Bariatric and Metabolic Unit Desenzano del Garda Fabrizio Bellini

1. REDO SURGERY • LA CONVERSIONEDA BAND A BY PASS • "single step" Bariatric and Metabolic Unit Desenzano del Garda Fabrizio Bellini

2. Restrictive Procedures: long-term break down up to 40% • Long term complications • Gastric pouch dilatation/slippage • Intragastric band migration • Poor quality of life • Psychologicalintolerance, frequent vomiting,GERD • Failure • Insufficientweight loss • Weight regain

3. Gastric Band Brake Down Reasonable morbidity and mortality • Aim • Achieve sufficient weight loss • Treat complications • Allow good quality of life • Technical troubles • Adhesions from previous surgery • Staple line insufficiency, disruption

5. BAND Complication Good weight loss Poor weight loss Good quality of life Conversion GBP / BPD Re L AGB (except band migration) Conversion GBP / BPD Rescue procedure choice Poor quality of life Sleeve gastrectomy (has though been reported as a potential revisional procedure)

6. RevisionalBariatricSurgeryforInadequateWeight Loss Andrew A. Gumbs, MD; AlfonsPomp, Michel Gagner, MD Obesity Surgery, 17, 2007

7. 70 patients, one session in 47 cases • Mostlypouch dilatation and insufficientweightloss (94 %) • 3 conversions • Morbidity 14,3 %, earlyreoperations 5,7 % • No mortality • BMI 32,2 after 18 months Mognol et al, ObesSurg 2004; 14: 1349

8. 218 patients (15 % of all bariatric procedures) • Mortality: 0,9 % • Serious morbidity: 26 % • 94 % conversion to RYGBP • Insufficient weight loss: 81 patients 46 % EWL, 78 % satisfaction rate • Complications/side-effects: 95 patients 88 resolved, 79 satisfaction rate Nesset EM et al. SOARD 2007; 3: 25-30

9. 47 patients (62 % for insufficient weight loss) • 26 laparoscopic (4 conversions), 21 open • No mortality, 19 % morbidity • EWL > 50 % in 47 % of patients Van Wageningen B, et al. ObesSurg 2006; 16: 137

10. 62 patients, 30 re-banding, 32 conversions to RYGBP • Two periods, different indications, short follow-up • Both techniques are safe • Further weight loss with RYGBP, not with re-banding Weber M, et al. Ann Surg 2003; 238: 827

11. Lanthaler M, et al. ObesSurg 2006; 16: 484 • 33 patients with pouch dilatation after GB (6,7 %) • 16 repositioning / re-banding • 9 band removal • 8 conversions to RYGBP • Patients often gain weight (10 / 16) and are dissatisfied after re-banding • All patients converted to RYGBP lost further weight and were extremely satisfied (better food tolerance, no vomiting)

12. How to approach revisional surgery : • Actual and maximal weight loss after first procedure and initial weight before the first procedure • Type of complication if present: barium swallow, EGDS • Quality of life: • Psychological tolerance • Digestive tolerance : • Alimentary comfort • Frequency of nausea and vomiting • Gastro - oesophagal reflux • Surgical team skill • Patients wish

13. Get the old operative report • Be sure that patients are aware of increased risks and lower likelihood of success. • Obtain Upper GI contrast study to determine staple line integrity and location of GE Junction. • Endoscopy GENERAL PRINCIPLES

14. Completely comfortable with performing primary procedure (100 cases). • Higher complication rate. • Lower success rate. • Unusual findings. GENERAL PRINCIPLES

15. Literature laparoscopic revision

16. Michel Gagner, Paolo Gentileschi, John de Csepel, SubhashKini, ObesitySurgery, 12, 2002 Retrospectivestudy • Morbidity : 22% • Mortality : 0% • Conversion : 3.7% • 2° revision : 14.8% • Operative time • Hospital stay

17. Technical features Gastro-gastric stitches dissection

18. Technical features “Smallerpouch”in case ofslippage.

19. Technical features Avoid fibrotic tissue!!

20. Technology enables surgeons to use staplers in a broader range of tissue thicknesses than before! • Largest Staple Height • Thickest Tissue Ever

21. The precise staple high

22. Trocars Position 3 • Optivew: 10 m • Liver retractor:10 • Surgeon: 10 mm • First aid: 10 mm 3 1 4 2

23. SIMPLIFIED LAPAROSCOPIC GASTRIC BYPASS BILIOPANCREATIC LIMB 60 cm ALIMENTARY LIMB 200 cm

24. 930 Gastric Bands • EWL < 25% • BMI > 40 Rescue Gastric By Pass • 35 patients (2,69%) • 33one step • 2 two steps • - 1 previously removed in pregnancy for slippage • - 1 gastric perforation during band removal

25. 1 yr WEIGHT LOSS AFTER LRYGB FOR LAGB FAILURE(35 pts) Bariatric and MetabolicUnit Ospedale di Desenzano del Garda

26. BAND → RYGB

27. Bariatric and MetabolicUnit Ospedale di Desenzano del Garda 2 yrsEWL% AFTER LRYGB FOR LAGB FAILURE(35 pts)

28. Conclusion • All restrictive procedure are theoretically associated with long term failure and/or mechanical complications • A lifelong multidisciplinary management and surveillance for these patients appears compulsory • Bariatric revisional surgery is a major concern • RYGBP is a very good rescue procedure after failure of restrictive procedure

29. Conclusion The laparoscopic conversion of failed gastric bands to Gastric Bypass in “one step” is reported in literature to be safe in high volume centres. • In our experience excellent results in term of: • Morbidity and mortality: 0% • Weight loss :EWL%>70

30. Thank You.