Revision of failed restriction to RYGB

Report
Mr Adam Skidmore FRACS
Assoc Professor Sim0n Woods FRACS
Upper GI and HPB Cabrini Medical centre, Melbourne
Introduction
 Look at 29 patients who have had either a failed Gastric
Band – adjustable and fixed , VBG/HGR or Jejuno-ileal
bypass
 Failure was either weight regain/non weight loss
 Technical failure of the original operation
 Other issues – gastroparesis, reflux and vomiting
 Techniques for revision
 Results of our experience
Sometimes surgery doesn't work
Revision is an option
 2 surgeon series
 29 cases of conversion of HGR/VBG, Gastric Band or
jejuno-ileal bypass to RYGB
 Experienced in RYGB – open and Laparoscopic
Gastric Band Failure
 Defined as either no weight loss at all or weight loss of
less than 10% EW
 Variety of reasons
 Maladaptive eating behavior
 Technical issues with the band
 Recurrent slip
 Dilation of the pouch
Failure of VBG/HGR
 Late failures - most 10years +
 Maladaptive eating behaviour
 Dilatation of the pouch – weight regain or reflux
 Staple line dehiscence – weight regain
Reversal of stapling
 Encouraged to reverse if severe maladaptive eating
 Reversal is by removal of the sutures
 6 months of normal diet and exercise prior to reversal
Methods of revision
 All patients are fully evaluated by a multidisciplinary
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team
Often have seen a Nutritional physician
Gastroscopy
Barium series
At least 2 pre operative consults with the surgeon
2 weeks of optifast BMI <50
4 weeks of optifast BMI>50
Slipped band
Dilated pouch with stenosis
Large hiatal hernia
Roux En Y Gastric Bypass
 Preferred method of revision
 Open approach
 Often multiple previous surgeries
 Midline laparotomy
 Laparoscopic staplers/seamguard
 Upper GI omnitract
 Handsewn Gastrojejunostomy or orvil 25mm circular
stapler
 Handsewn enteroenterostomy
Bariatric omnitract
Results
 29 patients
 Range of previous surgeries
 Often multiple operations - open and laparoscopic
 Mostly failure of weight loss
 Significant amount of failures related to technical
issues
 All successful completion to RYGB
 3 underwent a partial gastric resection
 2 underwent a partial liver resection
Results
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Limited by follow up of 2-18 months
Average weight – 121 kg
170kg – 80 kg
20 females and 9 males
Weight loss average – 60% EW excluding patients
<6months
All had resolution of gastroparesis
 Significant improvement in diabetes
 All had resolution of reflux and vomiting
Complications
 Leak – 2 gastrojejunostomy leaks
 Bile leak – 1 bile leak treated by percutaneous drain
 Wound infection – 2 wound infections requiring AB
and 1 requiring VAC dressing
 Incisional hernia and internal herniation – 5
incisional hernias and 1 internal hernia
LOS and return to work
 Average LOS – 5 days
 Return to work – 3.5 weeks
 TAKES AT LEAST 3 MONTHS TO RETURN TO
PREOPERATIVE QUALITY OF LIFE
Tips and pitfalls - stapling
 Important to determine if stapling is dehisced or if
large pouch
 If large pouch – must stay within the staple line – risk
of ischaemia
 Sometimes better to perform a fundectomy excising
the fundus and staple line – easier to enter the lesser
sac away from adhesions
 Fundectomy/mini sleeve can minimize splenic injury
Gastric band
If there is slippage – REMOVE THE BAND AND WAIT
If no slippage it is safe to perform in one surgery – MUST
REMOVE THE CAPSULE AND ALL SUTURES
GREEN LOADS +/- SEAMGUARD
Difficult Left lobe of Liver
 Bleeding
 Adhesions
 Can remove part of the left lobe safely with the echilon
stapler
 Less bleeding
 Less Bile leak
Post operative
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NGT – 24 hours
Gastrograffin swallow 24-48 hrs
Fluids after confirmation of no leak
Jackson pratt drain for 5 days
 In very large patients useful to drain the subcutaneous
space
 Vac dressings can be useful in very large patients with
wound infection
conclusions
 Technically challenging
 Access to ICU and Interventional radiology
 Multidisciplinary support
 Results can be as good as primary RYGB
 Morbidity is higher

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