Combination Surgical TherapyBanding the BypassBypassing the Band

Matthew Kroh,MD

Assistant Professor of SurgeryCleveland Clinic

Center for Surgical Innovation, Technology, and EducationBariatric & Metabolic Institute

Disclosures

• Research support from and/or consultant:– Covidien– Ethicon Endo-Surgery– Davol/Bard

Introduction

• Number of failures & revisions increasing– Initial weight– Weight regain

• Must be part of inter-disciplinary evaluation including diet and exercise

Year

1992 1994 1996 1998 2000 2002 2004

# W

eigh

t Los

s O

pera

tions

/Yea

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0

20000

40000

60000

80000

100000

120000

US Bariatric Surgery 1993-2004

Introduction

• Revisional bariatric surgery– More technically challenging – Higher complication rates

• Often open procedures• Increased laparoscopic experience

increasing successful outcomes

Indications

• Definitions of failure• Weight regain• Regain medical co-

morbdities• Failure to ameliorate

co-morbidities• Mechanical failure

– Operation– Device

Options for Failures

• Revisional procedures focus on:– Stoma size– Pouch size– Limb lengths

• Variables that can be surgically altered

Bypassing the Band

Reasons for Conversion

• Proportion of patients previously implanted requiring reoperation varies widely – (5-58%)

• Usually secondary to slippage or dilation• Revisions include replacement or re-

positioning of band• May convert to another procedure

– Most commonly sleeve gastrectomy or RYGB

Background

• Failure rates after banding are widely variable depending on criteria

• Different than RYGB• Include:

– Poor initial EWL– Long term weight regain– Slippage– Intolerance– Esophageal dilation– Infection– Gastric ischemia

AGB Failure

• Requires exclusion of band malposition or malfunction

• Conversion to RYGB described as 2- and 1-step procedures– Success of 1 step procedure enhanced with band

deflation in advance

• Conversion to RYGB more common procedure• Data improving, short and intermediate term

• 350 pts in 7 years underwent AGB

• 21 underwent conversion to RYGB

• Indications:– Poor weight loss, slippage, intolerance,

esophageal dilation, acute complications

• Average time to conversion 27 months

• 3 major complications (11%)– 1 leak, 1 j-j obstruction, 1 a-fib

• Follow-up 18 months

• Conclude safe and efficacious after failed LAGB

• 70 patients for failure – Inadequate weight loss

• Reinhold criteria (<25%)

– Slippage– Erosion

• Performed average 42 months after primary procedure

• Complication rate 14%, no mortality

Band to Bypass

• Several published series

• Overall low morbidity, mortality– Still significantly higher than primary

operations

• May be performed as staged procedure, especially for acute presentations

• Important to perform thorough pre-op evaluation

Re-operation After Primary Banding

• Not infrequent• Indications for re-operation should dictate plan• Repositioning or replacing AGB appears to be

good option for band related complications– Leakage, disconnection– Slippage? Up to 33% recurrence (Suter et al)

• Failure in terms of EWL and co-morbidities better treated with conversion– Most commonly RYGB

Banding the Bypass

Banding the Bypass- Simultaneous Procedures

• Usually in higher risk patients for failure– High BMI (Super-obese), Men

• Weight regain at 3-5 years• Greater experience with fixed rings

– Silastic, polypropylene– Concern for stenosis, erosion, infection

• Fobi, Capela and Capela– Large series of banded bypass pts, excellent

results

• Prospective study

• 90 pts, BMI >50

• Randomized intra-op to banded versus non-banded RYGB

• 1.5 x 7cm Marlex band, sutured around proximal pouch, 5.5 cm diameter

• 2 cm above G-J

• 36 month f/u

GI symptoms Complications

For Failure of Primary Operation

• Additional operation after RYGB

• Major complications for revision RYGB– Up to 50%

• Requires work-up– Anatomic

• Pouch dilation• Stoma dilation• Gatrogastric-fistula

– Exercise– Diet

Surgical Options

• Limb-lengthening procedures– Long-limb gastric bypass

• BPD with or without DS

• Revision of stoma– Surgical or endoscopic

• Revision of pouch– Surgical or endoscopic

Options

• Limb lengthening– Potentially severe metabolic problems

• BPD +/- DS – technically difficult– Excellent EWL, but malabsorption significant

• Endoscopic approaches– Promising– Durability, long term results

Surgical Options

• Banding the bypass

• Fixed versus adjustable bands– Interrupting propulsive wave with reduced

compliance versus outlet restriction

• Mainly silastic or polypropylene

Pre-operative Evaluation

• Operative notes• UGI• Endoscopy

– Hiatal hernia, G-G fistula, ulcer

– E-G junction– Length of pouch– Width of pouch– Size and

characteristics of G-J

Technique

• Laparoscopy versus open

• Knowledge of previous RYGB– Ante-colic, ante-gastric– Retro-colic, retro-gastric

• Recognize and repair hiatal hernia

• Identification of G-J– Intra-op endoscopy

Technique

• Identification of and mobilization of Angle of His

• Left pillar visualization

• Often requires dissection between remnant and pouch

Bessler et al, SOARD, (15) 1443-48.

Technique

• Pars flaccida approach

• Small retro-gastric tunnel

• Gastro-gastric plication– Remnant stomach– Large pouch– ? No plication

Outcomes

• Limited data

• Medical therapy still limited

• Short and medium term outcomes

• 6 pts s/p RYGB• Hyperphagia and weight

regain• BMI at reoperation 38,

initial BMI 36• Time interval 26 months

from 1st operation• Placement non-

adjustable silastic band (6.5-7cm)

• Results– No complications– F/U 14 months– Final BMI 26– EWL 70%– EWL before and after

revision statistically significant

• Hypothesize that fixed ring interrupts propulsive wave, delays emptying

• Different than restriction of AGB

Adjustable Band after Bypass

• Well documented safety• Excellent results as primary procedure

– 11 Pts, poor EWL or weight regain– Initial EWL 38%, after LAGB 59%– One flipped port, no other complications– Mean follow-up 13 months

• 23 patients failure RYGB– Persistent BMI after surgery >35– <50% EWL at 18 months

• Mean BMI at revision 45, initial BMI 53

• Majority laparoscopic

• Complications (13.5% re-operation rate)– 1 leak required removal – 1 slip, 1 port infection, 1 SBO from tubing

EWL at 5 Years

Advantages of AGB to RYGB

• Technically simpler– Especially after lap RYGB

• No anastomosis

• Unlikely additional metabolic sequelae

Conclusions

• Increasing number of failures after primary procedures

• Difficult group of patients requires thorough investigation as to etiology of failure

• Addition of AGB to RYGB for failure seems reasonable with short term data

• Long term outcomes required