SESSION 6 LONG TERM OUTCOMES AND THE IMPORTANCE OF FOLLOW UP OUTCOMES OF ENDOSCOPIC PROCEDURES. Kiron Bhatia MMedSci(Surg) FRACS
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1 SESSION 6 LONG TERM OUTCOMES AND THE IMPORTANCE OF FOLLOW UP OUTCOMES OF ENDOSCOPIC PROCEDURES Kiron Bhatia MMedSci(Surg) FRACS
2 DISCLAIMER Consultancy for Apollo Endosurgery
3
4 there is a prevalent reluctance to undergo surgery for Obesity
5 FADS-1
6
7 SPACE OCCUPYING DEVICES Orbera Spatz3
8 150/224 or 67% demonstrated regain post explant Long term effects of Intragastric balloon in the management of Obesity Sander et al DDW2017 Chicago Brazilian Intragastric Balloon Consensus Statement (BIBC): practical guidelines based on experience of over 40,000 cases, Manoel Galvao Neto et al, SOARD, Feb 2018
9 GASTRIC REMODELLING Overstitch Endoscopic gastroplasty TORe Articulating circular endoscopic stapler ACE IOP s POSE
10 OTHERS AspireAssist GI Windows Endobarrier
11 REVISION IOP s restore Overstitch Endoscopic gastroplasty TORe
12 Obesity is a chronic disease WHO 2000
13
14 Regain is part of the bariatric landscape
15 REGAIN >10kg from nadir Regain to BMI >35 >25%EWL from nadir Any regain post T2D remission >5 BMI Any regain!!!!!!
16
17 PATIENT FACTORS FOR REGAIN Adherence to FU (no. of visits, males) Motivated by appearance BED/grazing Low physical activity Support groups better Pregnancy >/=2 Psych
18 Dixon, O Brien et al, Motivation, readiness to change and weight loss following adjustable gastric band surgery, Obesity 2009
19 Lopez-Nava G et al. Factors predictive of success with endoscopic sleeve gastroplasty with 1-year follow-up: Factors predictive of success. Endoscopy International Open 2016; 04: E222 E227
20 P=0.005 LAGB 42 <6 >6 %EWL RYGB <3 >3 %EWL Roy Shen, Christine Ren et al, Impact of patient follow up on weight loss after bariatric surgery, Obesity Surgery 2004
21 ENGAGE Environment Adjunctive pharmacologics Re-engage with diet VLCD Structured exercise Psychosocial Ongoing psych Stressors SATI(R)ETY take the power back A consumers guide to appreciating satiety and learning when to say no more! by Dr Kiron Bhatia MD
22 MODIFIABLES Pro Con Contrast XR Less radiation Can t assess volume Endoscopy CT volumetry Examination Intervention Precise assessment of volume Assess anastomoses Volume assessment unreliable More radiation
23 MODIFIABLES Revised Sleeve Gastrectomy (Re-sleeve), Nedelcu, Gagner et al, SOARD 2015
24 As defined by stoma>2cm OR pouch >6cm long/>5cm wide Influence of pouch and stoma size on weight loss after gastric bypass, Bipan Chand et al, SOARD 2012
25 Gastrojejeunal stoma diameter predicts weight regain after roux en Y gastric bypass, Barham K Abu Dayyeh, Christopher Thompson et al, Clin Gastroenterol Hepatol 2011
26 Recognized higher risks Overall good results/increasing confidence However, some may find undesirable
27 ARGON PLASMA 215 patients Average value Diameter 24.8mm (16-40) Reduction 13.5mm (4-34) No. of sessions 1.36 (1-3) Weight loss between 1 st -last 13.8kg (5-35) BMI decrease 4.6 (1.7-11) Endoscopic revision with argon plasma coagulation for failed roux en Y gastric bypass (RYGB), first large series, Bruno Sander, Manoel Galvao Neto, SOARD 2015 Target diameter 18mm 32% failed to achieve No regain at 6 months (n=27)
28 OVERSTITCH
29
30 TECHNICAL CONSIDERATIONS Tactile feel Not completely benign Strength depends on FT bites Reinforcing sutures Suture management is critical Multiple bites with single suture, Crossing sutures Catching suture on tower Maintain orientation Understand where to place sutures Courtesy: Erik Wilson, MD Troubleshoot dropped and bent anchors/needle body, helix entrapment, etc
31 KEY POINTS Revision criteria Diameter Volumetric analysis Exclusion criteria FHx Gastric ca HP status Anticoagulants PPI dependant reflux GA/Left lateral/txa/dexamethasone CO2 Overtube Premed optifast (>35)/emend
32 TORE PRINCIPLES
33 SUTURE PATTERNS
34 TORE
35 N=25 Evaluation of an endoscopic suturing device for transoral outlet reduction in patients with weight regain following Roux-en-Y gastric bypass. Thompson et al, Endoscopy 2013.
36 Endoscopic gastrojejunostomy outlet reduction after RYGB: Is it worth it?, D Azagury, J Morton SOARD 2015
37 Transoral outlet reduction: a comparison of purse-string with interrupted stitch technique, Allison Schulman, Nitin Kumar, Christopher Thompson, Clinical Endoscopy 2018
38 SLEEVE REVISION No data
39 ?BAND TO ESG Suggested as feasible BUT. Resectional may be better No data
40 IN SUMMARY Non-invasive revision options don t work! TORe Sleeve revision Band Tailor approach Within MDT framework Bariatric endoscopy is an emerging field
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