Revision For Weight Regain

Transcription

1 Revision For Weight Regain When? Why? What? Ahmad Aly ANZMOSS Dietetics Workshop 2018

2 Reoperative Surgery What Is Reoperative? Reversal Correction Conversion } Revisional Surgery

3 Revisional Surgery 4000 Revisions

4 Revisional Surgery Revision Proportions Most Series Expect Revision Rate Approx 30%

5 Procedure Type Bypass 5% Band 60% Sleeve 35% 100,000 Bands Account for most revisions For now

6 Sleeve Catching Up Primary Bariatric Surgery Band Sleeve Bypass Total 0

7 How Much Of Revision Is Weight Loss Alone Austin Data 22% of patients underwent revision for poor weight loss alone. 39% 22% 39% Poor weight loss only Poor weight loss AND problems Problems only

8 Austin Data % Excess Body Weight Loss Initial At revision Post procedure Poor weight loss Poor weight loss AND problems Problems only

9 Revisional LAGB Group Doing As Well As Primary Group

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11 Article in press SOARD 2014

12 But Revisional Surgery More Morbid Corrective surgery less morbid band revision pouch plication in bypass Data From BOLD (USA) Conversion surgery more morbid 18% vs 1% Band (O Brien) 20% vs 5% Bypass (multiple)

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14 Why? When? What?

15 Fundamental Questions Why does weight regain occur? What is the aim of surgery? What defines success?

16 Obesity Chronic Disease Incurable Progressive Relapsing & Recurrent Disease Factors Lifestyle Factors Attenuation Of Therapeutic Effect

17 Aim of Surgery Satiety Hunger Reduction Weight Loss Is A Result

18 Aim Of Surgery If satiety and hunger control are preserved, what will further surgery add?

19 Define Success Of Surgery REALISTIC goals of therapy (Weight) Disease Function Quality of life Expectations Relative to the patient Patient vs Surgical Team

20 No One Agrees No Consensus On Definition Of Failure Dissatisfied patient <50% EWL Final BMI must be less than 30!

21 What Do We Know? Health benefits of surgery relate to the change in BMI (or % weight loss) NOT final BMI 1 Aim BMI <30 is unnecessary We can aim for greater weight loss but at what cost? Expected weight loss curves well established Benefits of derived weight loss well documented 1 Zalesin, K. C., et al. (2008). "Determinants of the Resolution of Type 2 Diabetes After Bariatric Surgery." Vascular disease prevention 5(2): 75.

22 Reoperative Surgery For Weight Failure Adaptive Weight Regain Do Not Mistake It For Failure Resist Patients Pushing Unrealistic Expectations O Brien et al Obes Surg 2006,

23 Mrs. I.F 38 year old lady Presenting BMI 40, No significant co morbidity Band: Wt at 2 years (126% ewl) Erosion wt back to 110 Sleeve wt 80 at 12 months (83% ewl) 90 and stable at 3 years (>60% ewl) Patient unhappy Satiety well preserved. Hunger control good. Offered bypass!!

24 This Patient Didn t Like Me 44 year old, Ht. 1.68, Wt, 94, Current BMI 33 PCOS Bariatric History VBG kg 110kg (BMI 59 38) Unhappy Still Obese JI Bypass kg 90kg (BMI 31) 2008 Weight Regain To 120kg (BMI 42) Very Unhappy Band 2008 Weight to 68kg but bad reflux : Slippage diagnosed Rebanded 2012 no effect Weight to 82 Erosion 2015: Band Removed I m obese and gaining weight and you have to do something My husband is saying I m gaining weight again

25 VBG JI Bypass Weight Loss Band Slippage & Reband Erosion & Band Removal % EWL

26 Indication (Why) Therapeutic Goal Not Met Comorbid disease control Unsatisfying weight loss* Complications Physical / Anatomical Nutritional Too much weight loss

27 Reoperation For Weight Failure When Might We Think About It? Weight loss significantly below expected norms for procedure AND Patient dissatisfied QOL continues to be impaired either from obesity or side effects of surgery Comorbidities still problematic

28 Pre Requisites (When) Patient Prepared Lifestyle Measures Exhausted / Medical Therapy Not Suitable Anatomical Change (?) Functional Loss*** (satiety / hunger control) Risks Not Preclusive

29 When Not Satiety / Hunger Function Preserved Lifestyle Non Engagement Unrealistic Weight Goals (body image / eating disorder)

30 What Depends on Current anatomy Goal of therapy Experience with previous surgery

31 Band Revision Band Fatigue Normal anatomy Anatomical Complication Pouch dilation Oesophageal Failure**

32 How Do Bands Work? Cardia Mediated Satiety Intact LECS Lower oesophagus Integrity of LOS

33 You Need A Happy Oesophagus Successful vs Symptomatic Patients 93% vs 43% normal swallows (<0.05) Failure of LECS / LOS Loss Satiety Side effects

34 Band - Band Preserved Oesophageal Function Good Experience & Outcome Prior Complication

35 NOT Band To Band

36 What About Sleeve After Band? Intragastric Pressure Is Raised After Sleeve 1 (Just like a band) 1 Mion et al Obes Surg 2016

37 Shape Is Everything!

38 The Deformed & Scarred Stomach More Difficult To Get Sleeve Shape Correct Higher Risk Of Leak

39 Increased Risk Meta-analyses Primary Leak Rate : 2.3% (Zellmer et al Am J Surg 2014) Revision Leak Rate: 5.6% (Coblijin et al Obes Surg 2013)

40 We Need Jason Bourne

41 RYGB Is The Jason Bourne Of Band Revision Not dependent on oesophageal function Shape of pouch not as critical Leak easier to manage Adds metabolic effect

42 Summary Band Revision Band Band Preserved oesophagus Good experience Band Sleeve Oesophageal function normal Minimal distortion (no anatomical complication) Staged Band Bypass Most reliable

43 Sleeve What About Resectional Procedures Bypass Typically attribute weight regain to anatomical deformity

44 What We Don t Know We don t know when something is broken! Many accepted anatomical causes are poorly defined What is a dilated gastric bypass pouch? What is a dilated anastomosis? What is a dilated sleeve? Focus is on volume but in fact it is pressure / compliance that is likely to be important in mediating satiety 1 1 Burton et al International Journal of Obesity (2011) 35, S26 S30

45 What Is Normal? Series of RYGB pts with weight regain Pouch volume 15ml -135 ml Mean 55 +/- 42 (!) Anastomotic Area 130mm mm 2 Mean 504 +/-388

46 Reoperation For Weight Failure SELECTION BIAS Poor Weight Loss Imaging / scope large pouch Intervention Some weight loss No control group Resultant added weight loss often modest 1,2 About half of the lost weight may be regained Non specific effect / placebo? Mechanical Restriction? Lack long term data 1 Brethauer et al Systematic review in press SOARD Horgan et al SOARD 2010;

47 Sleeve Two Scenarios 1. Unequivocal Dilation & Loss Function Re-sleeve Bypass 2. Normal Anatomy But Poor Weight Loss Bypass? MGB? SADI / BPD*?

48 Sleeve Suggestion that Sleeve RYGB not very useful Mixed effect on weight loss reported Better weight loss with MGB, SADI, BPD? Mechanism of action of sleeve and standard RYGB too similar?

49 Sleeve Gastrectomy How It Works Ghrelin Decreases CCK / PYY / GLP 1 Increase CCK / PYY / GLP 1 Increase

50 Sleeve Conversion RYGB BPD SADI MGB Length of BP Limb

51 Sleeve Add a band? NO! Re sleeve? good experience prior, unequivocal dilation*, risk leak RYGB? long BP limb MGB? beware reflux BPD / SADI nutritional consequences

52 Sleeve & Recurrent Diabetes Conversion to RYGB may offer some benefit even without significant weight loss Also benefited HT and OSA Yorke et al, Am J SurgRevision of sleeve gastrectomy to Roux-en-Y Gastric Bypass: A Canadian experience

53 Bypass Why? True dilation Trim / revise anastomosis Overstitch Lack restriction LAGB? Metabolic Failure Increase BP limb length Conversion to BPD

54 ANZMOSS Advocacy Next Steps Task force to develop national framework document Political endorsement : AMA, RACS, MSAC Press release Reiterate need now with solution Direct campaigning to government State tailored Mandated non activity based* funding for infrastructure support Materials to aid local advocacy to hospitals