Difficult situations. Band to sleeve: Pitfalls Jeff Hamdorf

Difficult situations Band to sleeve: Pitfalls Jeff Hamdorf

Disclaimer Airfare supported by UWA, but it was money I earnt Accommodation and registration supported by ANZMOSS as conference convener Director of CTEC which receives significant educational support from WA DoH and Industry partners Occasionally receive research support and (rarely) honoraria from Industry including Medtronic, WL Gore, Baxter and Olympus

Obes Surg 2018

Overview Gastric Band Revision Sleeve gastrectomy popular I ll what she s having Suboptimal weight loss Inadequate control of co-morbidities Band related complications Revision options Sleeve possibly most popular esp in Australia Single vs two stage approach

Band to sleeve revision - risks Surgeons worry about the leak rate following single stage conversion Historical leak rates up to 17.7%, mainly single site series Systematic reviews are unable to show patient characteristics within groups Why greater risk? Mechanical scar tissue thickness impacting on staple deployment Ischaemia?related to increased dissection around fundus/l crus

Advantages - Single vs two stage conversion Single stage Logistical Access Financial No interval for weight gain Surgeon experience Two stage Logistical Theatre list planning Overall safer?

So what data is there around this question? Meta-analysis vs RCT vs Cohort studies vs Big data

Mandatory data registry participation 2005 onward Obes Surg 2014 Recommendation Suggest 2-stage procedure

ACS-NSQIP registry 11,546 LSG pts 11,189 1 LSG vs 357 GBR/LSG 30 day sepsis* 0.58% vs 1.68% p 0.02 Somewhat limited as patient related data not available eg erosion, nor those who were 2 stage conversions and *sepsis a surrogate marker for staple line leak

MBSAQiP registry ASMBS sponsored Obes Surg 2017 4865 AGB conversions SG in 3364 (69%), RYGB in 1501 RYGB in higher risk patients (co-morbidities)

Obes Surg 2017 Conclusion AGB conversion to RYGB or SG as a single-stage procedure is associated with low postoperative morbidity

Kylie, 33 yo, 112 kg, BMI 37, MSK co-morbidities LAGB 2010, lost and regained 20 kg Unable to re-establish band control after pregnancy Assessed as suitable for single stage conversion to SG

Buckle buried in lesser omentum

Capsule 2-3 mm thick

Fundal mobilisation satisfactory

3 months later

Outcomes Patients from a single practice 2012-2014

Exclusion criteria for Single stage consideration Preoperatively: Patient consent Weight greater than initial banding BMI over 45 Any revision procedures Evidence of distal slip Intraoperatively: Presence of an extensively thickened capsule Potential interference to blood supply Moderately large hiatus hernia

Population 2012 2014 cohort 86 band to sleeve conversion procedures 47 Selectively offered single stage procedure 38 completed 9 crossed over to two stage procedure Total (86) 1-stage (38) 2-stage (48) Planned 1- stage (9) Planned 2- stage (39)

Group Comparison 1-stage conversions (n = 38): Age 48-years BMI at removal of LAGB 37kg/m 2 84.2% female, 15.8% male 2-stage conversions (n = 48): Age 48-years BMI at removal of LAGB 41kg/m 2 85.4% female, 14.6% male No significant difference in any patient profiles between groups: glucose, asthma, hypertension, lipid profile, sleep apnoea, arthritis, fertility and psychiatric co-morbidity

Primary Outcome: Clavien-Dindo Classification Total procedural complications, p = 0.801 Grade 1-Stage (38) 2-Stage (48) Total (86) 0/I 14 (36.8%) 14 (29.2%) 28 (36%) II 19 (50%) 24 (50%) 43 (50%) IIIa 2 (5.3%) 3 (6.3%) 5 (5.8%) IIIb 3 (7.9%) 6 (12.5%) 9 (10.5%) IV 0 1 (2.1%) 1 (1.2%) 2 staple line leaks in the 2 stage group managed endoscopically

Conclusions When managed under a multi-disciplinary team, 1-stage conversion appears as safe as 2-stage conversion, in terms of occurrence of operative complications.

Conclusions Single stage band to sleeve conversion appears to be safe in selected cases The pitfall? Case selection

Thank you