1. Combination Surgical Therapy Banding the Bypass Bypassing the Band Matthew Kroh,MD Assistant Professor of Surgery Cleveland Clinic Center for Surgical Innovation, Technology, and Education Bariatric & Metabolic Institute

2. Disclosures Research support from and/or consultant: –Covidien –Ethicon Endo-Surgery –Davol/Bard

3. Introduction Number of failures & revisions increasing –Initial weight –Weight regain Must be part of inter-disciplinary evaluation including diet and exercise US Bariatric Surgery 1993-2004

4. Introduction Revisional bariatric surgery –More technically challenging –Higher complication rates Often open procedures Increased laparoscopic experience increasing successful outcomes

5. Indications Definitions of failure Weight regain Regain medical co- morbdities Failure to ameliorate co-morbidities Mechanical failure –Operation –Device

6. Options for Failures Revisional procedures focus on: –Stoma size –Pouch size –Limb lengths Variables that can be surgically altered

7. Bypassing the Band

8. Reasons for Conversion Proportion of patients previously implanted requiring reoperation varies widely –(5-58%) Usually secondary to slippage or dilation Revisions include replacement or re- positioning of band May convert to another procedure –Most commonly sleeve gastrectomy or RYGB

9. Background Failure rates after banding are widely variable depending on criteria Different than RYGB Include: –Poor initial EWL –Long term weight regain –Slippage –Intolerance –Esophageal dilation –Infection –Gastric ischemia

10. AGB Failure Requires exclusion of band malposition or malfunction Conversion to RYGB described as 2- and 1-step procedures –Success of 1 step procedure enhanced with band deflation in advance Conversion to RYGB more common procedure Data improving, short and intermediate term

11. 350 pts in 7 years underwent AGB 21 underwent conversion to RYGB Indications: –Poor weight loss, slippage, intolerance, esophageal dilation, acute complications Average time to conversion 27 months

13. 3 major complications (11%) –1 leak, 1 j-j obstruction, 1 a-fib Follow-up 18 months Conclude safe and efficacious after failed LAGB

14. 70 patients for failure –Inadequate weight loss Reinhold criteria (<25%) –Slippage –Erosion Performed average 42 months after primary procedure Complication rate 14%, no mortality

16. Band to Bypass Several published series Overall low morbidity, mortality –Still significantly higher than primary operations May be performed as staged procedure, especially for acute presentations Important to perform thorough pre-op evaluation

17. Re-operation After Primary Banding Not infrequent Indications for re-operation should dictate plan Repositioning or replacing AGB appears to be good option for band related complications –Leakage, disconnection –Slippage? Up to 33% recurrence (Suter et al) Failure in terms of EWL and co-morbidities better treated with conversion –Most commonly RYGB

18. Banding the Bypass

19. Banding the Bypass- Simultaneous Procedures Usually in higher risk patients for failure –High BMI (Super-obese), Men Weight regain at 3-5 years Greater experience with fixed rings –Silastic, polypropylene –Concern for stenosis, erosion, infection Fobi, Capela and Capela –Large series of banded bypass pts, excellent results

20. Prospective study 90 pts, BMI >50 Randomized intra-op to banded versus non-banded RYGB 1.5 x 7cm Marlex band, sutured around proximal pouch, 5.5 cm diameter 2 cm above G-J 36 month f/u

22. GI symptomsComplications

23. For Failure of Primary Operation Additional operation after RYGB Major complications for revision RYGB –Up to 50% Requires work-up –Anatomic Pouch dilation Stoma dilation Gatrogastric-fistula –Exercise –Diet

24. Surgical Options Limb-lengthening procedures –Long-limb gastric bypass BPD with or without DS Revision of stoma –Surgical or endoscopic Revision of pouch –Surgical or endoscopic

25. Options Limb lengthening –Potentially severe metabolic problems BPD +/- DS –technically difficult –Excellent EWL, but malabsorption significant Endoscopic approaches –Promising –Durability, long term results

26. Surgical Options Banding the bypass Fixed versus adjustable bands –Interrupting propulsive wave with reduced compliance versus outlet restriction Mainly silastic or polypropylene

27. Pre-operative Evaluation Operative notes UGI Endoscopy –Hiatal hernia, G-G fistula, ulcer –E-G junction –Length of pouch –Width of pouch –Size and characteristics of G-J

28. Technique Laparoscopy versus open Knowledge of previous RYGB –Ante-colic, ante-gastric –Retro-colic, retro-gastric Recognize and repair hiatal hernia Identification of G-J –Intra-op endoscopy

29. Technique Identification of and mobilization of Angle of His Left pillar visualization Often requires dissection between remnant and pouch Bessler et al, SOARD, (15) 1443-48.

30. Technique Pars flaccida approach Small retro-gastric tunnel Gastro-gastric plication –Remnant stomach –Large pouch –? No plication

31. Outcomes Limited data Medical therapy still limited Short and medium term outcomes

32. 6 pts s/p RYGB Hyperphagia and weight regain BMI at reoperation 38, initial BMI 36 Time interval 26 months from 1 st operation Placement non- adjustable silastic band (6.5-7cm)

33. Results –No complications –F/U 14 months –Final BMI 26 –EWL 70% –EWL before and after revision statistically significant

34. Hypothesize that fixed ring interrupts propulsive wave, delays emptying Different than restriction of AGB

35. Adjustable Band after Bypass Well documented safety Excellent results as primary procedure –11 Pts, poor EWL or weight regain –Initial EWL 38%, after LAGB 59% –One flipped port, no other complications –Mean follow-up 13 months

36. 23 patients failure RYGB –Persistent BMI after surgery >35 –<50% EWL at 18 months Mean BMI at revision 45, initial BMI 53 Majority laparoscopic Complications (13.5% re-operation rate) –1 leak required removal –1 slip, 1 port infection, 1 SBO from tubing

37. EWL at 5 Years

38. Advantages of AGB to RYGB Technically simpler –Especially after lap RYGB No anastomosis Unlikely additional metabolic sequelae

39. Conclusions Increasing number of failures after primary procedures Difficult group of patients requires thorough investigation as to etiology of failure Addition of AGB to RYGB for failure seems reasonable with short term data Long term outcomes required