Revisional Surgery for Weight Regain or Insufficient Weight Loss after Gastric Bypass using the Minimizer Ring: Short Term Results of a Multi Center Study Valk J.W., Gypen B., Abdelgabar A., Hendrickx L. Department of General Surgery, ZNA Stuivenberg Hospital, Antwerp, Belgium Schijns W., Aarts E., Janssen I., Berends F. Department of General Surgery, Rijnstate Hospital, Arnhem, The Netherlands Rheinwalt K.P., Schneider S., Plamper A. Department for Bariatric and Metabolic Surgery, St. Franziskus-Hospital, Cologne, Germany Van Wagensveld B.A., De Raaff C Department of General Surgery, St. Lucas Andreas Hospital, Amsterdam, The Netherlands
St. Franziskus-Hospital, Cologne Germany
St. Lucas Andreas Hospital, Amsterdam, The Netherlands First laparoscopic GBP in 2008 Accreditation as Centre of Excellence
Rijnstate Hospital, Arnhem, The Netherlands First laparoscopic gastric bypass in 2000 IFSO accreditation as Centre of Excellence
Obesity Centre ZNA Stuivenberg Antwerp, Belgium First laparoscopic GBP in 2002 Since then > 6000 laparoscopic RYGBP procedures Accreditation as Centre of Excellence in 2011
Introduction (1)
Introduction (2) 15% (5-40%) patients fail to achieve or maintain 50% EWL or BMI < 35 Possible causes of insufficient weight loss or weight regain after RYGBP Pouch dilatation Gastro-jejunostomy dilatation Gastro-gastric fistula Inadequate length of the alimentary limb etc
Introduction (3) Surgical options for failed RYGBP: Malabsorption: Conversion to distal RYGBP Conversion to biliopancreatic diversion (BPD)/ duodenal switch (DS) Restriction: Revision of the pouch/stoma Band placement around the pouch
Introduction (3) Function band: External reinforcement to help prevent recurrent dilatation of the gastric pouch Better long-term control of the rate of emptying of the pouch and caloric intake Advantage over other revisional approaches: Safer, technically more simple Less risk of leaks, stenosis (since no transection or new anastomosis) Less malabsorption complications (no change in absorption)
Literature revision RnYGB Gobble et al., Gastric banding as a salvage procedure for patients with weightloss failure after Roux-en-Y gastric bypass, Surg Endosc (2008) Adjustable gastric band 11 patients Dapri et al., Laparoscopic Placement of Non-Adjustable Silicone Ring for Weight Regain after Roux en Y Gastric Bypass, Obes Surg (2009) 6 patients with hyperphagia Loosely fitted silicone ring Vijgen et al., Salvage banding for failed Roux en Y gastric bypass, SOARD (2012) Review of seven studies with total of 94 patients.
Literature Awad et Al., Ten Years Experience of Banded Gastric Bypass: Does it Make a Difference?, Obes Surg (2012) 82% EWL after 10 years with banded bypass vs 63% non-banded Fobi et al., Band Erosion: incidence, etiology, management after Banded Vertical Gastric Bypass, Obes Surg (2001) Band erosions in 1,63% Capella, Fobi, Stubbs Size matters! Ideal ring size : 6-6,5 cm circumference!
Surgical technique GaBP Study Ring by (Bariatec Abdelgabar corporation; et al, presented N=12) BypassBand at IFSO Brussels, (Surgtech 2014 AG; N=39) Complications (N) Disconnection/ breakage 5 (GaBP) 38% (5/13) Erosion 4 (BypassBand) Slippage 2 (BypassBand) 10,1% (4/39) 5,1% (3/39)
Surgical technique Minimizer Ring (Bariatric solutions; N=74)
Surgical technique (3) Abdominal insufflation pressure: 15mmHg 5 trocars: 10mm 20 cm below xyphoid process, 5mm left anterior axillary line, 2mm left mid-clavicular line, 5mm right mid-clavicular line, 5mm below xyphoid process Adhesiolysis Separating vertical part gastric pouch from gastric remnant- greater omentum-left crus Tunnel med-lat through lesser sac / dorsal to pouch - 1-2 cm cranial to GJ level Introduction band through 12mm trocar > through tunnel Fixation to gastric pouch with non-resorbable suture (Ethibond)
Study population (4 centers) Period: 2013-2015 74 patiënts, 68 and 6 Characteristics Mean Range Age (y) 42 21 63 (8%) 46 22-63 (92%) 41 21-62 Time RYGBP > Banding (m) 57 8 139 LOS (d) 2,0 1-8 Follow up (m) 14 3-20
Study population (2) Procedure pre-rygbp N (%) None 46 (62%) Gastric banding 27 (36%) Gastric balloon 2 (3%) Biliopancreatic diversion (BPD) Sleeve gastrectomy 2 (3%)
Study population (3) Characteristics Mean Range Pre-RYGBP BMI (kg/m²) 42 21 63 Excess weight (kg) 46 23-94 Post-RYGBP Lowest BMI (kg/m²) 31,3 21-50 Excess weight (kg) 16,7-8,9 66 Pre-Banding BMI (kg/m²) 37,1 23-53 Excess weight (kg) 34 3-81
Surgery Additional procedures Count (N) Percent (%) Partial pouch resection 19 25,6% Correction gastro-gastric fistula 1 1,3% Partial blind loop resection 2 2,7% Partial pouch resection + blind loop resection 9 12% Hiatal Hernia 3 4,0% Partial pouch resection + new gastroenterostomy 1 1,3%
Results Characteristics Mean Range Pre-banding BMI (kg/m²) 37,1 23-53 Excess weight (kg) 34 3-81 1 month BMI (kg/m²) 35,1 21-50 Excess weight loss (%) 13,5-2 - 58 6 months BMI (kg/m²) 33,1 23-53 Excess weight loss (%) 31,2-6 - 78 1 year BMI (kg/m²) 32,2 24-54 Excess weight loss (%) 34,3-22 - 105 2 years BMI (kg/m²) 32,0 20,9-54
Results 74% patients achieved 50% EWL or BMI < 35 kg/m² after 1 year Significant decrease in BMI (p < 0,05) Loss of weight greatest in the first year After 1 y no significant change in BMI EWL: 34% (1 year)
Results From 12 patients with Diabetes type 2, two patients were able to stop medication after 1 year. 13 patients with hypertension showed no improvement 3 out of 9 patients on anti-depressants needed larger dosis of medication. No new deficiencies were noted.
Results (2) Complications N (%) 1 band adjustment 7.5 -> 6.5 1 (1,5%) 7 band removals 7 (9,5%) No effect 2 (3%) Dysphagia 2 (3%) Gastric perforation within 3 days post banding * Migration /slipping after 6 months 2 (3%) 1 (1,5%) * Perforation in patients with combined resection pouch and blind loop
Results (2) Patients satisfaction N (%) Satisfied 30 (45%) Very satisfied 17 (25%) Neither 7 (9%) Not Satisfied Dysphagia 7 (9%) Poor result 7 (9%) Weight regain 2 (3%) * 3 patients with early band removal not included
Conclusion Placement of a laparoscopic non-adjustable band for failed RYGBP is a feasible procedure Significant excess weight loss after banding EWL mainly in the first year Ringsize important to minimize dysphagia After first year no significant change of BMI slight increase of weight More data needed!
Thank you for your attention Obesity Centre Hospital