gastric pouch and gastric bypass
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First International Consensus Conference on the Mini-Bypass / One
Anastomosis Bypass
Paris 2012 October 18-19
Email [email protected]
“Those who cannot remember the past are
condemned to repeat it.”George Santayana
Bariatric Surgery: A History of Failure
Dr. RutledgeDirector
Center for Laparoscopic Obesity SurgeryEmail: [email protected]
702-714-0011
http://minibypass.wordpress.com/http://www.facebook.com/DrRutledge
http://twitter.com/DrRRhttp://www.youtube.com/user/DrRRutledge
1454-1502: Bariatric Procedures Should Include Both Small Gastric
Pouch and Gastric Bypass for Maximum Effectiveness
Bariatric Surgery: A History of Failure
Bariatric Surgery: A History of Failure
Jaw Wiring
Jaw wiring in treatment of obesityLancet. 1977 Jun 11;1(8024):1221-2. Rodgers S, Burnet R, Goss A, Phillips P, Goldney R, Kimber C, Thomas D, Harding P, Wise P.
17 patients with severe (median percentage above ideal weight 100%) and resistant obesity underwent jaw wiring.
There were no major complications and patients tolerated the procedure and subsequent minor inconveniences.
All patients lost weight at a rate (median 25-3 kg in six months)
comparable with that of intestinal bypass surgery and one achieved and maintained her ideal weight.
Two-thirds of the patients, however, regained some weight after the wires were removed.
Jaw wiring is a simple effective procedure which can be carried out in most hospitals, and has a place in an integrated approach to obesity.
Br Med J (Clin Res Ed). 1981 March 14; 282(6267): 858–860.
Maintenance of weight loss in obese patients after jaw wiring
In this study jaw wiring was used to limit food intake.
...patients were followed for 4-14 months
after removal of jaw wires and regained a mean of only 5.6 kg of the 31.8 kg lost while their jaws were wired.
"This procedure compares favourably with other treatments for severe obesity."
Maintenance of weight loss in obese patients after jaw wiring
Bariatric Surgery: A History of Failure
Jaw WiringBioEnterics Intragastric Balloon (BIB)
BioEnterics Intragastric Balloon (BIB)Int J Obes (Lond). 2006 Jan;30(1):129-33. BioEnterics Intragastric Balloon (BIB): a short-term, double-blind, randomised, controlled, crossover study on weight reduction in morbidly obese patients. Genco A, Cipriano M, Bacci V, Cuzzolaro M, Materia A, Raparelli L, Docimo C, Lorenzo M, Basso N. Department of Surgery Paride Stefanini, University La Sapienza Medical School, Rome, Italy. [email protected]
The results of this study show that treatment of obese patients with BioEnterics Intragastric Balloon is a safe and
effective procedure. In association with appropriate diet it is significantly
effective in weight reduction when compared to sham procedure plus diet.
BioEnterics Intragastric Balloon (BIB)Obes Surg. 2008 Dec;18(12):1611-7. Epub 2008 Jun 21. Evidence-based review of the Bioenterics intragastric balloon for weight loss. Dumonceau JM. Division of Gastroenterology and Hepatology, Geneva University Hospitals,Geneva, Switzerland
Reviewed clinical studies performed with the Bioenterics intragastric balloon (BIB) to promote weight loss.
Thirty studies were included [18 prospective (5 randomized), 12 retrospective], totaling 4,877 patients.
Only one of three controlled trials found a significantly higher weight loss with the BIB vs the sham procedure
In nonrandomized studies, weight loss with the BIB averaged 17.8 kg, BMI changes of 4.0-9.0 kg/m(2).
Comorbidities resolved or improved in 52-100% of patients.
Bariatric Surgery: A History of Failure
Jaw WiringBioEnterics Intragastric Balloon (BIB)
Vertical Banded Gastroplasty
Surg Obes Relat Dis. 2009 Jan-Feb;5(1):94-8. Epub 2008 Jul 21.High revision rates after laparoscopic vertical banded gastroplasty. Marsk R, Jonas E, Gartzios H, Stockeld D, Granström L, Freedman J.Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
486 patients
The median follow-up was 3 years
104 patients, 21% required revision
High revision rates after laparoscopic vertical banded gastroplasty
Bariatric Surgery: A History of Failure
Jaw WiringBioEnterics Intragastric Balloon (BIB)
Vertical Banded GastroplastyLap Band
1: Elnahas A, Graybiel K, Farrokhyar F, Gmora S, Anvari M, Hong D. Revisionalsurgery after failed laparoscopic adjustable gastric banding: a systematicreview. Surg Endosc. 2012 Aug 31. [Epub ahead of print] PubMed PMID: 22936440.2: Deutsch GB, Gunabushanam V, Mishra N, Sathyanarayana SA, Kamath V, Buchin D.Laparoscopic vertical sleeve gastrectomy after open gastric banding in a patient with situs inversus totalis. J Minim Access Surg. 2012 Jul;8(3):93-6. PubMedPMID: 22837597; PubMed Central PMCID: PMC3401724.3: Meesters B, Latten G, Timmermans L, Schouten R, Greve JW. Roux-en-Y gastricbypass as revisional procedure after gastric banding: leaving the band in place. Surg Obes Relat Dis. 2012 Feb 10. [Epub ahead of print] PubMed PMID: 22440668.4: Deylgat B, D'Hondt M, Pottel H, Vansteenkiste F, Van Rooy F, Devriendt D.Indications, safety, and feasibility of conversion of failed bariatric surgery toRoux-en-Y gastric bypass: a retrospective comparative study with primarylaparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2012 Jul;26(7):1997-2002.Epub 2012 Jan 19. PubMed PMID: 22258299.5: Hii MW, Lake AC, Kenfield C, Hopkins GH. Laparoscopic conversion of failedgastric banding to Roux-en-Y gastric bypass. short-term follow-up and technicalconsiderations. Obes Surg. 2012 Jul;22(7):1022-8. PubMed PMID: 22252745.6: Vijgen GH, Schouten R, Pelzers L, Greve JW, van Helden SH, Bouvy ND. Revision of laparoscopic adjustable gastric banding: success or failure? Obes Surg. 2012Feb;22(2):287-92. PubMed PMID: 22094368; PubMed Central PMCID: PMC3266497.7: Scheffel O, Weiner RA. Therapy of stenosis after sleeve gastrectomy: stent andsurgery as alternatives--case reports. Obes Facts. 2011;4 Suppl 1:47-9. Epub 2011Apr 13. PubMed PMID: 22027291.8: Abu-Gazala S, Keidar A. Conversion of failed gastric banding into fourdifferent bariatric procedures. Surg Obes Relat Dis. 2012 Jul;8(4):400-7. Epub2011 Jun 30. PubMed PMID: 21937286.
Bariatric Surgery Failures: PubMed Search “failed gastric banding” >> 100 Articles
9: Burton PR, Brown WA. The mechanism of weight loss with laparoscopic adjustablegastric banding: induction of satiety not restriction. Int J Obes (Lond). 2011Sep;35 Suppl 3:S26-30. doi: 10.1038/ijo.2011.144. Review. PubMed PMID: 21912383.10: Berende CA, de Zoete JP, Smulders JF, Nienhuijs SW. Laparoscopic sleevegastrectomy feasible for bariatric revision surgery. Obes Surg. 2012Feb;22(2):330-4. Review. PubMed PMID: 21866377; PubMed Central PMCID: PMC3266499.11: Hedberg J, Gustavsson S, Sundbom M. Long-term follow-up in patientsundergoing open gastric bypass as a revisional operation for previous failedrestrictive procedures. Surg Obes Relat Dis. 2011 Jun 30. [Epub ahead of print]PubMed PMID: 21865097.12: Runkel N, Colombo-Benkmann M, Hüttl TP, Tigges H, Mann O, Sauerland S.Bariatric surgery. Dtsch Arztebl Int. 2011 May;108(20):341-6. doi:10.3238/arztebl.2011.0341. Epub 2011 May 20. Review. PubMed PMID: 21655459;PubMed Central PMCID: PMC3109275.13: Goitein D, Feigin A, Segal-Lieberman G, Goitein O, Papa MZ, Zippel D.Laparoscopic sleeve gastrectomy as a revisional option after gastric bandfailure. Surg Endosc. 2011 Aug;25(8):2626-30. Epub 2011 Mar 17. PubMed PMID:21416182.14: Bhasker A, Gadgil M, Muda NH, Lotwala V, Lakdawala MA. Revisional bariatricsurgery for failed gastric banding in Asia: a review of choice of revisionalprocedure, surgical technique and postoperative complication rates. Asian JEndosc Surg. 2011 Feb;4(1):26-31. doi: 10.1111/j.1758-5910.2010.00062.x. Epub2010 Nov 17. PubMed PMID: 22776171.15: Greenbaum DF, Wasser SH, Riley T, Juengert T, Hubler J, Angel K. Duodenalswitch with omentopexy and feeding jejunostomy--a safe and effective revisionaloperation for failed previous weight loss surgery. Surg Obes Relat Dis. 2011Mar-Apr;7(2):213-8. Epub 2010 Nov 10. PubMed PMID: 21215708
"Recent data from Marmuse on adjustable bands and BMI>50, who says that “At ten years, only 11% of patients (nine of 80) have successful bariatric results (%EWL>50%) and we were forced to remove the gastric band in 52.2% of patients (47 of
90) because of complications, regardless of the initial operative technique"
Michel Gagner
Bariatric Surgery Failures: PubMed Search “failed gastric banding” >> 100 Articles
Bariatric Surgery: A History of Failure
Jaw WiringBioEnterics Intragastric Balloon (BIB)
Vertical Banded GastroplastyLap Band
Sleeve Gastrectomy
Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients.
Surg Endosc. 2012 Jun;26(6):1509-15. Epub 2011 Dec 17. Aurora AR, Khaitan L, Saber AA. Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
" The risk of leak is low at 2.4%." !!
Himpens, in an article by Deitel et al, presented his early five-year results after sleeve gastrectomy he reported a disappointing 37 and 23 percent inadequate weight loss and second procedure rates, respectively.
Sleeve Gastrectomy Failure: Just When We Thought We Had the Perfect Operation
Bariatric Surgery: A History of Failure
What are the COSTS?
Jaw WiringBioEnterics Intragastric Balloon (BIB)
Vertical Banded GastroplastyLap Band
Sleeve Gastrectomy
• Bariatric surgery programs in VA medical centers.
• 847 were propensity matched to 847 nonsurgical control subjects from the same 12 VA medical centers.
• Bariatric surgery was NOT associated with reduced health care expenditures
Arch Surg. 2012 Jul 1;147(7):633-40.Health expenditures among high-risk patients after gastric bypass and matched controls.Maciejewski ML,
RNY & VBG Fail to Cut Healthcare Costs
American Society for Metabolic and Bariatric Surgery Bariatric Outcomes Longitudinal Database
Gastric banding 22,947 pts in BOLD by 2009
If 100% Fail:22,947 * (US$ 29 000) = 665 million U.S.
dollars
If 50% Fail22 947 * (US$ 29 000) * 50% = 332 million
U.S. dollars
1/3 Billion Dollar Debt for Failed Bands
Costs of Failure
Spectrum Bariatric Surgery
Restrictive
Malabsorbtive
Jaw Wiring
Balloon
Band
VBG
Sleeve
JI BypassBilopancreatic Diversion
Gastrectomy-Like
Alone => Weak Poor Success / High Failure Rates
Duodenal Bypass
Jong Won Kim, etal, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 135-720, South KoreaWorld J Gastroenterol. 2012 January 7; 18(1): 49–54.
METHODS:
403 gastric cancer patients with T2DM were studied, who underwent gastrectomy between May 2003 and September 2009.
A review of medical records and telephone interviews was performed in this cross-sectional study.
Outcome after gastrectomy in gastric cancer patients with type 2 diabetes
BMI % ReductionGastrectomy
Partial 8.2%Near Total 14.2%
Duodenal BypassNo Bypass 7.6%Bypass 11.4%
Outcome after gastrectomy in gastric cancer patients with type 2 diabetes
Diabetes Improvement/Resolution:Gastrectomy
Partial 40%Near Total 60%
Duodenal BypassNo Bypass 37%Bypass 52%
Outcome after gastrectomy in gastric cancer patients with type 2 diabetes
Obes Rev. 2011 Aug;12(8):602-21. doi: 10.1111/j.1467-789X.2011.00866.x. Epub 2011 Mar 28.Padwal R, Klarenbach S, Wiebe N, Birch D, Karmali S, Manns B, Hazel M, Sharma AM, Tonelli M.Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
31 RCTs involving 2619 patients; BMI Decrease
• Jejunoileal bypass [ -11.4 kg/m(2) ]
• Mini-gastric bypass [-11.3 kg/m(2) ]
• Biliopancreatic diversion [-11.2 kg/m(2) ]
• Sleeve gastrectomy [-10.1 kg/m(2) ]
• Roux-en-Y gastric bypass [-9.0 kg/m(2) ]
• Vertical banded gastroplasty [-6.4 kg/m(2) ]
• Adjustable gastric banding [-2.4 kg/m(2) ]
Bariatric surgery: a systematic review and network meta-analysis of randomized trials.
IFSO Varianational Committee Survey
• Over 100 Surgeons from Around the World:
IFSO Varianational Committee Survey
• Results (Preliminary)
• Experience with 39,000 cases in the prior year
• Lap Band is a "Poor" Surgery
• RNY & Sleeve Surgeons have "lots" of leaks
• MGB Surgeons Answered More Correct than Non-MGB Surgeons
Lap Band Unlikely to Get Major Weight Loss (5%)
The Lap Band is "Not a Very Good" Surgery
Spectrum Bariatric Surgery
Restrictive
Malabsorbtive
Jaw Wiring
Balloon
Band
VBG
Sleeve
JI BypassBilopancreatic Diversion
Gastrectomy-Like
Alone => Weak Poor Success / High Failure Rates
Duodenal Bypass
High Failure Rate after Bariatic Surgery that is Restrictive / Gastrectomy alone
These Failures Represent HUGE Future Debt (Billions of Dollars) to our patients, families and their children
History of Bariatric Surgery/Gastric Cancer Data Shows
Greatest effectiveness for operations that combine Restrictive/Gastrectomy anatomy withDuodenal Bypass
Conclusions