Why the band in the Gastric Bypass Operation.

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1 Center for Surgical Treatment of Obesity, Los Angeles, California C.S.T.O. Why the band in the Gastric Bypass Operation. M.A.L. Fobi, MD F.A.C.S. H. Lee, MD; B. Felahy, MD; N. Fobi, MD; P. Ako, MD Chi Che, MD; M. Sanguinette Tri City Regional Medical Center, Hawaiian Gardens, California Presented at: The Baritec Symposium, San Diego June

2 Banding the Pouch is not a new concept. It has stood the test of time The VBG has a banded pouch to control the outlet

3 Banding the Pouch is not a new concept. It has stood the test of time The SRVG has a banded pouch to control the stoma

4 Why the band in the GBP? 4

5 Observations and reports on patients with gastric bypass operations Inadequate weight loss in some patients; super obese Weight regain in a subset of patients after gastric bypass The stoma in these patients were noted to be significantly larger. There was a loss of the restrictive component of the operation confirmed by increased caloric intake in these patients.

6 Surgeons response to observations C.S.T.O. Increase the mal absorptive component of the gastric bypass operation Distal Roux-en-Y Gastric Bypass (Torres, Fobi) 1986

7 Surgeons response to observations Increase the mal absorptive component of the gastric bypass operation Brolin 1992

8 Surgeons response to observations Increase the restrictive component of the gastric bypass operation Banded Gastroenterostomy High Erosion Linner 1984

9 Salmon s Banded Vertical Gastroplasty Distal Roux-en-Y Gastric Bypass 1986 C.S.T.O. Surgeons response to observations

10 Serendipity C.S.T.O. Evolution Of The Fobi Pouch * GBP with Loop Gastro-Jejunostomy (Mason) Stapled Horizontal Greater Curvature Roux-en-Y GBP (Alden/Griffin) * Stapled Vertical Lesser Curvature Roux-en-Y GBP (Torres) * Vertical Banded Gastroplasty (Mason) * Silastic Ring Vertical Banded Gastroplasty (Laws) Transected Silastic Ring Vertical Rouxen-Y GBP with Jejunal Interposition and Gastrostomy Site Marker [ The Fobi Pouch Operation ] (Fobi) Transected Silastic Ring Vertical Roux-en-Y GBP with Jejunal Interposition (Fobi) Transected Silastic Ring Vertical Roux-en-Y GBP (Fobi) Stapled Vertical Banded Roux-en-Y GBP (Fobi) * Printed with permission from the A.S.B.S.

11 The Fobi-Pouch Operation for Obesity (The Transected Silastic Ring Vertical Banded Roux-en-Y Gastric Bypass) C.S.T.O. Small Bowel Imbrication of cut edge of gastric pouch reinforces the pouch and minimizes leaks and extravasations. Proximal Gastric Pouch <30cc in capacity. Restricts intake and provides some sense of satiation. Silastic Ring Band cm. long (based on surgeon's judgement). -pseudopyloris of proximal pouch -controls emptying of the pouch and enables long-term effectiveness of gastric restriction Bypassed Duodenum results in selective fat malabsorption and more weight loss than in the simple gastroplasty Temporary GastrostomyTube prevents acute gastric dilatation and provides route for nutritional support if needed Gastrostomy Site Marker for future percutaneous access to bypassed stomach for x-rays, endoscopy and feeding as the need may arise. Gastroenterostomy 11/2-2cm wide, hand sewn two layer closure, air and water sealed. Direct entry of proximal pouch contents into the small bowel causes release of satiety stimulating chemicals, enterokinins. This release is even induced by the individual's salivary secretions that go from the proximal pouch to the small bowel. This results in anorexia and enhances weight loss and maintenance. 11

12 Banding the Pouch in GBP : C.S.T.O. Band Types 1. Marlex Mesh 2. Porcine Graph 3. Bovine Graft 4. Silastic Tubing 5. Linea Alba Fascia 6. Ethibond Suture

13 Banding the Pouch in GBP : C.S.T.O. Cross Section through the Silastic Ring Space between Band and Stomach Wall (0.1 cm) 0.3cm 1.9cm 1.2cm 0.3cm Silastic Ring (Band) (6 cm circumference) Stomach Wall (0.3 cm) Lumen (1.2 cm)

14 Banding the Pouch in GBP : C.S.T.O. Banded vs. Non-Banded Increased pouch capacity with dilated proximal jejunum

15 Banding the Pouch in GBP : C.S.T.O. Results of banding the pouch GBP Non banded Banded Av. PEWL Success Rate* 2 yr f-up 6 yr f-up 2 yr f-up 6 yr f-up 67 % 58 % 80 % 66 % 77 % 69 % 97 % 92 % * Success Rate = Patients with > 50% PEWL

16 Banding the Pouch in GBP : C.S.T.O. Prospective Study 10 year follow-up: APWL: 68.7%

17 Banding the Pouch in GBP : C.S.T.O. Follow-up 15yrs statistics since Follow-up : 14/27 (51.9%) APWL : 69.2%

18 C.S.T.O. COMPARATIVE WEIGHT LOSS VBG, RYGBP, 2 BGBP AND BGBP

19 3-4cm VS

20

21 6 Years Result S-SRVGBP T-SRVGB p-value %EWL No. (%) No. (%) <25% Failure NS <40% Failure NS >40% Satisfactory NS >50% Good NS >60% Very Good NS >70% Excellent NS

22 BGPB Success rate - 90% *** 90% of patients with documented five year follow-up lost and maintained at least 50% percent excess weight loss ***

23 Advantage 1. Significantly reduced incidence of outlet stenosis in the immediate post-op period, which usually requires repeated endoscopic dilatation 2. Increased weight loss 3. More patients with successful weight loss 4. Enhanced weight loss maintenance

24 Corroborating Surgeons Dr. Alvarez-Cordero Dr. J. Alston Dr. P. Alston Dr. Anderson Dr. Baltasar Dr. Bonanato Dr. Burrowes Dr. Bruderer Dr. Capella Dr. Charuzi Dr. Cowen Dr. Cruz Dr. Drew Dr. Fabito Dr. Felahy Dr. Fischer Dr. Gagner Dr. Garrido Dr. Greenbaum Dr. Heyler Dr. Husted Dr. Igwe Dr. James Dr. Joao Dr. Kuvhenguhwa Dr. Lavryk Dr. Lee Dr. Lirio Dr. Liu Dr. Marema Dr. Martinez Dr. Matielli Dr. Mitchell Dr. Nazarian Dr. Norman Dr. Oliveira Dr. Otterman Dr. Pinto Dr. Popoola Dr. A. Salinas Dr. R. Salinas Dr. Salmon Dr. Spaw Dr. Stubbs Dr. Szego Dr. Tyvonchuk Dr. Wright Dr. Yales Dr. Yasrebi

25 Complication of the Band C.S.T.O. Band Erosion or Extrusion

26 Incidence of Band Erosion ( May May 2002 ) Transected Banded Vertical Gastric Bypass 3,484 (100 %) Primary 2,851 ( 81.8 %) Band Erosion 27 ( 0.9 %) Secondary 410 ( 11.8 %) Band Erosion 23 ( 5.6 %) Revision 223 ( 6.4 %) Band Erosion 8 ( 3.6%) Total Incidence of Band Erosion: 58/ 3,484 (1,7 %)

27 Treatment of Band Erosion 1 - Expectant treatmentspontaneous extrusion 2 - Endoscopic removal 3 - Surgical Removal with revision of FPO

28 Endoscopic removal

29 Revision of Fobi-Pouch Operation to Distal Roux-en-Y Gastric Bypass

30 If the need does arise Reversal-Reconstruction of Roux-en-Y Gastric Bypass

31 Conclusion The Banded Gastric bypass can be done with relative perioperative safety, open or laparoscopically. Morbidity 10% and mortality 0.5% It is apparent that Banding the Pouch in the GBP results in more weight loss results in weight loss in more patients results in better weight loss maintenance reduces incidence of outlet stenosis in the immediate post-op period

32 Before July 2001 Age-15 yrs Wt. 405 lbs. Ht BMI After October 2003 Age 17 yrs Wt. 180 lbs. Ht BMI- 27.4

33 Before ( age 74 yrs) Wt. 324 lbs. Ht.-5 5 BMI C.S.T.O. After ( age 78 yrs) Wt. 199 lbs. Ht.-5 5 BMI-33.11

34 Before (1999) Wt. 215 lb. Ht.-5 7 BMI After (2003) Wt. 126 lb. Ht.-5 7 BMI-20.20

35 Before After (1996) Wt. 591 lbs. Ht-5 11 BMI ( 2003) Wt. 207 lbs. Ht-5 11 BMI

36 Since Roux-en-Y Gastric Bypass is primarily a restriction operation, just as with VBG, it is important that the outlet of the pouch does not stretch. ( E.Mason. Obesity Surgery 1994;4:66-72)

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