The document discusses revisional bariatric surgery options for patients who experience weight regain or inadequate weight loss after an initial Roux-en-Y gastric bypass procedure (RYGBP). It reviews various surgical techniques for revising the gastric pouch size and shape, lengthening or shortening the Roux limb, and adding an adjustable gastric band. A summary of the author's experience with 212 revisional surgeries found that patients experienced significant additional weight loss, though complication rates were high at 26%. Most patients reported being satisfied with the results of revisional surgery.

1. Revision of RYGBP (Weight loss failures) (Weight loss failures) Kelvin D Higa, MD, FACS, FASMBS Clinical Professor in Surgery, UCSF Director Bariatric and Minimally Invasive Surgery Program Fresno Heart and Surgical Hospital 10 V Congreso Internacional de Cirugia Bariatrica y Metabolica Mendoza Argentina May 19 & 20, 2011 Advanced Laparoscopic Surgery Associates Medical Group

2. Who failed whom? The “bad” patient The “program” Compliance Responsibility

3. “ Since all types of bariatric operations can be defeated, it is virtually impossible to assign all of the “blame” for poor weight loss to the patient. Moreover, many of these patients suffer from obesity-related comorbidities and physical disability. Because morbid obesity is highly resistant to all methods of nonsurgical treatment, it seems unethical to categorically deny the opportunity for patients to have revisional surgery.” Robert Brolin WHY PERFORM REVISION SURGERY?

4. GBP considerations Gastric bypass is not standard - Varying pouch sizes and orientations - Variable limb lengths - Variable followup and education Weight recidivism usually associated with significant psychological issues Revision surgery associated with higher risk

5. GBP considerations Psychological issues can be addressed, but usually never resolved Optimization of anatomy may not deliver the desired result Most revision surgery associated with positive short-term, but disappointing long-term results More distal; higher nutritional issues

6. Anatomic Optimization POUCH ANASTOMOSIS BYPASS

7. The Anastomosis

8. 19±9 lb 23±17 lb ±5 lb

9. 71 patients < 50% EWL or 5% weight gain after GBP 26 month follow-up Only predictive variable was pre-endoscopy weight gain (p=0.02)

10. Stoma Reduction Spaulding L. Treatment of dilated gastrojejunostomy with sclerotherapy. Obes Surg 2003;13:254 –7 Catalano MF, Rudic G, Anderson AJ, Chua TY. Weight gain after bariatric surgery as a result of large gastric stoma: endotherapy with sodium morrhuate may prevent the need for surgical revision. Gastrointest Endosc 2007;66:240 –5. Herron D, Birkett D, Thompson C, Bessler M, Swanstrom L. Gastric bypass pouch and stoma reduction using a transoral endoscopic anchor placement system: A feasibility study. Surg Endosc (2008) 22:1093–1099. 75% lost weight (6.8kg @ 6 month) 25% gained weight (3.6kg @ 6 month) 64% lost weight (22.3 ± 9.2 kg) @ 18 months

11. Herron D, Birkett D, Thompson C, Bessler M, Swanstrom L. Gastric bypass pouch and stoma reduction using a transoral endoscopic anchor placement system: A feasibility study. Surg Endosc (2008) 22:1093–1099.

12. Endoluminal Thompson 2006 - 8 patients; 10 kg @ 4 months Bard Endocinch Mullady 2009 - 20 patients; 8.8 kg @ 3 months Rose procedure (USGI) Ryou 2009 - 5 patients: 7.8 kg @ 3 months Rose procedure (USGI) Mikami 2009 - 6 patients; 10 kg @ 1 year StomaphyX™

13. Anastomosis Revising anastomosis alone does not result in durable weight loss or maintenance Endoluminal interventions are still investigational; probably will not be viable revision solutions

14. The Pouch

15. Pouch Reduction Preservation of GJ Complete Revision

16. 5 patients: BMI: 32 ➔ 28 12 months F/U

17. (6) patients - mean BMI: 36.3 kg/m 2 mean F/U 14 ± 9.2 months Final BMI: 26.4 ± 4.2 kg/m 2 70.4 ± 30.4% EWL No complications Obesity Surgery 2009

18. 2-year follow-up

20. Banded gastric bypass superior?

23. Adjustable Gastric Band O’brien PF, et al. Revisional surgery for morbid obesity-conversion to the Lap Band system. Obes Surg 2000;10:557-63. Kyzer S, et al. Use of adjustable silicone gastric banding for revision of failed gastric bariatric operations. Obes Surg 2001;11:66-9. Bessler M, et al. Adjustable gastric banding as a revisional bariatric procedure after failed gastric bypass. Obes Surg 2005;15:1443-8. Gobble RM, et al. Gastric banding as a salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass. Surg Endosc 2008;22:1019-1022. Chin PL, et al. Adjustable gastric band placed around gastric bypass pouch as revision operation for failed gastric bypass. SOARD 2009;5:38-42.

24. Adjustable Gastric Band O’brien PF, et al. (2/50) patients; unknown results of GBP subset Kyser S, et al. (12/37) patients; unknown results of GBP subset (all revisions performed open)

25. Adjustable Gastric Band O’brien PF, et al. (2/50) patients; unknown results of GBP subset Kyser S, et al. (12/37) patients; unknown results of GBP subset (all revisions performed open) Bessler M, et al. (8) patients EWL 38.1±10.4% @ 1 year, 44.0±36.3% @ 2 years* Gobble RM, et al. (11) patients EWL 20.8±16.9%; 13 months (2-32 months)* Chin PL, et al. (8) patients EWL 24.3% @ 1 year, 36.4% @ 2 years, 66.2% @ 3 years (all surgeries were done open)* *No complications

26. The Bypass

27. Limb Length Studies Study Limb Length BP Roux BMI EWL Inabnet 2005 1 year F/U 50 100 100 150 <50 NS Chobin 2002 5 year F/U 30 75 150 250 <50 >50 NS MacLean 2001 4-6 year F/U 10 100 40 100 <50 >50 NS S Brolin 1992 5 year F/U 15 30 75 150 >50 S

28. BMI > 50 kg/m 2 Brolin RE, Kenler HA, Gorman JG, et al. Long-limb gastric bypass in the superobese: a prospective randomized study. Ann Surg. 1992; 215:387–395. MacLean LD, Rhode BM, Nohr CW. Long or short-limb gastric bypass? J Gastrointest Surg. 2001;5:525–530. Nelson WK , Fatima J , Houghton SG , Thompson GB , Kendrick ML , Mai JL , Kennel KA , Sarr MG . The malabsorptive very, very long limb Roux-en-Y gastric bypass for super obesity: results in 257 patients. Surgery. 2006 Oct;140(4):517-22 “ A subgroup of 20 patients, all of whom had a body mass index greater than 60 kg/m 2 , benefited the most from long-limb bypass.”

29. 40-60 cm Roux Limb Bruder SJ, Freeman JB, Brazeau-Gravelle P. Lengthening the Roux–Y limb increases weight loss after gastric bypass: a preliminary report. Obes Surg. 1991;1(1):73–7. Choban PS, Flancbaum L. The effect of Roux limb lengths on outcome after Roux-en-Y gastric bypass: a prospective, randomized clinical trial. Obes Surg. 2002;12(4):540–5. Fox SR, Oh KH, Fox K. Vertical banded gastroplasty and distal gastric bypass as primary procedures: a comparison. Obes Surg. 1996;6(5):421–5. Equivalent weight loss

30. Annals of Surgery • Volume 244, Number 5, November 2006 “ The gastric bypass limb length does not impact long-term weight loss.”

31. No correlation between limb lengths and weight loss after proximal “Fobi/Capella”

32. J Gastrointest Surg. 2002 Mar-Apr;6(2):195-203

33. 66 GBP 49 D-RY 75cm common channel 12 T-RY re-stapled 5 Loop GBP standard RY (150cm Roux) 48 %EWL 51 %EWL 58.8 %EWL Annals of Surgery • Volume 248, Number 2, August 2008 Single surgeon experience 151 patients over 22 years 55% followup @ 5 years; 28% followup @ 10 years

36. Most revisions also included resizing the pouch along with shortening the common channel Significant medium to long term weight maintenance Complication rate: 15.5% Mortality: 1.5%

37. Improvement and/or Resolution Buchwald et al. JAMA 2004; 292:1724-1737 Brolin 2008 100% 94% 92% 100% Arthritis 97% Condition Buchwald 2004 Diabetes 84% Hypertension 75% Hyperlipidemia 94% Sleep Apnea 87%

38. 27 super-obese patients EWL 30% -> 61% @ 1 year; 69% @ 5 year (5) 50cm CC: (2) died of hepatic failure; all revised for malnutrition (22) 150 cm CC: (3) revised for malnutrition Journal of GastrointestinalSurgery 1997

39. Weight maintenance obtainable Malnutrition is unacceptable with common channel 50 cm “Adding malabsorption to restriction...” Journal of GastrointestinalSurgery 1997

41. Results -65 patients BMI: 42 kg/m 2 -> 35 kg/m 2 15/65 patients (23%) developed protein-calorie malnutrition 6 patients ultimately required re-revision to S-FPO

42. Obesity Surgery 1992 Achieved BMI 31 kg/m 2 for revisions 79% > 50% EWL

43. 218 patients; mean F/U 7 years serious complications: 26% mortality 0.9%

44. “ None of the patients undergoing revision of a previous RYGB to a nonmalabsorptive RYGB achieved successful weight loss.” Standard Distal weight loss 68 ± 7 lb 115 ± 12 lb p < .001 satisfaction 78% 90% NS > 50% EWL 45% 52% NS

46. Conclusions No studies delineate the optimal Roux, biliopancreatic and common channel limb lengths. There may be a long term effect on BMI > 50 kg/m 2 with additional nutritional concerns Long-term data (>10 years) inconclusive

47. Personal Experience Variable Mean ± SD Sample size (n) 212 Female:Male 64:8 Age (years) 46.6 ± 8.12 Initial BMI (kg/m 2 ) prior to first RYGBP 53.2 ± 11.4 BMI (kg/m 2 ) @ time of revision 41.6 ± 7.7 % EWL prior to revision 32.5 ± 20.5 Mean time to revision (years) 8.4 ± 4.59 Advanced Laparoscopic Surgery Associates Medical Group

48. Revision Procedures Group 1 Static band (Fobi/Capella) Group II Revision gastroplasty only Group III Adjustable gastric band Group IV Distal ➔ proximal gastric bypass & revision gastroplasty Group V Distal gastric bypass Advanced Laparoscopic Surgery Associates Medical Group

49. Results Performance Performance ANOVA & Bonferroni Post Hoc Tests p-value by paired T-test Variable GROUP 1 Fobi GROUP II Revision only GROUP III AGB GROUP IV Distal -> Prox GROUP V Distal TOTAL p-value Followup (years) 2.3 ± 0.96 3.0 ± 2.16 1.3 ± 0.44 3.4 ± 2.13 2.6 ± 0.98 2.6 ± 1.70 NS % EWL before revision 35.4 ± 19.56 32.3 ± 14.66 43.7 ± 11.06 31.2 ± 14.85 40.8 ± 12.86 34.4 ± 16.56 NS % EWL after revision 63.5 ± 17.28 62.2 ± 20.25 60.0 ± 24.79 73.4 ± 25.74 62.0 ± 21.36 63.7 ± 19.62 NS Absolute % EWL 28.1 ± 15.71 29.9 ± 12.02 16.3 ± 14.01 42.2 ± 32.4 21.2 ± 16.06 29.3 ± 16.85 NS p-value < 0.001 < 0.001 < 0.001 < 0.040 < 0.001 < 0.001 Advanced Laparoscopic Surgery Associates Medical Group (5) removed

50. Overall Performance p-value determined by Paired T-test % EWL prior to revision 34.4 ± 16.56 % EWL after revision 63.7 ±19.62 Absolute % EWL 29.3 ± 16.85 p-value < 0.001 BMI prior to revision 41.6 ± 7.74 BMI after revision 34.9 ± 7.32 Absolute change in BMI 6.7 ± 7.53 p-value < 0.001 Advanced Laparoscopic Surgery Associates Medical Group

51. Patient Satisfaction percent Completely satisfied 80,6% Unsatisfied 19,3% Inadequate weight loss 6,4% Weight recidivism 6,4% Unrealized expectations 6,4% Advanced Laparoscopic Surgery Associates Medical Group

52. *Flum et al: Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. JAMA 2005;294:1903-8. Higa K, Ho T, Boone K. Laparoscopic Roux-en-Y gastric bypass: technique and 3-year follow-up. J Laparoscopic & Adv Surg Tech 2001, 11: 377-382 1.9% Mortality among MCARE pts* 0.8% 0 1.4% Brolin Higa-VBG Higa-GBP Higa-Primary Morbidity 21,8% 46,6% 26% 14,8% Mortality 1,3% 0,2%

53. Complications *Higa K, Ho T, Boone K. Laparoscopic Roux-en-Y Gastric Bypass: Technique and 3-Year Follow-Up. J Laparoscopic & Adv Surg Tech 2001, 11: 377-382. Advanced Laparoscopic Surgery Associates Medical Group Primary* Brolin Higa Stenosis 4,9% 2% 6% Leaks 0,7% 6% 9,5% Hemorrhage 0,8% NR 2,4%

54. Conclusions Laparoscopic revision of RYGBP results in significant weight loss There is no difference between groups as far as performance or overall complications Most patients are very satisfied after revision Complication rates are high: 26% Advanced Laparoscopic Surgery Associates Medical Group

55. Personal Approach weight recidivism abnormal anatomy revise pouch good anatomy add AGB inadequate weight loss good anatomy satiety no surgery poor nutrition good nutrition distal bypass (if compliant) reversal

56. AGB after open GBP

57. Revise pouch (Higa)

58. THANK YOU