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Sls 01


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Presentation at Society of Laparoscopic Surgeons Sept 2009 (Boston)

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Sls 01

  1. 1. Endoscopic Plication and Reduction of the Gastric Pouch in Patients who Previously Underwent Gastric Bypass Surgery Chiranjiv S Virk MD, Dimitrios V. Avgerinos, MD, Radha Patel, Burton Surick, MD, John L. Holup, DO, Elliot R. Goodman, MD and I. Michael Leitman, MD Department of Surgery Beth Israel Medical Center New York, NY
  2. 2. Commercial Disclosures: <ul><li>StomaphyX ® is a product of EndoGastric Solutions ®(Redmond, WA). </li></ul><ul><li>None of the authors have any financial relationship with EndoGastric Solutions ®. </li></ul>
  3. 3. Background <ul><li>150,000-200,000 bariatric operations done a year in the USA </li></ul><ul><li>Weight loss of 67-75% EBWL in 80% of patients in 2 years </li></ul><ul><li>14 year follow up study: 95% of patients maintained at least 50% EBWL </li></ul>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.
  4. 4. Background <ul><li>Usually a nadir weight is reached at 2 years </li></ul><ul><li>Estimated 10% - 20% will regain significant weight at 5 and 10 years </li></ul><ul><li>12% of patients undergo surgical revision after gastric bypass surgery </li></ul>Gagner M., et al. Laparoscopic Reoperative Bariatric Surgery : Experience from 27 consecutive patients. Obes Surg, (12) 254-260, 2002.
  5. 5. Background <ul><li>Review of literature on re-operative bariatric surgery </li></ul><ul><ul><li>17 publications (838 patients) </li></ul></ul><ul><ul><ul><li>118 major complications (14%) </li></ul></ul></ul><ul><ul><ul><li>11 deaths (1.3%) </li></ul></ul></ul><ul><ul><li>64 patients - laparoscopic reoperation </li></ul></ul><ul><ul><ul><li>6 major complications (9%) </li></ul></ul></ul><ul><ul><ul><li>Average OR time 4.5 hours </li></ul></ul></ul>Jones KB. Revisional bariatric Surgery-potentially safe and effective. SOARDS 1 (2005) 599-603
  6. 6. Background <ul><li>Weight regain after gastric bypass- multifactorial </li></ul><ul><li>Indication of revisional surgery : Exhaustion of medical, psychological and dietary efforts </li></ul>
  7. 7. Complications of Revisional Surgery: <ul><li>Anastomotic leaks </li></ul><ul><li>Wound dehiscences </li></ul><ul><li>Incisional hernias </li></ul><ul><li>Pulmonary complications </li></ul><ul><li>Death </li></ul><ul><li>StomaphyX : Transoral/incisionless method–avoids most of theses complications </li></ul>
  8. 8. Goal: <ul><li>To investigate if it is possible to restore the pouch to its original volume and decrease the diameter of the gastro-jejunostomy, trans-orally by utilizing natural orifice surgical techniques. </li></ul>
  9. 9. Endoluminal Gastric Pouch Reduction <ul><li>StomaphyX TM (EndoGastric Solutions, Redmond Washington) </li></ul><ul><ul><li>Approved in the United States and Europe for endoluminal tissue approximation </li></ul></ul><ul><ul><li>Patients who want further weight loss after gastric bypass surgery </li></ul></ul><ul><ul><li>Patients with rapid gastric emptying or dumping syndrome associated with diarrhea </li></ul></ul>
  10. 10. Methods: <ul><li>Selection criteria: patients at least 2 years after original gastric bypass surgery and had gained at least 10 % of lowest nadir weight. </li></ul><ul><li>Preoperative work up: Upper endoscopy/ Upper GI swallow study. </li></ul><ul><li>Dietician session for postoperative diet. </li></ul>
  11. 11. Endoluminal Gastric Pouch Reduction <ul><li>Anesthesia: general endotracheal </li></ul><ul><li>Upper Endoscopy : To measure GE and GJ </li></ul><ul><li>Gastroscope and StomaphyX passed down esophagus as one unit </li></ul><ul><li>StomaphyX uses suction to draw gatric wall into device </li></ul><ul><li>First 5 patients had simultaneous laparoscopy to evaluate safety of plications </li></ul>
  12. 12. Procedure: <ul><li>7mm, 3-0 polypropylene fasteners </li></ul><ul><li>20-40 fasteners per case </li></ul><ul><li>Start 1 cm proximal to stoma-6 o’clock </li></ul><ul><li>1-2 cm proximal to first row 6 fasteners </li></ul><ul><li>Additional fasteners depending upon pouch size </li></ul>
  13. 13. Diagram for fasteners H H H H H H
  14. 14. Serosa-to-serosa Fusion Full thickness tissue plication and serosa-to-serosa fusion seen in several animal models
  15. 15. Endoluminal Gastric Pouch Reduction
  16. 16. <ul><li>Results to follow: </li></ul>
  17. 17. THANK YOU