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.

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?

7. The Anastomosis

8. 19±9 lb 23±17 lb ±5 lb

14. The Pouch

15. Pouch Reduction Preservation of GJ Complete Revision

18. 2-year follow-up

20. Banded gastric bypass superior?

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

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

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%

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

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

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%

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