1. Revision of failed restriction to RYGB
Mr Adam Skidmore FRACS
Assoc Professor Sim0n Woods FRACS
Upper GI and HPB Cabrini Medical centre, Melbourne

2. Introduction
Look 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 loss
Technical failure of the original operation
Other issues – gastroparesis, reflux and vomiting
Techniques for revision
Results of our experience

3. Sometimes surgery doesn't work

4. Revision is an option 2 surgeon series
29 cases of conversion of HGR/VBG, Gastric Band or jejuno-ileal bypass to RYGB
Experienced in RYGB – open and Laparoscopic

5. Gastric Band Failure
Defined as either no weight loss at all or weight loss of less than 10% EW
Variety of reasons
Maladaptive eating behavior
Technical issues with the band
Recurrent slip
Dilation of the pouch

6. Failure of VBG/HGR Late failures - most 10years +
Maladaptive eating behaviour
Dilatation of the pouch – weight regain or reflux
Staple line dehiscence – weight regain

7. Reversal of stapling
Encouraged to reverse if severe maladaptive eating
Reversal is by removal of the sutures
6 months of normal diet and exercise prior to reversal

8. Methods of revision
All patients are fully evaluated by a multidisciplinary team
Often have seen a Nutritional physician
Gastroscopy
Barium series
At least 2 pre operative consults with the surgeon
2 weeks of optifast BMI <50
4 weeks of optifast BMI>50

9. Slipped band

10. Dilated pouch with stenosis

11. Large hiatal hernia

12. Roux En Y Gastric Bypass
Preferred method of revision
Open approach
Often multiple previous surgeries
Midline laparotomy
Laparoscopic staplers/seamguard
Upper GI omnitract
Handsewn Gastrojejunostomy or orvil 25mm circular stapler
Handsewn enteroenterostomy

14. Bariatric omnitract

16. Results 29 patients Range of previous surgeries
Often multiple operations - open and laparoscopic
Mostly failure of weight loss
Significant amount of failures related to technical issues
All successful completion to RYGB
3 underwent a partial gastric resection
2 underwent a partial liver resection

17. Results Limited by follow up of 2-18 months Average weight – 121 kg
170kg – 80 kg
20 females and 9 males
Weight loss average – 60% EW excluding patients <6months
All had resolution of gastroparesis
Significant improvement in diabetes
All had resolution of reflux and vomiting

18. Complications Leak – 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

19. LOS and return to work Average LOS – 5 days Return to work – 3.5 weeks
TAKES AT LEAST 3 MONTHS TO RETURN TO PREOPERATIVE QUALITY OF LIFE

20. Tips and pitfalls - stapling
Important to determine if stapling is dehisced or if large pouch
If large pouch – must stay within the staple line – risk of ischaemia
Sometimes 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

21. Gastric band
If 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

22. Difficult Left lobe of Liver
Bleeding
Adhesions
Can remove part of the left lobe safely with the echilon stapler
Less bleeding
Less Bile leak

23. Post operative NGT – 24 hours Gastrograffin swallow 24-48 hrs
Fluids after confirmation of no leak
Jackson 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

24. conclusions Technically challenging
Access to ICU and Interventional radiology
Multidisciplinary support
Results can be as good as primary RYGB
Morbidity is higher