surgical options for weight regain after gastric bypass · weight regain after rygb estimated 10 -...
TRANSCRIPT
![Page 1: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/1.jpg)
Surgical Options for Weight Regain after Gastric Bypass
Alfonso Torquati, MD, MSCI, FACS
Associate Professor and Chief
Division of Metabolic and Bariatric Surgery
![Page 2: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/2.jpg)
Disclosures
Allergan: grant support
Covidien: consulting agreement
2
![Page 3: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/3.jpg)
Definition of a RYGB “Failure”
Inadequate initial EWL: <50%
Significant Weight Regain :> 20% of weight gain
above nadir weight
![Page 4: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/4.jpg)
Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5
and 10 years postoperatively
Wide consensus that weight regain (20% of
weight gain above nadir weight)warrants
surgical anatomy evaluation : • EGD
• Upper GI contrast study
4
![Page 5: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/5.jpg)
Surgical Causes of Weight Regain after RYGB
Large pouch at time of
surgery
Dilated gastric pouch
5
![Page 6: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/6.jpg)
Surgical Causes of Weight Regain after RYGB
Gastro-gastric fistula
Dilated gastro-jejunostomy
6
![Page 7: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/7.jpg)
Other Causes of Weight Regain after RYGB
hyperphagia
polyphagia
sweet eating
Lack of exercise
Steroids
Pregancy
![Page 8: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/8.jpg)
Multidisciplinary consultation - radiologist
- gastroenterologist
- nutritionist
- psychologist
![Page 9: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/9.jpg)
MAIN CAUSES OF RYGB FAILURES
Treatment: LAPAROSCOPIC or ENDOSCOPIC
TECHNICAL PROBLEMS
1- gastric pouch dilatation
2- gastrojejunostomy dilatation
3- presence of gastro-gastric fistula
![Page 10: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/10.jpg)
MAIN CAUSES OF RYGB FAILURES
1) Gastric pouch dilatation:
- Laparoscopic resection or plication
- Endoscopic plication
2) Gastrojejunostomy dilatation:
- Endoscopic plication or sclerosing agent
3) Presence of gastro-gastric fistula
- Laparoscopic resection
- Endoscopic closure
![Page 11: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/11.jpg)
G-G Fistula Laparoscopic Technique
1- lateral to medial approach
2- isolation greater curve of gastric remnant (body to
fundus)
3- section of remnant from gastric pouch (fundectomy)
4- try to salvage the gastrojejunostomy
![Page 12: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/12.jpg)
Dealing with Polyphagia
polyphagia = grazing, eating too frequent
meals
conversion to malabsorptive procedure:
DISTAL RYGB
Kellum JM, et al. SOARD 2011;7:189-93
Rawlins ML et al. SOARD 2011;7:45-9
Brolin RE et al. J Gastrointest Surg 2002;6:195-205
Fobi MAL et al. Obes Surg 2001;11:190-5
Surgerman HJ et al. J Gastrointest Surg 1997;6:517-25
![Page 13: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/13.jpg)
Confusion?
![Page 14: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/14.jpg)
Nelson WK, Fatima J, Houghton SG, Thompson GB,
Kendrick ML, Mai JL, Kennel KA, Sarr MG. The
malabsorptive very, very long limb Roux-en-Y gastric
bypass for super obesity: Results in 257 patients
Surgery Volume 140, Issue 4 2006 517 - 523
Terminology
![Page 15: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/15.jpg)
Giovanni Dapri, Guy Bernard Cadière, and Jacques Himpens. Journal of Laparoendoscopic & Advanced Surgical
Techniques. January/February 2011, 21(1): 19-23.
Revision to distal RYGB
![Page 16: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/16.jpg)
Comparison of weight, BMI, and % excess weight loss (%EWL) at RYGB, at extreme values before the conversion to
DRYGB, at the conversion, and at follow-up (mean values).
Giovanni Dapri, Guy Bernard Cadière, and Jacques Himpens. Journal of Laparoendoscopic & Advanced Surgical
Techniques. January/February 2011, 21(1): 19-23.
Between April 2005 and November 2009, 7 patients benefited from laparoscopic conversion of
RYGB to DRYGB for weight regain mainly due polyphagia
Revision to distal RYGB
![Page 17: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/17.jpg)
Revision to Distal RYGB
![Page 18: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/18.jpg)
Proximal vs. Distal RYGB
![Page 19: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/19.jpg)
Characteristics of the two groups
![Page 20: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/20.jpg)
Results
British Journal of Surgery
Volume 95, Issue 11, pages 1375-1379, 9 OCT 2008
![Page 21: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/21.jpg)
Sweet Eating: Conversion to DS
![Page 22: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/22.jpg)
RYGB to DS Taking down Roux Limb
Gastro-Gastrostomy
Sleeve Gastrectomy
Duodenoileostomy
Ileoileostomy
Jejunojejunostomy
![Page 23: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/23.jpg)
Dealing with Hyperphagia
hyperphagia = volume eating, eating too large
meals
Increased restriction by placement of band
(adjustable or non)
Irani K et al. SOARD 2011;7:219-24
Bessler M et al. SOARD 2010;6:31-5
Chin PL et al. SOARD 2009;5:38-42
Gobble RM et al. Surg Endosc 2008;22:1019-22
![Page 24: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/24.jpg)
![Page 25: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/25.jpg)
Excess body mass index loss (%EBMIL)
after revision. Values shown for follow-up
(in months) after revisional surgery (t = 0).
![Page 26: Surgical Options for Weight Regain after Gastric Bypass · Weight Regain after RYGB Estimated 10 - 30% of patients will regain weight at 5 and 10 years postoperatively Wide consensus](https://reader035.vdocuments.mx/reader035/viewer/2022081407/5f280e10755f4d1cc06c78ce/html5/thumbnails/26.jpg)
Conversion of RYGB into Distal RYGB