Why the band in the Gastric Bypass Operation?

Transcription

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 15 2004.
C.S.T.O.
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
1980
2
C.S.T.O.
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
1981
3
C.S.T.O.
Why the band in the GBP?
4
C.S.T.O.
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.
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
C.S.T.O.

Increase the mal absorptive component of
the gastric bypass operation
Brolin 1992
C.S.T.O.
Increase the restrictive component of the
gastric bypass operation
Banded Gastroenterostomy
High Erosion
Linner 1984
C.S.T.O.
Salmon’s Banded Vertical Gastroplasty
Distal Roux-en-Y Gastric Bypass
1986
Serendipity
Evolution Of The Fobi Pouch
C.S.T.O.
* GBP with Loop
Gastro-Jejunostomy
(Mason)
Stapled Horizontal
Greater Curvature
Roux-en-Y GBP
(Alden/Griffin)
Transected Silastic Ring Vertical Rouxen-Y GBP with Jejunal Interposition
and Gastrostomy Site Marker [ The
Fobi Pouch Operation ] (Fobi)
* Stapled Vertical
Lesser Curvature
Roux-en-Y GBP
(Torres)
Transected Silastic Ring
Vertical Roux-en-Y GBP
with Jejunal Interposition
(Fobi)
* Vertical Banded
Gastroplasty (Mason)
Transected Silastic Ring
Vertical Roux-en-Y
GBP (Fobi)
* Silastic Ring
Vertical Banded
Gastroplasty (Laws)
Stapled Vertical
Banded Roux-en-Y
GBP (Fobi)
* Printed with permission from the A.S.B.S.
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
6.0-6.5 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
Banding the Pouch in GBP :
Band Types
C.S.T.O.
1.
2.
3.
4.
5.
6.
Marlex Mesh
Porcine Graph
Bovine Graft
Silastic Tubing
Linea Alba Fascia
Ethibond Suture
Cross Section through the Silastic Ring
C.S.T.O.
Silastic Ring
(Band)
(6 cm circumference)
Space between
Band and
Stomach Wall
1.9cm
(0.1 cm)
1.2cm
0.3cm
0.3cm
Lumen
Stomach Wall
(0.3 cm)
(1.2 cm)
C.S.T.O.
Banded vs. Non-Banded
Increased pouch
capacity with
dilated proximal
jejunum
C.S.T.O.
GBP
Results of
banding the pouch
Av. PEWL
2 yr f-up
Success Rate*
6 yr f-up
2 yr f-up
6 yr f-up
Non
banded
67 %
58 %
80 %
66 %
Banded
77 %
69 %
97 %
92 %
* Success Rate = Patients with > 50% PEWL
C.S.T.O.
Prospective Study
• 10 year follow-up: 1992 – 2002
• APWL: 68.7%
C.S.T.O.
Follow-up
• 15yrs statistics since 1985-87
• Follow-up : 14/27 (51.9%)
• APWL
: 69.2%
C.S.T.O.
COMPARATIVE WEIGHT LOSS
VBG, RYGBP, 2° BGBP AND BGBP
C.S.T.O.
3-4cm
VS
C.S.T.O.
C.S.T.O.
6 Years Result
%EWL
S-SRVGBP
No.
(%)
T-SRVGB
No.
(%)
<25%
<40%
>40%
>50%
>60%
>70%
1
1
18
16
13
7
1
2
19
18
14
11
Failure
Failure
Satisfactory
Good
Very Good
Excellent
5.3
5.3
94.7
84.2
68.4
36.8
4.8
9.5
90.5
85.7
66.7
52.4
p-Value
NS
NS
NS
NS
NS
NS
C.S.T.O.
BGPB Success rate - 90%
*** 90% of patients with documented five year
follow-up lost and maintained at least 50%
percent excess weight loss ***
C.S.T.O.
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
C.S.T.O.
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
Complication of the Band
C.S.T.O.
Band Erosion or Extrusion
Incidence of Band Erosion
( May 1992- May 2002 )
C.S.T.O.
Transected Banded Vertical Gastric Bypass
3,484 (100 %)
Primary
2,851
( 81.8 %)
Secondary
410
( 11.8 %)
Revision
223
( 6.4 %)
Band Erosion
27 ( 0.9 %)
Band Erosion
23 ( 5.6 %)
Band Erosion
8 ( 3.6%)
Total Incidence of Band Erosion:
58/ 3,484 (1,7 %)
C.S.T.O.
Treatment of
Band Erosion
1 - Expectant treatmentspontaneous extrusion
2 - Endoscopic removal
3 - Surgical Removal
with revision of FPO
Endoscopic removal
C.S.T.O.
Revision of Fobi-Pouch Operation
to Distal Roux-en-Y Gastric Bypass
C.S.T.O.
If the need does arise
Reversal-Reconstruction of Roux-en-Y Gastric Bypass
C.S.T.O.
C.S.T.O.
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”
C.S.T.O.
Before
July 2001
Age-15 yrs
Wt. 405 lbs. Ht.-5’10” BMI- 57.39
After
October 2003
Age 17 yrs
Wt. 180 lbs. Ht.-5’10”
BMI- 27.4
After
(2003 - age 78 yrs)
Wt. 199 lbs. Ht.-5’5” BMI-33.11
C.S.T.O.
Before
(1999 - age 74 yrs)
Wt. 324 lbs. Ht.-5’5” BMI-53.91
C.S.T.O.
Before
After
(1999)
(2003)
Wt. 215 lb.
Wt. 126 lb.
Ht.-5’7”
Ht.-5’7”
BMI-33.67
BMI-20.20
C.S.T.O.
Before
After
(1996)
( 2003)
Wt. 591 lbs. Ht-5’11” BMI-82.42
Wt. 207 lbs. Ht-5’11” BMI- 28.87
C.S.T.O.
“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)