OUTCOMES CONGRESS: BARIATRIC REVISIONAL SERIES

After the success of the 4 episodes of this Series, we are ready to talk about Patients Outcomes. On November 8th, do not miss the final phase of “AIS WORLD BARIATRIC REVISIONAL SERIES”.
Dr. Boza from Chile, Dr. Dillemans from Belgium, Dr. Gagner from Montreal and Dr. Blackstone from Phoenix, will debate about Patients Outcomes and the evolution of their surgeries.
Do not miss this exclusive event chaired by Professor Miller, Associate Professor of Surgery Mohamed Bin Rashid Al Maktoum Academic Medical Center UAE. Advances In Surgery: the ultimate surgical training experience.

Sleeve Gastrectomy has become the most common bariatric procedure worldwide due to its good results, simplicity, and low complication rate. However, a number of patients can experience weight regain after several years. Although most of the time bariatric surgeons would prefer revision to a duodenal switch or a bypass, new evidence has shown that a re-sleeve gastrectomy is a feasible option, specially when the patient had a good initial outcome in the absence of reflux and hiatal hernia and when there is a dilation of the gastric tube.

We will present the case of a 34-year-old female patient who underwent a Sleeve gastrectomy 6 years ago, losing 43 kilos, from 113 to 70 kilos over 18 months (BMI 41 to 25). She maintained her weight for 3 years, but after having her second daughter she progressively regained weight. She came to the hospital with a BMI of 35, a relapse of joint disease, and sleep apnea. Weight 97, Height 1.66m.

Preoperative studies showed a dilated gastric tube but no evidence of hiatal hernia or reflux. After the assessment of the multidisciplinary team, the re-sleeve surgery has been selected as the reasonable option.

At the conclusion of this AIS World Event, participants will have:

• – Reviewed patient selection, preparation and positioning for revisional bariatric surgery procedures
• – Interacted with expert thought leaders in revisional surgery
• – Discussed complex cases and learned strategies and methods for optimizing outcomes following revisional bariatric surgery
• – Observed the safe and effective use of HARMONIC® technology and ECHELON FLEXTM GST System

Advances In Surgery: the ultimate surgical training experience

Camilo Boza Clínica las Condes Santiago, Chile.
Medical Director

Even though long-term results support the consideration of sleeve gastrectomy as a standard-alone procedure, when weight loss failure (insufficient weight loss or weight regain) occurs, or complications such as de novo GERD appear, a reversal procedure must be considered.
There is no consensus on the procedure of choice for LSG reversal. Weight loss after revisional procedures tends to be modest and decision making must consider not only morphological aspects but also other patient-related factors such as resolution of comorbidities, dietary habits, or the presence of sleeve-related sequelae.
Therefore, several options such as re-sleeve, RYGBP, banded sleeve, BPD, SADI-S or OAGB can be offered not only to add weight loss but also to improve both metabolic results and procedure-related complications.
Current evidence suggests that in the presence of GERD, conversion from SG to RYGBP could regarded as the procedure of choice.

We present the case of a 48-year-old female patient who underwent a laparoscopic sleeve gastrectomy 4 years ago. She had a good initial weight loss from 137 kg to 100 kg, BMI 58.5 to 42.7. At presentation she had regained weight, resulting in a BMI of 49.4. The patient’s history also included hypertension, reflux and dyspnea. An upper GI series showed a relatively wide sleeve with a good contrast passage and a small sliding hernia. In the subsequent endoscopy a reflux esophagitis grade B was detected.
 
A laparoscopic conversion to a long limb Roux-en-Y gastric bypass is the option selected. We will opt for a long limb gastric bypass, a 150 cm biliopancreatic limb, to enhance the malabsorptive effect of the bypass. Other surgical options could include a revision to a SADI procedure, a Santoro procedure, a mini bypass, a duodenal switch or a re-sleeve gastrectomy, but the patient’s symptomatic reflux problems of the patient resulting from a previous Sleeve will be optimally treated by this tailored Roux-en-Y gastric bypass.

At the conclusion of this AIS World Event, participants will have:
– Reviewed patient selection, preparation and positioning for revisional bariatric surgery procedures
– Interacted with expert thought leaders in revisional surgery
– Discussed complex cases and learned strategies and methods for optimizing outcomes following revisional bariatric surgery
– Observed the safe and effective use of HARMONIC® technology and ECHELON FLEXTM GST System

Advances In Surgery: the ultimate surgical training experience

Bruno  Dillemans Director of the Center of Obesity Surgery AZ Sint-Jan Hospital, Bruges, Belgium

Sleeve gastrectomy (SG) is currently regarded as a standalone procedure for most morbidly obese patients due to its results for both weight loss and comorbidity resolution. Nevertheless, up to 64 and 70% of patients can present with insufficient weight loss and weight regain in the long term. Hence revisional techniques are often needed in order to improve both weight loss and metabolic control. Although there is no consensus on which technique should be performed after SG as a second-step procedure, Roux-en-Y Gastric Bypass (RYGBP), re-sleeve and bilio-pancreatic diversions (duodenal switch, SADI-S, SIPS) are commonly considered. Due to its excellent results for both weight loss and comorbidity improvement, specially in super-obese patients, duodenal switch can be an optimal option for those patients with very significant weight regain or por metabolic control.

We present the case of a 40-year-old female patient who underwent a laparoscopic sleeve gastrectomy 6 years ago. She had a good initial weight loss from 164 kg to 73 kg, (BMI 54.7 to 24.3 kg/m2). In a recent consultation, she had regained weight, resulting in a weight of 118 kg and a BMI of 39.5 kg/m2. The patient’s history also included anemia. An upper GI series showed a relatively cylindric sleeve.
 
A laparoscopic conversion to a classic duodenal switch has been the option selected, since she was super-obese initially and 2-stages had been discussed 6 years ago. We are opting for a 100 cm common limb and a 150 cm alimentary limb, as described by Dr Picard Marceau. Other surgical options could include a revision to a SADI-s procedure, or a SIPS.

At the conclusion of this AIS World Event, participants will have:
– Reviewed patient selection, preparation and positioning for revisional bariatric surgery procedures
– Interacted with expert thought leaders in revisional surgery
– Discussed complex cases and learned strategies and methods for optimizing outcomes following revisional bariatric surgery
– Observed the safe and effective use of HARMONIC® technology and ECHELON FLEX™ GST System

Advances In Surgery: the ultimate surgical training experience

Michel Gagner Hôpital du Sacré Coeur, Montreal Clinical Professor of Surgery, FIU Senior Consultant

Reoperative bariatric surgery procedures are becoming a significant part of MBS practice. They are performed to deal with complications and weight gain after the primary procedure. One of the most common complications in patients with a history of gastric bypass is marginal ulcer (MU) and stricture. The incidence of marginal ulcer (MU) is 1-16%, although true incidence is unknown. Bleeding and perforation are the presenting factors in some patients. Chronic MU is often accompanied by abdominal pain and stricture as in the case presented today.
We present the case of a 47-year-old woman who had a banded, undivided gastric bypass performed in 2000. She was not a smoker and did not take NSAIDs. Her BMI was 33 in April 2017 and 29 in April 2018.  She was eating mainly things that were soft and would go down easily. She had been identified with a marginal ulcer a few years before and was treated with sucralfate and Protonix daily. The ulcer healed for a certain period of time, resulting in stricture. The gastroenterologist was unaware of the band around the GJ and attempted to dilate the area with no long-term effects.

This cycle of treatment and dilation attempts had been going on for some years prior to her referral to our clinic. She did not have any overt bleeding at the site of ulcer but was chronically anemic, due in part to a chronic iron deficiency and B12/Folate deficiency.  She also had chronic pain and was on daily narcotic therapy. Her psychiatric disorders include borderline personality disorder, dissociative and conversion disorder, and bipolar disorder. She was evaluated by our psychologist and was found to be stable on medication, with her counselor making home visits twice a week. Her medical history includes current treatment for hypertension, T2DM, asthma and she had a history of Mitral Valve Proplase with SVT. She had not been monitored in a bariatric clinic until she was referred to us last summer. For her insurance to pay for the revision, even in this situation of chronic stricture and recurrent marginal ulcer, a multiple month medical weight loss period was required, and she took part in the entire education program and was monitored on a monthly basis by our RD/NP team, in an attempt to improve her overall nutritional status by using liquid protein shakes. She also had extensive workup and clearances by pulmonary and cardiac specialists. Her previous abdominal procedures also include umbilical hernia repair with mesh, open hysterectomy, c section and open cholecystectomy.

Options for treatment included reversal of the procedure vs. revision. She was definitely not interested in reversal. She consented to a laparoscopic revision of gastrojejunostomy with a partial gastrectomy, possible revision of jejunojejunostomy, and other procedures as indicated. The Roux limb will be measured and if it is longer than 100 cm we will not revise it. The previous gastrojejunostomy, distal remnant and ring will be removed en bloc.

At the conclusion of this AIS World Event, participants will have:
– Reviewed patient selection, preparation and positioning for revisional bariatric surgery procedures
– Interacted with expert thought leaders in revisional surgery
– Discussed complex cases and learned strategies and methods for optimizing outcomes following revisional bariatric surgery
– Observed the safe and efective use of HARMONIC® technology and ECHELON FLEX™ GST System

Advances In Surgery: the ultimate surgical training experience

Robin  Blackstone University of Arizona School of Medicine-Phoenix, Arizona Professor of Surgery