Revision of failed restriction to RYGB

Mr Adam Skidmore FRACSAssoc Professor Sim0n Woods FRACS

Upper GI and HPB Cabrini Medical centre, Melbourne

IntroductionLook at 29 patients who have had either a failed

Gastric Band – adjustable and fixed , VBG/HGR or Jejuno-ileal bypass

Failure was either weight regain/non weight lossTechnical failure of the original operationOther issues – gastroparesis, reflux and vomiting

Techniques for revision

Results of our experience

Sometimes surgery doesn't work

Revision is an option2 surgeon series

29 cases of conversion of HGR/VBG, Gastric Band or jejuno-ileal bypass to RYGB

Experienced in RYGB – open and Laparoscopic

Gastric Band FailureDefined as either no weight loss at all or

weight loss of less than 10% EW

Variety of reasonsMaladaptive eating behaviorTechnical issues with the band Recurrent slipDilation of the pouch

Failure of VBG/HGRLate failures - most 10years +

Maladaptive eating behaviour

Dilatation of the pouch – weight regain or reflux

Staple line dehiscence – weight regain

Reversal of staplingEncouraged to reverse if severe maladaptive

eatingReversal is by removal of the sutures6 months of normal diet and exercise prior to

reversal

Methods of revisionAll patients are fully evaluated by a

multidisciplinary teamOften have seen a Nutritional physicianGastroscopyBarium series At least 2 pre operative consults with the

surgeon2 weeks of optifast BMI <504 weeks of optifast BMI>50

Slipped band

Dilated pouch with stenosis

Large hiatal hernia

Roux En Y Gastric BypassPreferred method of revisionOpen approachOften multiple previous surgeriesMidline laparotomyLaparoscopic staplers/seamguardUpper GI omnitract Handsewn Gastrojejunostomy or orvil 25mm

circular staplerHandsewn enteroenterostomy

Bariatric omnitract

Results 29 patientsRange of previous surgeriesOften multiple operations - open and

laparoscopicMostly failure of weight lossSignificant amount of failures related to

technical issuesAll successful completion to RYGB3 underwent a partial gastric resection2 underwent a partial liver resection

ResultsLimited by follow up of 2-18 monthsAverage weight – 121 kg170kg – 80 kg20 females and 9 malesWeight loss average – 60% EW excluding patients

<6months

All had resolution of gastroparesis

Significant improvement in diabetes

All had resolution of reflux and vomiting

ComplicationsLeak – 2 gastrojejunostomy leaks

Bile leak – 1 bile leak treated by percutaneous drain

Wound infection – 2 wound infections requiring AB and 1 requiring VAC dressing

Incisional hernia and internal herniation – 5 incisional hernias and 1 internal hernia

LOS and return to workAverage LOS – 5 days

Return to work – 3.5 weeks

TAKES AT LEAST 3 MONTHS TO RETURN TO PREOPERATIVE QUALITY OF LIFE

Tips and pitfalls - staplingImportant to determine if stapling is dehisced

or if large pouchIf large pouch – must stay within the staple

line – risk of ischaemiaSometimes better to perform a fundectomy

excising the fundus and staple line – easier to enter the lesser sac away from adhesions

Fundectomy/mini sleeve can minimize splenic injury

Gastric bandIf there is slippage – REMOVE THE BAND AND

WAIT

If no slippage it is safe to perform in one surgery – MUST REMOVE THE CAPSULE AND ALL SUTURES

GREEN LOADS +/- SEAMGUARD

Difficult Left lobe of LiverBleeding

Adhesions

Can remove part of the left lobe safely with the echilon stapler

Less bleedingLess Bile leak

Post operative NGT – 24 hoursGastrograffin swallow 24-48 hrsFluids after confirmation of no leakJackson pratt drain for 5 days

In very large patients useful to drain the subcutaneous space

Vac dressings can be useful in very large patients with wound infection

conclusionsTechnically challengingAccess to ICU and Interventional radiologyMultidisciplinary supportResults can be as good as primary RYGBMorbidity is higher