ANZMOSS 2018 Melbourne Bariatric Surgery Masterclass WHICH OPERATION TO CHOOSE ANTHONY CLOUGH The options
SURGICAL OPTIONS? - A MINEFIELD An explosion of operative variants Local technical variations Local biases Lack of good comparative trials esp. RCTs comparing one operation against another, particularly with long term data So opinions based on 1. my practice & experience 2. my appraisal of the literature
MAIN PLAYERS IN 2018 Main Players Sleeve gastrectomy Gastric bypass Gastric banding Touch on Bypass variants One anastomosis Other variants: One anastomosis gastric bypass Banded Roux en Y gastric bypass Duodenal Switch (loop variant SADI/SIPS) Banded bypass Duodenal switch (SADI/SIPS)
CONCEPTS Any patient could potentially have any operation - true? Predictors of success on an individual level have been by and large difficult to isolate What are the key unique characteristics of the main bariatric proedures to help guide your discussions with patients?
GASTRIC BANDING Key characteristics Better for diabetes? Is it true? 1. Safe option, reversible 2. High maintenance Better weight loss? 3. A number of system related issues which may require revision surgery More risky compared to sleeve? 4. Well studied
GASTRIC BAND - EFFICACY Efficacy points Bands have a reliability problem For those who keep their bands long term they can expect mean EWL% 40-45 maintained. These are by definition a selected group of successful patients! Removal rates hard to track and typically under-reported easy to reverse! Expect between 20-50%+ removals
GASTRIC BAND PERSONAL TAKE My personal take I like bands But only in selected motivated patients with appropriate expectations I have many successful & happy band patients No real bridges are burnt Converting a band to bypass (for example) is complex but good outcomes can be achieved with experience. Ideally converted after only one band, no revisions, no erosions.
SLEEVE GASTRECTOMY Key characteristics Better for diabetes? Is it true? More reliable weight loss compared to banding Irreversible option Better weight loss? Reflux is the unique adverse effect for some More risky compared to sleeve? Unknown significance Barrett s oesophagus Low maintenance
Sleeve gastrectomy long term results summary Study Nos. FU time (yrs) (Arman, Himpens et al. 2016) %FU %EWL (kept LSG anatomy) Revision rate (mostly RYGB or DS) %EWL all (including revisions) Total Failure Rate* 118 11 59.1% 62.5% 31.3% 67.4% 49.2% (Felsenreich, Langer et al. 2016) (Chouillard 2016) (Noel, et al. 2017) (Sarela, et al. 2012) (Kowalewski, et al. 2017) 53 10 100% 52.5% 36% 53.5% 60.5% 26 10 84.6% ns 22.7% 48.4% ns 168 8 82.7% 67% 16.6% 67.0% 41.0% 20 8-9 85.0% 69.0% 20% 68.0% 35.5% 127 8 78.7% 51.5% 16% ~52.5% 58% *%EWL < 50% with no revision PLUS numbers who underwent revision
Key outcomes - sleeve In achieving approx. 60% EWL long term with sleeve you need to revise about 25% for either reflux or suboptimal weight loss These revisions are relatively complex operations The chance of the original unrevised sleeve to successfully achieve 50% EWL is around 50%
SLEEVE & BARRETT S SUMMARY RECOGNIZING THE ISSUE OF NO CONTROL GROUPS (Felsenreich, et al. 2017) found in 43 sleeve patients over 10 years De novo Barrett s in 3/20 patients scoped (15%) (Genco, et al. 2017) found in 110 patients over 3 years De novo Barrett s in 19/110 (17.2%) (Braghetto and Csendes 2016) found in 66 patients over 5 years De novo Barrett s in 2/66 (3.0%) However not stated how many actually endoscoped so percentage could be greater
ROUX EN Y GASTRIC BYPASS Key characteristics Longest Better operating for diabetes? time, most complex Is Carries it with true? it a list of half a dozen or so unique adverse effects Felt to Better have metabolic weight loss? effects independent of weight loss esp. pertinent More to diabetes risky compared treatment to GLP-1, sleeve? PYY etc More impact on nutrition esp. Fe, Vit D, others Well studied
ROUX EN Y GASTRIC BYPASS Unique Adverse Events Dumping Syndrome Hypoglycaemic phenomena Marginal ulcers Internal hernias Stomal strictures Other Roux limb issues
A FEW KEY QUESTIONS Who should consider a gastric band? Why should someone consider a bypass instead of a sleeve? What about variants such as duodenal switch, banded bypass or one anastomosis bypass as a primary option?
WHO SHOULD HAVE A GASTRIC BAND? In my practice the majority of my new patients are not interested in discussing banding Most patients I discuss band seriously with to are BMI < 40 with minimal metabolic disease who I am concerned about the concept of overtreatment with stapled procedures. Most of these patients would probably not warrant revisional surgery after a band as low BMI Must have an enthusiastic attitude and reasonable expectations Young patients who wish to avoid plunging down the pathway of major irreversible options sleeve bypass etc.
WHY SHOULD SOMEONE HAVE A BYPASS INSTEAD OF A SLEEVE? 1. Weight Loss? 2. Diabetes effects? 3. Reversibilty? 4. Long term data? 5. Super Obese? Adverse effects from bypass
COMPARING EFFICACY SLEEVE TO BYPASS A few Randomised Controlled Trials Short to medium term FU Middle range BMI patients 43-47 Weight loss 1. Generally found to be slightly better in RYGB at two years. The difference tends to grow slightly in subsequent years. 2. But who needs the extra weight loss? RCT References 1. BJS 2017; 104: 248 256 2. JAMA. 2018;319(3):241-254 3. JAMA. 319(3):255-265, 2018 01 16 BJS 2017; 104: 248 256
DIABETES SLEEVE OR BYPASS Sleeve, Bypass effectiveness vs diabetes controversial Preponderance of evidence for me points to bypass more powerful but perhaps only the poorly controlled diabetic benefits? OBES SURG (2016) 26:1814 1820 Adverse effects from bypass
COMPARING ADVERSE EFFECTS Readmission and reoperation rates for RYGB over first couple of years are up to twice that of sleeve Short/medium term comparisons are the only ones available However long term series indicate up to 25% conversion to bypass rate for sleeve over 10 years RYGB Unique Adverse Events Dumping Syndrome Hypoglycaemic phenomena Marginal ulcers Internal hernias Stomal strictures Other Roux limb issues
PREDICTORS OF POOR OUTCOME AFTER SLEEVE? Spanish study Multivariate analysis: 1. BMI > 50 2. Diabetics Cir Esp. 2017;95 (3) : 135 142 US Study 1. High BMI esp > ~55 2. Diabetics 3. HTN Cottam, S., Cottam, D., Cottam, A. et al. OBES SURG (2018). https://doi.org/10.1007/s11695-018-3417-3
SUPER OBESE CATEGORY The RCTs focus on middling BMI ranges Weight loss 1. Hard to find good quality comparative data that includes sleeve for super obese 2. In terms of observational data all the literature I have come across on RYGB vs LSG on BMI > 50 is suggestive of (significantly) better outcomes with RYGB mostly short term data 3. RCTs BMIs 43-47 show less difference 4. Low BMI LSG studies show 80-100% EWL 1. OBES SURG (2018) 28: 649 Conclusion? Any extra efficacy of RYGB over sleeve for weight loss is likely accentuated in the super obese groups. One could argue pts with BMI < 45 may not get much benefit in terms of efficacy by choosing the bypass over the sleeve BMI > 50 Citations 1. Surg Endosc (2016) 30: 2097 2. Zerrweck, C., Sepúlveda, E.M., Maydón, H.G. et al. OBES SURG (2014) 24: 712 3. XCelio, A.C., Wu, Q., Kasten, K.R. et al. Surg Endosc (2017) 31: 317x
WHO GETS A BYPASS THEN? Personally I commence discussion with.. 1. BMI > 50 2. Severe metabolic disease esp insulin dependent diabetes 3. Younger patients With sleeve I worry about Barrett s issue, lack of long term data and presumably 25% at least will end up with an irreversible bypass situation
COMMON VARIANTS Banded Bypass One anastomosis Bypass (Loop) Duodenal Switch (SADI procedure)
BANDED BYPASS Increase durability by maintaining restrictive function with a ring? OBES SURG (2012) 22:271 278 10 year banded vs non-banded bypass (non randomized)
BANDED BYPASS For me, this is a simple well studied intervention that has been around for Systemic review: PBRYGB is an attractive bariatric procedure with superior weight loss outcomes, best demonstrated in superobese OBES SURG (2014) 24:1771 1792 decades. Revising bypass for weight regain is difficult. The preponderance of evidence not all is suggestive that Banded Bypass gives more durable results To me offering banded bypass gives it more distinction from sleeve in terms of efficacy and especially durability
LOOP DUODENAL SWITCH SADI/SIPS A more benign version of the original malabsorptive procedure. Avoids a small bowel to stomach anastomosis as well as a Roux limb. So theoretically shouldn t suffer from most of the unique adverse effects of Roux en Y Gastric Bypass But has at least the same efficacy or more with malnutrition rates only 1%
LOOP DUODENAL SWITCH SADI/SIPS Who gets it? High BMI/Bad comorbidities etc. where a standard sleeve might be predicted to have a relatively high failure rate. An alternative to primary bypass with theoretically less adverse effects although less long term data Zaveri, H., Surve, A., Cottam, D. et al. OBES SURG (2018).
ONE ANASTOMOSIS GASTRIC BYPASS A similar procedure to loop DS although does not preserve the pylorus in the system and (usually) preserves more of the distal small bowel for absorption No Roux limb issues. Marginal ulcers and dumping may still be an issue and raises the question of bile reflux Efficacious Much less literature available compared to RYGB currently
CONCLUSION I hope this short discussion has helped you. pick your way through your own minefield!