Why a loop and new approach makes sense!

Transcription

1 IP: tomach Intestinal Pylorus paring urgery Why a loop and new approach makes sense! Mitchell Roslin, MD, FAC Chief of Bariatric and Metabolic urgery Lenox Hill Hospital Northern Westchester Hospital Center NLIJH

2 Disclosures Covidien/Medtronic Principal Investigator of IP registry, teaching consultant Ethicon J & J teaching consultant ValenTX AB urgiquest AB

3 Is Duke Unbeatable?

4 Upsets Happen

5 Duodenal witch Extremely effective weight loss procedure Excellent resolution of comorbid conditions, with favorable long term results for weight loss and diabetes Accounts for <5% of currently performed bariatric surgery 1 due to concerns of technical difficulty, malnutrient deficiency, and postoperative frequent bowel movements 1 Estimate of Bariatric urgery Numbers, AMB, March 2014

6 D had greater GI complaints and re-operations RYGB 13 BMI Units D 22 BMI Units Patient satisfaction equal Editorial: Beware of D RYGB not effective enough D too effective for certain patients

7 Bariatric surgery = um of Gastric and Intestinal Contribution

8 Why does Bariatric urgery Work?

9 What is the best pouch? Vertical leeve Advantages Long narrow (wider for D) Resection = hormonal reduction, reduces chance of ulcer disease High pressure Preserves pylorus Anastomosis lower protected by liver

10 To Roux or Not? Advantages Disadvantages Do they go away post pyloric? Avoids bile reflux Long term studies show endoscopic advantage and lower Visick score post gastrectomy Reduces theoretical risk of cancer Extra anastomosis and mesenteric defect Pedicle graft Roux stasis and interrupts intestinal pacemaker Lower marginal ulcer than Billroth II Marginal ulcer rare after D Tradition and accepted practice Returns bile to where it originated

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12 IP Approach IP Advantages lightly larger sleeve (42 bougie) Attachment to Mid gut (not distal ileum) Preserve adequate bowel to prevent short bowel (3m) Combines ghrelin suppression withactivation of the ileal brake leeve with intestinal

13 This is not a Mini Gastric Bypass

14 International Data 1) Laparoscopic Roux en Y versus mini gastric bypass for the treatment of morbid obesity A randomized trial Lee et al Annals of urgery ) Laparoscopic Roux en Y vs Mini-gastric bypass for morbid obesity: A 10 year experience Lee et al Obes urg ) One Thousand consecutive mini-gastric bypass: short and long term outcome Noun et al: Obes urg ) The laparoscopic mini-gastric bypass: The Italian experience: outcomes from 974 consecutive cases Musella et al: urg Endosc ) imilar reports from France and other European centers 6) um total is equal or better wt loss to rygb, revision rate comparable, conversions secondary to bile reflux gastritis do not seem high. Risk of peptic ulcer also lower

15 Obesity Treatment: Control Glucose and Insulin Fluctuations RYGB PROMOTE GLUCOE AND INULIN PEAK

16 Ratio 3.5 1:2-hour glucose ratio at baseline,6,9 and 12 months by surgery RYGB VG D

17 REPONE TO GLUCOE TOLERANCE TETING AND OLID HIGH CARBOHYDRATE CHALLENGE: COMPARION BETWEEN ROUX EN Y GATRIC BYPA, VERTICAL LEEVE GATRECTOMY AND DUODENAL WITCH. Mitchell Roslin MD FAC,, Yuriy Dudiy MD, Andrew Brownlee MD, Joanne Weiskopf PA, Paresh hah MD FAC

18 Ratio 50 1-hour: fasting insulin ratio at Baseline,6,9 and 12 months by surgery RYGB VG D

19 Ratio 3 1-hour: fasting glucose ratio at baseline,6,9 and 12 months by surgery RYGB VG D

20 Methods IRB approved retrospective analysis of patients who met NIH criteria for obesity surgery, and underwent IP procedure. All procedures were performed by two surgeons at three centers Lenox Hill Hospital NY, NY Northern Westchester Hospital Center Mount Kisco, NY Bariatric and Metabolic Institute alt Lake City, UT

21 Inclusion Criteria Procedure performed January 2013 July 2014 Age IP as the initial primary bariatric surgery All bariatric conversions excluded

22 Technique Bougie size (42F) Length of bypass (300cm common limb) Hand sutured duodeno-intestinal anastomosis

23 Preoperative Characteristics No. of patients 129 (Utah: 92, NY: 37) Preoperative Characteristics Age (years) a ± Weight (lbs) a ± Height (in) a ± 3.68 BMI a ± 9.65 Male 84 (65.1 %) Female 45 (34.9%) Ideal Body Weight (lbs) a ± Excess Body Weight (lbs) a ± Rates of Comorbidities leep Apnea 60 (46.51%) Diabetes 52 (40.31%) GERD 47 (36.43%) Hypertension 56 (43.41%) a Values are expressed as means ± EM

24 Utah vs New York Analysis Utah NY p No. of Patients Age (years) a ± ± BMI (kg/m2) a ± ± a Values are expressed as mean ± EM

25 Weight loss % 60.00% catter Plot demonstrating percentage weight loss for each patient at respective intervals 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Post-Operative Days

26 Post-op complications Diarrhea 2 (1.55%) Abdominal hematoma 4 (3.10 %) Intra abdominal collection 1 (0.77%) Dysphagia requiring Intervention 1 (0.77%) Procedure Time (Minutes) a ± Length of Hospital tay (Days) a 2.24 ± 1.29 Readmission b <30 days 2 (1.55%) >30 days 1 (0.77%) Reoperations 1 (0.77%) a Values are expressed as mean ± EM b Data available from NY subset

27 <3 months (n=129) 3-6 months (n=129) 6-9 months (n=69) 9-12 months (n=22) >12 months (n=12) Total body Weight loss (lbs) ± ± ± ± ± Total body Weight loss (%) 9.59 ± ± ± ± ± 5.06 Excess weight loss (%) ± ± ± ± ± BMI reduction (kg/m2) 4.97 ± ± ± ± ± 4.02 Excess BMI reduction (%) ± ± ± ± ± Values are expressed as mean ± EM

28 Average Percentage Total body Weight Loss in IP 50.00% 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Post Operative Months

29 Average Percentage Excess BMI loss in IP % % 80.00% 60.00% 40.00% 20.00% 0.00% Post Operative Months

30 Average Percentage Excess BMI loss NY vs Utah % % 80.00% 60.00% NY UT 40.00% 20.00% 0.00% Post Operative Months

31 Conclusion Early results show that IP is an effective weight loss procedure, with equivalent results across two separate centers Key beneficial aspects of procedure include: -Gastrectomy reducing ghrelin -Attachment 3 meters from colon activates hind gut receptors -adequate length avoiding consequences of short bowel syndrome hort term results did not show any negative aspect of a lack of roux limb No evidence of afferent loop syndrome No subjective bile reflux gastritis

32 Conclusion Acceptable morbidity: No evidence of any small bowel obstructions or internal hernia One postoperative therapeutic endoscopy No leaks Analyzing NY Data in first 30 patients, no hypoalbunemia or critical deficiencies on follow lab work

33 Conclusion Future Questions will focus on quantifying GI side effects and quality of life in comparison to other current bariatric procedures All short term data will need to analyze long term effects of the operation, and whether the low morbidity remains constant

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