Surgical Options for Weight Regain (or Poor Weight ... Surgical Options for Weight Regain (or Poor Weight

  • View
    0

  • Download
    0

Embed Size (px)

Text of Surgical Options for Weight Regain (or Poor Weight ... Surgical Options for Weight Regain (or Poor...

  • 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

    Page 11

  • Insufficient Weight Loss and/or Weight Regain

    SURGICAL OPTIONS

    • Re-sleeve

    • Band over sleeve

    • Conversion to RYGB

    • Conversion to BPD/DS

    12

  • 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)

    13

  • 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

    14

  • Page 15

    Etiology of sleeve enlargement CONT

    How close do you get to the GE junction?

  • Page 16

    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

    26

  • 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?

    29

  • 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