Surgical Options for Weight Regain

(or Poor Weight Loss)

After Sleeve Gastrectomy

GASTRIC BYPASS

Jin S. Yoo M.D.

Assistant Professor of Surgery

Duke University Medical Center

Jin.Yoo@duke.edu

Financial Disclosures

• Medtronic

• Novadaq

• Stryker

• W.L. Gore

• Teleflex

Meta-analysis of outcomes of SG in high/

risk staged approach versus primary procedure

Page 3

• 36 SG studies

- 2 RCTs (112 patients with 56

SG patients)

- 1 non-randomized controlled

trial (91 patients with 39 SG

patients)

- 33 cases series (2,475 SG

patients)

Brethauer SA et al. SOARD 2009; 14 (6): 469-75

Review Article on SG studies

Page 4 Shi X et al. Obes Surg 2010; 20: 1171-7.

Sleeve versus the other procedures

Page 5 Shi X et al. Obes Surg 2010; 20: 1171-7.

Definition of “Weight Regain” and

“Poor Weight Loss”

• DEFINITION ARBITRARY and TEMPORAL FACTOR

• “Poor Weight Loss”

- < 30-50% of EWL after primary procedure (at least 2 years out)

• “Weight Regain”

- After “successful” weight loss, regain of “significant” weight (>

20% of weight regain from their nadir)

Page 6

Data from Interntional Sleeve Gastrectomy

Expert Panel Consensus Statement

Page 7 Rosenthal RJ et al. SOARD 2012; 8: 8-19

SURGEON Cases (n) Average BMI Bougie Size (Fr) Reinforcement Stricture (%) Leak (%) Post-op GERD (%) Wt Regain or Poor Wt Loss (%)

Ramos-Galvao 714 45 32 1 0.14 0.42 6.02 0.84

Shah-Todkar 498 49 36 1 0.2 0.4 28 1

Aceves 1127 42 36 1 0.35 0.62 18 1

Jossart 617 47 32 1 0 0.6 20 1.6

Noca 700 46 36 0 0 3.9 15 2.8

Lakdawala 484 44 36 3 0 1.2 10 3.3

Vix 350 46 36 1 0.5 3 10 3.5

Prager 267 50 48 3 0.8 3.3 31 4.9

Basso 505 47 48 3 0 2.7 10 6.1

France 716 43 34 2 1.4 0.7 7 8

Zundel 892 42 34 1 1 0 1 12

Baker 828 54 34 2 0.12 0.5 15 15

Boza 1431 37 50 1 0.06 0.5 0.5 18.5

Bellanger 675 44 34 0 0 0 5 23

Jacobs 526 45 36 3 0.19 1.5 NR 28

Rosenthal 547 45 42 1 0.2 0.36 27 NR

Himpens 710 43 32 3 1 2.9 23 NR

Arvidsson 700 35 32 1 0.3 1.1 10 NR

Jorgenson 512 45 36 2 0.5 0 10 NR

Causes of POOR WEIGHT LOSS after SG

• Lost to follow-up

- no guidance or education

- no accountability

- also increase risk of developing long-term

complications

• Dietary non-compliance

- due to complacency

- due to lack of guidance and/or education

- recurrence or new development of maladaptive

eating habit / disorder

Page 8

Causes of POOR WEIGHT LOSS after SG

CONT

• Increase in portion size

- sleeve dilation?

- psychologic?

Page 9

Page 10 Slide borrowed from Dr. Rudolf Weiner’s 8 year follow-up after SG

Weight regain and/or poor weight loss

is NOT an urgent indication for revision…

• A thorough evaluation is a must

- review op note, pre-op/post-op clinic notes

- obtain UGI series and EGD

- consider esophageal manometry (if UGI series abnormal)

• Evaluation with psychologist and dietician

• Proof of compliant behavior and follow-up

• Surgeon/Patient expectation

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Insufficient Weight Loss and/or Weight Regain

SURGICAL OPTIONS

• Re-sleeve

• Band over sleeve

• Conversion to RYGB

• Conversion to BPD/DS

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Insufficient Weight Loss and/or Weight Regain

Re-sleeve

• Perfect candidate:

1) has a correctable anatomic defect – dilation of sleeve

stomach

2) someone who had good weight loss, but regained some

weight despite “perfect” diet.

3) someone who had insufficient weight loss, despite “perfect”

diet

4) still doesn’t (or cannot have) gastric bypass

• If the patient does not have a correctable anatomic

defect, then not a good option (do something else)

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Insufficient Weight Loss and/or Weight Regain

Re-sleeve

• Possible causes of sleeve dilation

- last fire of stapler > 1 cm away from GE junction

- missing posterior gastric fold of the fundus near GE junction

- missing a hiatal hernia

- creating a gastric tube that is too large

- antral dilation

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Etiology of sleeve enlargement CONT

How close do you get to the GE junction?

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Etiology of sleeve enlargement

Bougie size? How close do you snug the Bougie?

RISK OF STRICTURE/LEAK RISK OF DILATION

Etiology of Pre-pyloric dilation

Does it matter where you start?

Page 17

INCREASE RISK OF GERD INCREASE RISK OF WEIGHT REGAIN

• fgfggfgf

Page 18 Iannelli A et al. Obes Surg 2011; 21: 832-5. (France)

-13 patients

-all had proximal stomach dilation

-Mean BMI 44.6 32.3 -> 32 -> 27.5

1m 6m 12m

Page 19

Page 20 Cesana G et al. World J Gastrointest Surg 2014; 6(6): 101-6.

Considerations when re-sleeving

Sleeve dilation

Page 21

• Use a smaller bougie

and/or hug the

bougie tighter

• Make sure the new

staple line stays

INSIDE the old

staple line (avoid

creating ischemic

zone)

• Anticipate thicker

tissues

AREA OF ISCHEMIA

• RATIONALE:

1) To slow passage of food bolus across the proximal part of the

stomach to achieve satiety while…

2) Maintaining fast transit of food bolus into small intestines to

trigger the “ileal break” mechanism (and other hormonal

changes)

• Another example adding a restrictive procedure to

another restrictive procedure.

- BOB (band over bypass)

- BUB (bypass under band)

22

Insufficient Weight Loss and/or Weight Regain

Band over a sleeve

Insufficient Weight Loss and/or Weight Regain

Band over a sleeve

• First case report of adjustable gastric banding after

“failed”gastrectomy

• 42yo male who failed to lose sufficient weight after SG

• Patient refused adding malabsorptive component due to

dependence on several anti-psychotic medications

• At 9 months from his second surgery, he has achieved 57%

EWL from his original weight of 390 lbs

23 Greenstein AJ et al. Surg Endosc 2009; 23: 884

Insufficient Weight Loss and/or Weight Regain

Band over a sleeve

• First case report of adjustable gastric

banded sleeve gastrectomy as a

primary procedure

• 39yo female, BMI 80

• Band secured 6cm distal to GE

junction, secured laterally with sutures

to peri-pancreatic tissue

• Doing well 6 weeks post-op

24 Agrawal S et al. Obes Surg 2010; 20: 1161-3 (UK)

Page 25 Obes Surg 2009; 19: 1591-6

Insufficient Weight Loss and/or Weight Regain

Sleeve to Gastric Bypass

• Historically, BPD/DS and RYGB has been the

second part of the “staged approach” for high-risk

patients

• Sleeve-to-bypass revision are now being performed

for other indications – significant post-op GERD,

stricture, and fistula

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Page 27 Obes Surg 2010; 20: 835-40. (Austria)

Page 28 Obes Surg 2013; 23: 212-5. (France)

Technical Considerations

Sleeve to Gastric Bypass

• Straightforward… transect the gastric tube, 5-6 cm

distal to the GE junction to create gastric pouch

• Things to keep in mind…

- managing small-caliber gastric pouch

- in cases with lot of adhesions, limit dissection on the lesser

curvature of the proximal gastric tube

- be careful of clips!!!

- should the gastric tube remanant be resected?

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Insufficient Weight Loss and/or Weight Regain

Sleeve to BPD / DS

• SG is part of the BPD / DS

• Historically, conversion of SG to BPD/DS (or RYGB)

is the expected 2nd procedure of a staged approach

for high risk patients

• But it is still being performed for insufficient weight

loss / significant weight regain

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Technical Considerations

Sleeve to BPD / DS

• Straightforward… continue on with BPD/DS

procedure

• Things to keep in mind…

- consider re-sleeving the gastric tube (if dilation found)

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How about single duodeno-ileal anastomosis DS?

aka

-SADI-S

-SIPS procedure

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Summary

• Proper patient selection is key for any revisional

surgery, especially when done for poor weight loss

or weight regain

• Technical improvements on the way we do sleeves

have been recommended by sleeve experts to

minimize “surgical failures” as the cause of poor

weight loss or weight regain.

• Good intermediate results are possible with RYGB

and SG after failure of SG.

Page 38

Which one of these statements is FALSE regarding revisional

surgery after sleeve gastrectomy?

A) Surgical failure (i.e. sleeve dilation) is the most common

cause of insufficient weight loss and/or weight regain after

sleeve gastrectomy.

B) A more intense pre-operative evaluation should be

implemented for patients who are considering revisional

surgery for poor weight loss or weight regain.

C) When performing re-sleeving procedure, care should be taken

not to cross the previous gastric transection staple line to

avoid ischemic complications.

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