Revisional procedures after bariatic surgery is always a theme for debate where protocols and references are still necesarry This presentations provides some guidances in putting tighter endoscopy and radiologic images in order to help a better understanding of the bariatric anatomy

1. Presenter Name: Manoel Galvao Neto, MD
As previously disclosed, these are the companies with which I
have a financial or other relationship(s):
• Company Name(s) Nature of Relationship(s)
• Ethicon EndoSurgery Consultant / International Prof. ed.
• GI Dynamics Consultant / SAB
• Apollo EndoSurgery Consultant

2. JOSEMBERG M.
CAMPOS, PHD
MANOEL GALVAO
NETO, MD
ALMINO C.
RAMOS, MD
Recife, PE, Brazil Sao
Paulo, SP, Brazil
Sao
Paulo, SP, Brazil
Recife, PE, Brazil

3. A Window with a View:
Endoscopic and X-ray Images Before
Revisional Surgery:
What To Look For

6. A Window with a View:
Revisional Surgery:
Reasons to do it…

7. Revisional Surgery
• Reasons to do it…
• Poor weight loss
• Prosthesis malfunction
• Band or ring dislodgement, migration, intolerance…
• Inflammation (chronic…)
• Ulcers
• Chronic leaks
• Persistent symptoms
• Reflux, Diarrhea, Dumping, vomiting, smelling…
• Malnutrition

8. Revisional Surgery
• So many leading reasons…
• Lets focus in one were imaging might help…
Weight loss failure
P.S: as a window with a view do not
expect many objective data…

9. Revisional Surgery
• Weight loss failure
• Fail in achieve:
• Clinically – co morbidities improvement
•Clinical and Endocrinology societies
• Loose less than 10-20%EWL
• Surgically
•INH, IFSO,ASBS…
• Loose less than 50%EWL
• Patients perspective
•Loose less than personal objectives

10. Revisional Surgery
• Weight loss failure
• Defining criteria
• Primary procedure failure
• Do not achieve at least 50%EWL
• Secondary procedure failure
• Initial success followed by weight regain
• Over 50%EWL

11. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”

12. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”

13. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• Adjustable Gastric Band

14. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• Adjustable Gastric Band
• Endoscopy

15. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• Adjustable Gastric Band
• Endoscopy

16. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• Adjustable Gastric Band
• X-ray

17. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• Adjustable Gastric Band
• Imaging

18. Revisional Surgery
• Weight loss failure
• Defining on surgical – anatomical criteria
• Adjustable Gastric Band – AGB
• Do not loose enough weight with maximum adjustment
• Do not achieve maximum adjustment
• Complicated esophagitis / Acalasia like / Band leakage
• Band slippage / pouch enlargement
• Band erosion

19. DILATED POUCH
STASIS
DEVIED STOMA
LUSH
FUNDOPLICATION
ADJUSTABLE GASTRIC BAND
SLIPPAGE

20. ADJUSTABLE GASTRIC BAND
EROSION / MIGRATION

21. ADJUSTABLE GASTRIC BAND
COMPLICATED ESOPHAGITIS

22. ADJUSTABLE GASTRIC BAND
ACALASIA LIKE

23. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• RYGB

24. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• RYGB
• Endoscopy

25. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• RYGB – Small pouch – Narrow GJ
• Endoscopy
1
3
2
1. “POUCH”
2. ANASTOMOSIS
3. BOWEL

26. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• RYGB
• X-ray

27. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• RYGB
• imaging

28. Revisional Surgery
• Weight loss failure
• Defining on surgical – anatomical criteria
• RNY Gastric bypass
• Loss of restriction
• Pouch enlargement
• Stomal enlargement
• Band/ring removal
• Gastro-Gastric Fistula

29. RNY GASTRIC BYPASS
STOMAL ENLARGEMENT/ DILATION

30. RNY GASTRIC BYPASS
RING EROSION + ENDOSCOPIC REMOVAL

31. RNY GASTRIC BYPASS
GASTRO-GASTRIC FISTULA

32. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• Sleeve Gastrectomy

33. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• Sleeve Gastrectomy
• Endoscopy

34. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• Sleeve Gastrectomy
• Endoscopy

35. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• Sleeve Gastrectomy
• Endoscopy

36. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• Sleeve Gastrectomy
• Imaging

37. Revisional Surgery
• Weight loss failure
• Defining on surgical – anatomical criteria
• Sleeve gastrectomy
• Loss of restriction
• Pouch enlargement
• Overall enlargement
• Partial enlargement

38. SLEEVE GASTRECTOMY
POUCH ENLARGEMENT

39. SLEEVE GASTRECTOMY
POUCH ENLARGEMENT

40. SLEEVE GASTRECTOMY
STENOSIS

41. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• BPD - DS

42. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• BPD – DS
• Endoscopy

43. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• BPD – DS
• Endoscopy

44. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• BPD – DS
• Endoscopy

45. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• BPD – DS
• Imaging

46. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• BPD – “Scopinaro’s”

47. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• BPD
• Endoscopy

48. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• BPD
• Endoscopy

49. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• “New procedures”
• Gastric plication

50. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• “New procedures”
• Gastric plication
• Endoscopy

51. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• “New procedures”
• Gastric plication
• Imaging

52. Endoscopic and X-ray Images Before
Revisional Surgery
• Regular “bariatric anatomy”
• “New procedures”
• Intestinal transit bipartition

53. A Window with a View:
Endoscopic and X-ray Images During
Revisional Surgery:
Guidance….

54. Endoscopic and X-ray Images During
Revisional Surgery
• Identifying altered “bariatric anatomy”
• RYGB

55. Endoscopic and X-ray Images During
Revisional Surgery
• Identifying altered “bariatric anatomy”
• RYGB

56. Endoscopic and X-ray Images During
Revisional Surgery
• Intra-op control of the new “bariatric anatomy”
• RYGB

57. A Window with a View:
Endoscopic and X-ray Images Before
Revisional Surgery:
What to expect….

58. Endoscopic and X-ray Images Before
Revisional Surgery
•What to expect….
• What the “merge” of the imaging X case
peculiarities tells you…
•Revisional surgery should be decided on
•“one-O-one” basis

59. THANKS!!