Revision Surgery After Laparoscopic Sleeve Gastrectomy
Introduction to bariatric surgery
When to Revise a Weight Loss Surgery?
Options for redo surgery.
Laparoscopic Roux-en-Y gastric Bypass.
Artery first approach For Pancreatic Head tumours by Dr Harsh Shah (www.gastr...Dr Harsh Shah
Artery first approach to Pancreatic head tumour. There are various approaches as described in this presentation. Pros & Cons of all approaches are discussed.
The classic technique of PD consists of the en-bloc removal of the distal segment of the stomach (antrum), the first and the second portions of the duodenum, specifically the head of the pancreas, the distal CBD, and the gallbladder. Another approach to this procedure is known as the pylorus-sparing PD. In this approach, a small segment of the duo denum is left in situ with the entire stomach to preserve the pylorus and prevent the post–gastrectomy-related symptoms and complications. The classic Whipple and the pylorus-preserving operations are associated with comparable operation times, blood loss, hospital stays, mortality, morbidity, and the incidence of delayed gastric emptying (Mathur et al., 2015). The overall long-term and the disease-free survival is comparable in both groups.
This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.
This presentation summarizes the state of the art with respect to the management of GIST. It covers the basics of surgical and medical management including the role of neoadjuvant and adjuvant targeted therapy. www.ellenhornmd.com
gastric resection, reconstruction and post gastrectomy syndromessanyal1981
discussion regarding history of gastrectomy, types of gastrectomy, billroth I, billroth II and roux en y gastrojejunostomy........discussion of post gastrectomy syndromes
Devascularization in portal hypertension.dr quiyumMD Quiyumm
role of surgery in portal hypertension is promising. Devascularization is one of the procedure of choice in unshuntable portal vein. Though LT is treatment of choice
Cholangiocarcinoma: Pathology, diagnosis and treatment.Marco Castillo
A brief description with many abdominal imaging of the Cholangiocarcinoma.
Includes definition, epidemiology, pathology, classification, clinical presentation, diagnosis, staging and treatment.
Artery first approach For Pancreatic Head tumours by Dr Harsh Shah (www.gastr...Dr Harsh Shah
Artery first approach to Pancreatic head tumour. There are various approaches as described in this presentation. Pros & Cons of all approaches are discussed.
The classic technique of PD consists of the en-bloc removal of the distal segment of the stomach (antrum), the first and the second portions of the duodenum, specifically the head of the pancreas, the distal CBD, and the gallbladder. Another approach to this procedure is known as the pylorus-sparing PD. In this approach, a small segment of the duo denum is left in situ with the entire stomach to preserve the pylorus and prevent the post–gastrectomy-related symptoms and complications. The classic Whipple and the pylorus-preserving operations are associated with comparable operation times, blood loss, hospital stays, mortality, morbidity, and the incidence of delayed gastric emptying (Mathur et al., 2015). The overall long-term and the disease-free survival is comparable in both groups.
This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.
This presentation summarizes the state of the art with respect to the management of GIST. It covers the basics of surgical and medical management including the role of neoadjuvant and adjuvant targeted therapy. www.ellenhornmd.com
gastric resection, reconstruction and post gastrectomy syndromessanyal1981
discussion regarding history of gastrectomy, types of gastrectomy, billroth I, billroth II and roux en y gastrojejunostomy........discussion of post gastrectomy syndromes
Devascularization in portal hypertension.dr quiyumMD Quiyumm
role of surgery in portal hypertension is promising. Devascularization is one of the procedure of choice in unshuntable portal vein. Though LT is treatment of choice
Cholangiocarcinoma: Pathology, diagnosis and treatment.Marco Castillo
A brief description with many abdominal imaging of the Cholangiocarcinoma.
Includes definition, epidemiology, pathology, classification, clinical presentation, diagnosis, staging and treatment.
Bariatric surgery – improving life, longterm.Jia Maheshwari
Going under the scalpel, may be the last resort for some obese people but it certainly has many advantages besides losing weight and increased self-esteem. Sleep apnea can be driven away too. Ditto for depression, anxiety and scores of other mindblocks in daily life situations which require interacting and networking with people.
Laparoscopic Adjustable Gastric Banding Around Roux En-y Gastric BypassBradEdwards38
Gastric banding is an option for people that have had a gastric bypass that still need to lose more weight but do not want another maladaptive procedure.
Gastric sleeve surgery how does it worklauraperez908
"AMBI Surgery specializes in the surgical treatment of obesity and metabolic disorders. For more information about vertical sleeve gastrectomy visit www.ambisurgery.com today.
"
Similar to Rivision surgery after laparoscopic sleeve gastrectomy (20)
Background.
Treatment Algorithm.
Pre-Op preparation.
Surgical Techniques and Technology in stone removal:
Intracorporeal Lithotripters.
Extracorporeal Shock wave Lithotripsy.
Percutaneous Nephrolithotomy.
Ureteroscopic Management of Stones.
Laparoscopic and Open stone Surgery.
Urinary stones During Pregnancy.
AUA and EAU guidelines.
Questions.
Ureteric stent versus percutaneous nephrostomy for acute ureteral obstruction - clinical outcome and quality of life: a bi-center prospective study
Urology Journal Club
Approach to Hematuria including:
Definition of Hematuria.
Pathophysiology of Hematuria.
Differential Diagnosis of Red Urine.
Causes of Hematuria.
Approach to a patient with Hematuria.
Diagnostic Algorithms.
Management and Disposition.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
Rivision surgery after laparoscopic sleeve gastrectomy
1. Revision Surgery After
Laparoscopic Sleeve Gastrectomy
Advanced Laparoscopic in Robotic and Bariatric Surgery
King Saud University Medical City
30 December, 2018
Ibrahim Abunohaiah
R1, Urology
7. Introduction
It is estimated that 179,000 weight-loss surgeries were
performed in 20131.
Of those, 42% were sleeve gastrectomy, 34% were gastric
bypass, 14% were gastric band, and 1% were biliopancreatic
diversion with duodenal switch. The remaining 6% were
revisional procedures.
1. connect.asmbs.org/may-2014-bariatric-surgery-growth.html (Accessed on April 12, 2016).
8. What is revision surgery?
In general, between about 10 and 30 per cent of patients
having any type of weight loss surgery will end up needing
later surgery to treat complications or weight regain.
When an ineffective procedure results in weight regain, a
revision procedure may be the best solution.
http://www.sydneyobesity.com.au/revision-surgery.html
https://www.smartdimensions.com/bariatric-weight-loss-orange-county/revision-bariatric-surgery/
9. When to Revise a Weight Loss
Surgery?
A small number of patients who have weight loss surgery
relapse years later. These individuals may benefit from an
additional procedure, called revision surgery, to help them
lose again and treat specific symptoms.
There are many different factors that might contribute to
weight regain. Revision surgery may be done because the
patient's anatomy has changed over time and needs repair.
http://columbiasurgery.org/news/2017/08/14/when-revise-weight-loss-surgery
10. Options for redo surgery
http://www.sydneyobesity.com.au/revision-surgery.html
If a patient needs redo surgery we can then create a solution that is specific to your
particular problem that a patient has. Redo surgery can be planned to:
• Fix a complication with an operation
• Repair or fix an operation that is no longer working
• Change an operation to another procedure (band/sleeve/bypass)
11. Revision Surgery for Weight Regain
After Gastric Sleeve (Re-Sleeve)
In some cases, improper eating (frequent large meals,
drinking carbonated beverages, and binge eating) or a failure
to completely remove all necessary portions of the stomach,
can result in weight regain after gastric sleeve surgery.
When significant or lasting weight loss is not achieved in
patients who have undergone gastric sleeve surgery, a “re-
sleeve” may aid in further weight loss.
https://www.smartdimensions.com/bariatric-weight-loss-orange-county/revision-bariatric-surgery/
12. Gastric Sleeve Revision Surgeries
There are 4 gastric sleeve revision surgery options for
addressing inadequate weight loss, weight regain, or
persistent side effects:
• A conversion to a duodenal switch (DS)
• A conversion to a gastric bypass
• Re-sleeve
• A conversion to a Lap-Band
https://www.bariatric-surgery-source.com/gastric-sleeve-revision-surgery.html
13. Reasons for Revision
The most common reasons for gastric sleeve revision surgery
are:
1. Inadequate weight loss
2. Weight regain
3. Side effects like gastric reflux (but are much less common (1)).
https://www.bariatric-surgery-source.com/gastric-sleeve-revision-surgery.html
(1) http://www.soard.org/article/S1550-7289(14)00394-3/abstract
14. Revising a Failed Procedure
A failed weight loss procedure can be defined as one that has
resulted in:
• Less than 50% loss of the expected weight loss
• Weight loss followed by partial or total regain
• An intolerance to normal/solid foods
• Signs that the overall quality of life is diminishing
• Additional health issues caused by the procedure
https://obesitycontrolcenter.com/weight-loss-surgery-options/weight-loss-surgery-revision/
15. 1. Inadequate weight loss
The average gastric sleeve patient loses weight at the
following pace:
• 3 months: about one-third of excess weight
• 6 months: about half of excess weight
• 12 months: up to 70% of excess weight
https://www.bariatric-surgery-source.com/gastric-sleeve-revision-surgery.html
16. 2. Weight Regain
As many as 3 out of 10 gastric sleeve patients eventually experience
weight regain.
The amount of regain varies widely, ranging from a few pounds to all of
the weight lost (1) (2). For these patients, the weight begins to creep back
anywhere from 18 months to 6 years after surgery and is the result of:
• The stomach stretching out, causing patients to eat more
• The amount of hunger-causing hormones going back up (e.g., ghrelin) (3) (4)
• Not enough follow-up support for the patient
• Patient not adhering to recommended diet & lifestyle changes
Stomach stretching as a result of overeating is the most common reason
for weight regain after gastric sleeve surgery (3).
https://www.bariatric-surgery-source.com/gastric-sleeve-revision-surgery.html
(1) https://www.sciencedirect.com/science/article/pii/S0899900715003858
(2) https://link.springer.com/article/10.1007/s11695-016-2165-5
(3) https://www.ncbi.nlm.nih.gov/pubmed/20094819
(4) https://www.ncbi.nlm.nih.gov/pubmed/17132410
17. 3. Persistent Side Effects
Although it’s relatively rare, gastric sleeve revision surgery
may be required in the case of persistent side effects like acid
reflux and hiatal hernia (1).
Approximately 2% of revisional surgeries are due to acid reflux
symptoms that haven’t responded to dietary changes or the
use of medication (2).
https://www.bariatric-surgery-source.com/gastric-sleeve-revision-surgery.html
(1) https://www.sages.org/meetings/annual-meeting/abstracts-archive/revision-of-primary-sleeve-gastrectomy-to-roux-en-y-gastric-bypass-indications-and-
outcomes-from-a-high-volume-center/
(2) https://www.soard.org/article/S1550-7289(18)30123-0/fulltext
18. Conversion to Gastric Bypass Surgery for
Weight Regain After Gastric Sleeve Surgery
If gastric sleeve surgery has failed to achieve lasting or desired
weight loss in a patient, conversion to a gastric bypass
procedure can be an effective alternative for additional
weight loss.
There are some cases in which gastric sleeve surgery is
followed by gastric bypass surgery or duodenal switch surgery.
This is often referred to as a “staged” approach to bariatric
surgery and is typically performed in “high-risk” cases where
the second procedure (the gastric bypass surgery) is less risky
than it would have been if performed as the first and only
procedure.
https://www.smartdimensions.com/bariatric-weight-loss-orange-county/revision-bariatric-surgery/
20. Background
Laparoscopic Roux-en-Y gastric Bypass
• LRYGB was first described in 19942
• By 2003, over 130,000 gastric bypasses were done in the
United States, with more than half of them being done
laparoscopically.
• Currently over 90% are performed laparoscopically.
• It has been established as the gold standard against which
other bariatric procedures are measured.
2. Deitel M. Overview of operations for morbid obesity. World J Surg. 1998;22:913-918.
21. Components of a Roux-en-Y
gastric bypass
It involves the creation of a small gastric
pouch and an anastomosis to a Roux limb
of jejunum that bypasses 75 to 150 cm of
small bowel, thereby restricting food and
limiting absorption.
Adapted from UpToDate.com
22. Background, cont.
• The major feature of the operation is a proximal gastric
pouch of small size (often <20 mL) that is totally separated
from the distal stomach.
• A Roux limb of proximal jejunum is brought up and
anastomosed to the pouch.
• The length of the biliopancreatic limb from the ligament of
Treitz to the distal enteroenterostomy is 20 to 50 cm, and
the length of the Roux limb is 75 to 150 cm.
23. Figure 1
Enteroenterostomy of laparoscopic Roux-en-Y gastric bypass
Adapted from Schwartzs Principles of Surgery, 10th Edition.
26. Mechanism of Action
• It works by restricting the amount of food one
ingests (restriction) and by limiting the amount of
nutrients absorbed from the ingested food
(malabsorption).
• Ghrelin levels are lower and leptin levels higher after
Roux-en-Y gastric bypass, which results in decreased
hunger and increased satiety, respectively.
27. Physiologic or anatomic reasons
to favor RYGB
• RYGB treats insulin resistance better than other bariatric
procedures, it may be preferred in patients with uncontrolled
type 2 diabetes, nonalcoholic fatty liver disease, metabolic
syndrome, or polycystic ovarian syndrome.
• While sleeve gastrectomy (SG) and RYGB are equally effective
in improving diabetes in the short term, RYGB is associated
with better long-term control of diabetes and lower rates of
relapse3.
• Patients with Barrett's esophagus or severe /
complicated gastroesophageal reflux disease (GERD) are
better candidates for RYGB than for SG.
3. Can Sleeve Gastrectomy "Cure" Diabetes? Long-term Metabolic Effects of Sleeve Gastrectomy in Patients With Type 2 Diabetes.
https://www.ncbi.nlm.nih.gov/pubmed?term=27433906
28. Outcomes of LRYGB
• Patients undergoing LRYGB usually lose between 60% and
70% of excess body weight during the first year after surgery.
• Resolution of comorbidities varies, but is over 90% for GERD
and venous stasis ulcers and over 80% for patients with type
2 diabetes of less than 5 years in duration.
• Hyperlipidemias are almost always improved and resolve
totally in about 70% of cases.
• Hypertension resolves in 50% to 65% of cases.
29. General Complications of Gastric
Bypass
• Leakage along staple lines / surgical connections.
• Strictures / obstructions of the digestive tract.
• Dumping syndrome
• Nutritional deficiencies
• General Surgical risks
30. Complications of LRYGB
• 0.3% incidence of anastomotic leak4
• 0.33% incidence of venous thromboembolism5
• 3% - 5% incidence of wound infections or problems6
• 3% - 15% incidence of marginal ulcers7
• 7% incidence of bowel obstruction8
• 4% incidence of postoperative transfusion9
• 1% - 19% incidence of anastomotic stenosis10 based on
the type of anastomosis created.
4. Masoomi H, Kim H, Reavis K, et al. Analysis of factors predictive of gastrointestinal tract leak in laparoscopic and open gastric bypass. Arch Surg. 2011;146:1048-1051.
5. Finks JF, English WJ, Carlin AM, et al. Predicting risk for venous thromboembolism with bariatric surgery: results from the Michigan Bariatric Surgery Collaborative. Ann Surg. 2012;255:1100-1104
6. Hutter MM, Schirmer BD, Jones DB, et al. First report of the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness
positioned between the band and the bypass. Ann Surg. 2011;254:410-422
7. Gumbs AA, Duffy AJ, Bell RL. Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass. Surg Obes Relat Dis. 2006;2:460-463
8. Parakh S, Soto E, Merola S. Diagnosis and management of internal hernias after laparoscopic gastric bypass. Obes Surg. 2007;17:1498-1502
9. Nguyen NT, Rivers R, Wolfe BM. Early gastrointestinal hemorrhage after laparoscopic gastric bypass. Obes Surg. 2003;13:62-65.
10. Gonzalez R, Lin E, Venkatesh KR, et al. Gastrojejunostomy during laparoscopic gastric bypass: analysis of 3 techniques. Arch Surg. 2003;138:181-184
32. 1. Anastomotic Leak
• In the immediate postoperative period, anastomotic leak is
the single most feared complication after RYGB, either open
or laparoscopic.
• High index of suspicion for this problem are the only
appropriate approach.
• Tachycardia, tachypnea, fever, and oliguria are the most
common symptoms that arouse suspicion for this problem.
• The treatment is surgical except in rare circumstances where
a drain is already in place, no hemodynamic or clinical
deterioration is present, and the leak is contained.11
11. Thodiyil PA, Yenumula P, Rogula T, et al. Selective non- operative management of leaks after gastric bypass: les- sons learned from 2675 consecutive patients. Ann Surg.
2008;248:782-792.
33. 1. Anastomotic Leak, cont.
• In the first few hours or day after surgery, hematemesis
indicates bleeding from the gastrojejunostomy unless proven
otherwise.
• Any obstructive symptoms in the first few weeks after
surgery or any signs of obstruction of the biliopancreatic limb
on postoperative swallow studies due to stenosis of the
enteroenterostomy require immediate surgical intervention
to prevent rupture of the distal gastric staple line.
34. 2. Stomal Stenosis
• Stenosis of the gastrojejunostomy has been remarkably
reduced by the use of a linear stapling technique.12
• Stenosis symptoms usually appear from 6 to 12 weeks
postoperatively, but less commonly can occur later.
• Diagnosis is by upper endoscopy.
• Treatment is balloon dilatation.
• Resolution normally occurs with one or two treatments.
12. Schirmer BD, Lee SK, Northup CJ, et al. Gastrojejunal anastomosis stenosis is lower using linear rather than circular stapling during Roux-en-Y gastric bypass. Presented
at SAGES 2006 Scientific session, April 2006.
35. 3 & 4. Marginal ulcers and GG fistula
• Patient presents with pain in the epigastric region
that is not altered by eating.
• Diagnosis is by endoscopy.
• Treatment is medical with proton pump inhibitors,
which are effective in 90% of cases.
• Only those with a gastrogastric fistula to the distal
stomach, severe stenosis of the lumen of the
gastrojejunostomy, or acute perforation require
surgical therapy.
36. 5. Dumping Syndrome
• After RYGB, approximately 50% of patients will experience
symptoms of flushing, crampy diarrhea, palpitations, and
diaphoresis after ingesting a meal rich in simple
carbohydrates.
• This may contribute to weight loss by encouraging patients
to replace simple sugar with high-fiber, complex
carbohydrate, and protein-rich food items.
37. 6. Small bowel obstruction
• This complication must be treated differently than in the
average general surgery patient, whose complication is
usually from adhesions and often will resolve with
conservative, non-operative therapy.
• Patients who have had LRYGB who present with obstructive
symptoms generally require surgical therapy on an
emergent basis.
• This is because the etiology of the bowel obstruction after
LRYGB is often an internal hernia from inadequate or
nonclosure of the mesenteric defects by the surgeon at the
time of operation.
38. 6. Small bowel obstruction
• The cecum and terminal ileum are identified laparoscopically,
and the bowel is followed retrograde from the terminal ileum
to determine the anatomy.
• Often much of the small bowel is herniated through a
mesenteric defect.
• If the bowel is viable, suturing the mesenteric defect is all that
is needed for treatment.
39. Obstruction of contrast at enteroenterostomy with small bowel obstruction from internal hernia after laparoscopic Roux-en-Y gastric
bypass.
Adapted from Schwartzs Principles of Surgery, 10th Edition.
40. Nutritional Complications
Postoperative nutritional complications after LRYGB includes:
• 66% incidence of iron deficiency.
• 5% incidence of iron deficiency anemia.
• 50% incidence of vitamin B12 deficiency.13
• At least 15% incidence of vitamin D deficiency,14 which
usually is present preoperatively.
13. Aarts EO, van Wagenhingen B, Janssen IM, Berends FJ. Prevalence of anemia and related deficiencies in the first year following laparoscopic gastric bypass for morbid
obesity. J Obes. 2012;2012:193705.
14. Clements RH, Yellumahanthi K, Wesley M, et al. Hyperparathyroidism and vitamin D deficiency after laparoscopic gastric bypass. Am Surg. 2008;74:469-475.
The surgical treatment of this particular problem can, if addressed early in the course of the obstruction, be treated laparoscopically. The surgeon must place a trocar for the telescope low enough in the abdomen to adequately survey most of the small intestine. The cecum and terminal ileum are identified, and the bowel is followed retrograde from the terminal ileum to determine the anatomy. Often much of the small bowel is herniated through a mesenteric defect, and only this technique allows the surgeon to reliably identify the bowel and decompress it appropriately. If the bowel is viable, suturing the mesenteric defect is all that is needed for treatment. It should be emphasized that either an antecolic or retrocolic placement of the Roux limb can result in this complication, as internal hernias can arise from either approach.