31. [Epub ahead of print] PubMed PMID: Sep;35 Suppl 3:S26-30. doi: 10.1038/ijo.2011.144. Review. PubMed PMID: 22936440. 21912383. 2: Deutsch GB, Gunabushanam V, Mishra N, Sathyanarayana SA, Kamath 10: Berende CA, de Zoete JP, Smulders JF, Nienhuijs SW. Laparoscopic V, Buchin D.Laparoscopic vertical sleeve gastrectomy after open gastric sleeve banding in a patient gastrectomy feasible for bariatric revision surgery. Obes Surg. 2012 with situs inversus totalis. J Minim Access Surg. 2012 Jul;8(3):93-6. PubMed Feb;22(2):330-4. Review. PubMed PMID: 21866377; PubMed Central PMCID: PMID: 22837597; PubMed Central PMCID: PMC3401724. PMC3266499. 3: Meesters B, Latten G, Timmermans L, Schouten R, Greve JW. Roux-en-Y 11: Hedberg J, Gustavsson S, Sundbom M. Long-term follow-up in patients gastric undergoing open gastric bypass as a revisional operation for previous failed bypass as revisional procedure after gastric banding: leaving the band in restrictive procedures. Surg Obes Relat Dis. 2011 Jun 30. [Epub ahead of place. print] Surg Obes Relat Dis. 2012 Feb 10. [Epub ahead of print] PubMed PMID: PubMed PMID: 21865097. 22440668. 12: Runkel N, Colombo-Benkmann M, Hüttl TP, Tigges H, Mann O, Sauerland 4: Deylgat B, DHondt M, Pottel H, Vansteenkiste F, Van Rooy F, Devriendt D. S. Indications, safety, and feasibility of conversion of failed bariatric surgery Bariatric surgery. Dtsch Arztebl Int. 2011 May;108(20):341-6. doi: to 10.3238/arztebl.2011.0341. Epub 2011 May 20. Review. PubMed PMID: Roux-en-Y gastric bypass: a retrospective comparative study with primary 21655459; laparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2012 Jul;26(7):1997- PubMed Central PMCID: PMC3109275. 2002. 13: Goitein D, Feigin A, Segal-Lieberman G, Goitein O, Papa MZ, Zippel D. Epub 2012 Jan 19. PubMed PMID: 22258299. Laparoscopic sleeve gastrectomy as a revisional option after gastric band 5: Hii MW, Lake AC, Kenfield C, Hopkins GH. Laparoscopic conversion of failure. Surg Endosc. 2011 Aug;25(8):2626-30. Epub 2011 Mar 17. PubMed failed PMID: gastric banding to Roux-en-Y gastric bypass. short-term follow-up and 21416182. technical 14: Bhasker A, Gadgil M, Muda NH, Lotwala V, Lakdawala MA. Revisional considerations. Obes Surg. 2012 Jul;22(7):1022-8. PubMed PMID: 22252745. bariatric 6: Vijgen GH, Schouten R, Pelzers L, Greve JW, van Helden SH, Bouvy ND. surgery for failed gastric banding in Asia: a review of choice of revisional Revision procedure, surgical technique and postoperative complication rates. Asian J of laparoscopic adjustable gastric banding: success or failure? Obes Surg. Endosc Surg. 2011 Feb;4(1):26-31. doi: 10.1111/j.1758-5910.2010.00062.x. 2012 Epub Feb;22(2):287-92. PubMed PMID: 22094368; PubMed Central PMCID: 2010 Nov 17. PubMed PMID: 22776171. PMC3266497. 15: Greenbaum DF, Wasser SH, Riley T, Juengert T, Hubler J, Angel K. 7: Scheffel O, Weiner RA. Therapy of stenosis after sleeve gastrectomy: Duodenal stent and switch with omentopexy and feeding jejunostomy--a safe and effective surgery as alternatives--case reports. Obes Facts. 2011;4 Suppl 1:47-9. Epub revisional 2011 operation for failed previous weight loss surgery. Surg Obes Relat Dis. 2011 Apr 13. PubMed PMID: 22027291. Mar-Apr;7(2):213-8. Epub 2010 Nov 10. PubMed PMID: 21215708 8: Abu-Gazala S, Keidar A. Conversion of failed gastric banding into four different bariatric procedures. Surg Obes Relat Dis. 2012 Jul;8(4):400-7. Epub
  14. 14. Bariatric Surgery Failures: PubMed Search“failed gastric banding” >> 100 Articles"Recent data from Marmuse onadjustable bands and BMI>50,who says that“At ten years, only 11% of patients(nine of 80) have successful bariatric results(%EWL>50%)and we were forced toremove the gastric band in 52.2% of patients (47 of 90) because of complications,regardless of the initial operative technique" Michel Gagner
  15. 15. Bariatric Surgery: A History of Failure Jaw Wiring BioEnterics Intragastric Balloon (BIB) Vertical Banded Gastroplasty Lap Band Sleeve Gastrectomy
  16. 16. Sleeve Gastrectomy Failure:Just When We Thought We Had the Perfect OperationSleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients.Surg Endosc. 2012 Jun;26(6):1509-15. Epub 2011 Dec 17. Aurora AR, Khaitan L, Saber AA. Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio" The risk of leak is low at 2.4%." !!Himpens, in an article by Deitel et al, presented his early five-year results after sleeve gastrectomy he reported a disappointing 37 and 23 percent inadequate weight loss and second procedure rates, respectively.
  17. 17. Bariatric Surgery: A History of FailureWhat are the COSTS? Jaw Wiring BioEnterics Intragastric Balloon (BIB) Vertical Banded Gastroplasty Lap Band Sleeve Gastrectomy
  18. 18. RNY & VBGFail to Cut Healthcare Costs• Bariatric surgery programs in VA medical centers.• 847 were propensity matched to 847 nonsurgical control subjects from the same 12 VA medical centers.• Bariatric surgery was NOT associated with reduced health care expenditures Arch Surg. 2012 Jul 1;147(7):633-40. Health expenditures among high-risk patients after gastric bypass and matched controls. Maciejewski ML,
  19. 19. Costs of FailureAmerican Society for Metabolic and Bariatric Surgery Bariatric Outcomes Longitudinal DatabaseGastric banding 22,947 pts in BOLD by 2009If 100% Fail: 22,947 * (US$ 29 000) = 665 million U.S. dollarsIf 50% Fail 22 947 * (US$ 29 000) * 50% = 332 million U.S. dollars 1/3 Billion Dollar Debt for Failed Bands
  20. 20. Spectrum Bariatric Surgery Duodenal Bypass Restrictive Bilopancreatic Diversion JI Bypass Balloon VBGJaw Wiring Sleeve Band Gastrectomy-Like MalabsorbtiveAlone => Weak Poor Success / High Failure Rates
  21. 21. Outcome after gastrectomy in gastriccancer patients with type 2 diabetesJong Won Kim, etal, Gangnam SeveranceHospital, Yonsei University College of Medicine, Seoul 135-720, South KoreaWorld J Gastroenterol. 2012January 7; 18(1): 49–54.METHODS:403 gastric cancer patients with T2DM were studied, who underwent gastrectomy between May 2003 and September 2009.A review of medical records and telephone interviews was performed in this cross-sectional study.
  22. 22. Outcome after gastrectomy in gastriccancer patients with type 2 diabetesBMI % Reduction Gastrectomy Partial 8.2% Near Total 14.2% Duodenal Bypass No Bypass 7.6% Bypass 11.4%
  23. 23. Outcome after gastrectomy in gastriccancer patients with type 2 diabetesDiabetes Improvement/Resolution: Gastrectomy Partial 40% Near Total 60% Duodenal Bypass No Bypass 37% Bypass 52%
  24. 24. Bariatric surgery: a systematic review andnetwork meta-analysis of randomized trials.Obes Rev. 2011 Aug;12(8):602-21. doi: 10.1111/j.1467-789X.2011.00866.x. Epub 2011 Mar 28.Padwal R, Klarenbach S, Wiebe N, Birch D, Karmali S, Manns B, Hazel M, Sharma AM, Tonelli M.Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.31 RCTs involving 2619 patients; BMI Decrease• Jejunoileal bypass [ -11.4 kg/m(2) ]• Mini-gastric bypass [-11.3 kg/m(2) ]• Biliopancreatic diversion [-11.2 kg/m(2) ]• Sleeve gastrectomy [-10.1 kg/m(2) ]• Roux-en-Y gastric bypass [-9.0 kg/m(2) ]• Vertical banded gastroplasty [-6.4 kg/m(2) ]• Adjustable gastric banding [-2.4 kg/m(2) ]
  25. 25. IFSO Varianational Committee Survey Over 100 Surgeons from Around the World:
  26. 26. IFSO Varianational Committee SurveyResults (Preliminary)Experience with 39,000 cases in the prior yearLap Band is a "Poor" SurgeryRNY & Sleeve Surgeons have "lots" of leaksMGB Surgeons Answered More Correct than Non-MGB Surgeons
  27. 27. Lap Band Unlikely to Get Major Weight Loss (5%)
  28. 28. The Lap Band is "Not a Very Good" Surgery
  29. 29. Spectrum Bariatric Surgery Duodenal Bypass Restrictive Bilopancreatic Diversion JI Bypass Balloon VBGJaw Wiring Sleeve Band Gastrectomy-Like MalabsorbtiveAlone => Weak Poor Success / High Failure Rates
  30. 30. ConclusionsHigh Failure Rate after Bariatic Surgery that is Restrictive / Gastrectomy aloneThese Failures Represent HUGE Future Debt (Billions of Dollars) to our patients, families and their childrenHistory of Bariatric Surgery/Gastric Cancer Data ShowsGreatest effectiveness for operations that combineRestrictive/Gastrectomy anatomy withDuodenal Bypass