1 / 24

Revision of failed restriction to RYGB

Revision of failed restriction to RYGB. 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

wesley
Download Presentation

Revision of failed restriction to RYGB

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Revision of failed restriction to RYGB Mr Adam Skidmore FRACS Assoc Professor Sim0n Woods FRACS Upper GI and HPB Cabrini Medical centre, Melbourne

  2. 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

  3. Sometimes surgery doesn't work

  4. 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

  5. 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

  6. Failure of VBG/HGR • Late failures - most 10years + • Maladaptive eating behaviour • Dilatation of the pouch – weight regain or reflux • Staple line dehiscence – weight regain

  7. 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

  8. Methods of revision • All patients are fully evaluated by a multidisciplinary 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

  9. Slipped band

  10. Dilated pouch with stenosis

  11. Large hiatal hernia

  12. Roux En Y Gastric Bypass • Preferred method of revision • Open approach • Often multiple previous surgeries • Midline laparotomy • Laparoscopic staplers/seamguard • Upper GI omnitract • HandsewnGastrojejunostomy or orvil 25mm circular stapler • Handsewnenteroenterostomy

  13. Bariatric omnitract

  14. 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

  15. Results • 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. Difficult Left lobe of Liver • Bleeding • Adhesions • Can remove part of the left lobe safely with the echilon stapler • Less bleeding • Less Bile leak

  21. Post operative • 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

  22. conclusions • Technically challenging • Access to ICU and Interventional radiology • Multidisciplinary support • Results can be as good as primary RYGB • Morbidity is higher

More Related