Surgical Options for Weight Regain (or Poor Weight Loss) After Adjustable Gastric Banding Jin S. Yoo M.D. Assistant Professor of Surgery Duke University Medical Center Jin.Yoo@duke.edu
Financial Disclosures Covidien (consultant / speaker) Cook Medical (consultant / speaker) Musculoskeletal Tissue Foundation (consultant) W.L. Gore (consultant / speaker)
Restriction What does it mean?
How does bariatric surgery work? From a reductionist point-of-view. - RESTRICTION - restricts how much and how fast one eats - MALABSORPTION - portion of small intestines are bypassed so that not all the calories are absorbed In reality, the real answer is a bit more complex. - metabolic and hormonal pathways affected Page 4
Defining healthy restriction Being able to eat small amount of food without getting hungry. Getting full after eating small amount of food. Page 5
BIG adjustment after surgery Getting used to going from NO restriction to MAXIMUM restriction. Page 6
BIG adjustment after surgery Before surgery 4-lane, major highway After surgery 1-lane, back road Biggest car that can come through (and speed) - food bolus size of a peanut M&M, every 30 sec - liquid ½ oz (1/2 of medicine cup), every 5 sec Portion size - 4 12 oz (depending surgery and patient) - dictates frequency of meals Page 7
More defintions (So we re comparing apples to apples )
Definition of Weight Regain and Poor Weight Loss DEFINITION ARBITRARY and TEMPORAL FACTOR Poor Weight Loss < 50% of EWL after primary procedure (at least 2 years out) Weight Regain After successful weight loss, regain of significant weight (> 20% of weight regain from their nadir) Page 9
Causes of POOR WEIGHT LOSS after AGB Dietary non-compliance Lack of follow-up (for PATIENT adjustments) Lack of follow-up (for BAND adjustments) Insufficient number of (and/or poor quality) band adjustments Lack of satiety Band/port-related complications (that prevent proper usage of the band) Page 10
Causes of WEIGHT REGAIN after AGB Dietary non-compliance through complacency Lack of follow-up (for PATIENT adjustments) Lack of follow-up (for BAND adjustments) Insufficient number of (and/or poor quality) band adjustments Lack Loss of satiety of through loss of vagal nerve feedback? Band/port-related complications (that prevent proper usage of the band) Page 11
Weight regain and/or poor weight loss is NOT an urgent indication for revision A thorough evaluation is a must - review op note, pre-op/post-op clinic notes - obtain UGI series and EGD - consider manometry Evaluation with psychologist and dietician Proof of compliant behavior and follow-up Surgeon/Patient expectation Page 12
Band to sleeve? Conversion from restrictive only to restrictive only procedure? Ideal patient for this conversion: 1) significant problem with hunger 2) compliant with the proper bariatric surgery dietary behavior (healthy, small, frequent meals) 3) cannot hit the green spot despite multiple band adjustments (even with fluoroscopy) 4) still doesn t (or can t) have a gastric bypass Page 13
AGB to SG studies Page 14 Yazbek T et al. Obes Surg 2013; 23: 300-5.
90 patients underwent revisional surgery (SG) for failed LAGB Mean BMI 42 (26 58) Complications leak 5.5% No post-operative mortality %EWL was 52% at 6 mos, 61% at 12 mos, 62% at 18 mos, 53% at 24 mos, 55% at 36 mos, and 54% at 48 mos Page 15
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Band to bypass Conversion from restrictive to combined modality procedure It just makes sense 1) addresses hunger issues (like SG) 2) eliminates access to band adjustment issues (like SG) 3) has additional tools the band didn t have, such as malabsorption, metabolic effect, and policing system Page 17
AGB RYGB studies Page 18
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VIDEOS
AGB to SG
AGB to SG (insufficient weight loss and GERD) Page 22
AGB to SG (insufficient weight loss) Realize Band-C Page 23
AGB to SG (Staged)
AGB to SG (for band erosion) PART 1 of 2 Page 25
AGB to SG (for band erosion) PART 2 of 2 Page 26
AGB to RYGB
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AGB to RYGB (Staged)
AGB to RYGB (for chronic gastric prolapse) PART 1 of 2 Page 30
AGB to RYGB (for chronic gastric prolapse) PART 2 of 2 Page 31
Summary Proper patient selection is key for any revisional surgery, especially when done for poor weight loss or weight regain Good intermediate results are possible with both RYGB and SG after failure of AGB Revision of AGB to bypass or sleeve may be performed in one-stage or two-stage, with the latter associated with higher leak rate Page 32