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Evaluation of Revisional Bariatric Surgery in Patients with Weight Regain
Poster Presentations / Surgery for Obesity and Related Diseases 12 (2016) S76–S232
Background: Obesity is closely connected to non-alcoholic fatty liver disease (NAFLD) affecting the vast majority of patients. The most effective therapy for NAFLD is sustained weight loss, therefore bariatric surgery has successfully been utilized to reverse or prevent further progression of NAFLD. However, case reports have shown substantial deterioration of liver function and liver failure after performing radically malabsorptive bariatric operations as the jejunoileal bypass (JIB) and the biliopancreatic diversion (BPD). Clinically evident deterioration of liver function has not been reported in the currently established surgical procedures such as the Roux -en- Y gastric bypass (RYGB), one-anastomosis gastric bypass (OLGB) or sleeve gastrectomy (SG). The aim of our study was to evaluate major liver function impairment after bariatric surgery in patients treated at the Medical University of Vienna, Department of Surgery. Methods: Consecutive in- and outpatients after bariatric surgery within the preceding two years who presented with severe liver dysfunction were included in this case series. Results: In total, 7 patients (m:f¼1:6; median age 40a, range¼3066a) are reported. Deterioration of liver function occurred after RYGB (n¼5), OLGB (n¼1 (þ1/conversion into OLGB)) and even gastric banding (n¼1) after a median postoperative time of 6 months (range¼2- 24months). Clinical symptoms varied from fatigue (86%) to ascites (57%), hepatic encephalopathy (29%), and variceal bleeding (14%). Elevation of transaminases, impairment of coagulation parameters, thrombocytopenia and hypalbuminemia were present in 57%, 86%, 71%, and 100%, respectively. Liver cirrhosis was proven by biopsy in 3 out of 7 patients and a 100% steatosis was present in 1 of the patients. Median % excess weight loss (%EWL) was 113.3% (range¼81- 257%).In 5 patients bypass' (BP) length reduction or reversal was performed and led to an improvement of symptoms, determinable also by imaging, histology and blood exam. In one patient liver transplantation was needed, one patient died in septic shock and decompensated liver disease. Conclusion: To the best of knowledge this is the first description of liver failure/dysfunction after OLGB and gastric banding. Bypass reversal or elongation of the intestinal resorption length led to a rapid improvement of liver dysfunction. However, guidelines for handling bariatric patients suffering from a certain degree of liver pathology are lacking and the long-term outcome is still undetermined. As long as there are only speculations for the patho-mechanism of liver alteration, a meticulous preoperative evaluation including liver status, as well as a regularly scheduled post-operative follow-up for the early identification of liver impairment should be aspired in all patients.
A5209
MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE AND HIATAL HERNIA POST SLEEVE GASTRECTOMY: CARDIOPEXY WITH LIGAMENTUM TERES Salman Alsabah1; Shehab Akrouf2; Mohanad Al-Hadad1; Jonathon Vaz3; 1Royale Hyatt Hospital, Kuwait, Mesilla Kuwait; 2 Al-Amiri Hospital, Kuwait, Kuwait City Kuwait; 3Al-Amiri Hospital, Kuwait, Dasman Kuwait Background: This video demonstrates the management of Gastroesophageal Reflux Disease (GERD) post Laparoscopic Sleeve
S185
Gastrectomy (LSG). We present the case of a 26 year old female who underwent LSG 4 years ago. Her pre-operative weight was 116 kgs and her BMI was 44 kg/m2. Her post-operative weight was 59 kgs and her BMI was 22kg/m2. Post-operatively she had GERD and regurgitation and did not respond to medical treatment and dilatation. Endoscopy, barium swallow and CT scan revealed severe reflux, regurgitation with hiatal hernia. We discussed the treatment options as per our management of GERD protocol with the patient. She agreed to the ligamentum teres cardiopexy (LTC) technique which is currently being researched. In this video we demonstrate reproducible laparoscopic repair of hiatal hernia and cardiopexy utilizing ligamentum teres in 2 patients suffering from GERD and hiatal hernia. We discussed the option of gastric bypass with the patient as it is the standard of care in treating such complications, however after explaining both procedures the patient opted for LTC with the knowledge that if the procedure fails, she would require subsequently a gastric bypass.The video demonstrates step-by-step the technique of LTC repair which was successful in the short term follow up in both patients as evident in the post operative barium swallow which shows no hiatal hernia or reflex. At 6 months both patients had no symptoms of GERD. Conclusion: LTC combined with the reduction of the hernia is a good alternative treatment for GERD in patients with previous LSG following our algorithm. The use of intra-operative endoscopy is important in such procedures. Further studies with a longer period of follow-up are needed to address clinical efficacy and safety of the procedure
A5210
EVALUATION OF REVISIONAL BARIATRIC SURGERY IN PATIENTS WITH WEIGHT REGAIN Seyed Mohammad Kalantar Motamedi; Amir Aryaie; Mohammad Alshehri; Leena Khaitan Khaitan; Tomasz Rogula; Adel Alhaj Saleh; Mujjahid Abbas; University Hospitals Case Medical Center, Case Western Reserve University, Cleveland Ohio Background: Obesity is a worldwide increasing health problem. Bariatric surgery has been proven to be the most effective strategy to obtain long term weight loss for patients with morbid obesity. However, not all of the patients achieve the optimum desirable outcomes. Moreover among those who are primarily successful, weight regain is not unlikely specifically in the long run. Revisional bariatric surgery remains as an option for such patients to lose weight again. We evaluated the effectiveness of such procedures in a single institution. Method: A retrospective review of prospectively maintained database for all patients who underwent revisional bariatric procedures in a single academic institution from January 2013 to December 2015 under IRB approval was performed. Cases with history of inadequate weight loss or weight regain included for further evaluation. Patients' records were reviewed for demographic data, type of revision, body mass index (BMI) and excess body weight (EBW) at the time of initial bariatric surgery. In addition, percentage of excess body weight loss (%EWL) at the time of revision and in sequential follow-ups after revision were evaluated. We excluded patients with less than 3 months of post-revision follow up. Results: Eighteen patients were included in this study (Female n¼16, 88.9 %; White n¼12, 66.7%) with the mean age of
S186
Poster Presentations / Surgery for Obesity and Related Diseases 12 (2016) S76–S232
49.2 ⫾8.6 years. The mean BMI at primary bariatric surgery was 52.6 ⫾12.7. The mean duration between primary surgery and revision was 122 ⫾27 months (median¼102). Before regain weight, all patients had shown history of more than 50% weight reduction before revision except in two cases (%EWL of 37.6 and 42.6). Mean of their best %EWL was from 64.0(⫾25.4) down to mean BMI of 35.9⫾9.4. All cases had weight regain reaching the mean BMI (⫾SE) of 42.9 (⫾8.6) at the time of revisional operation. None of the patients had final %EWL of more than 50% at the time of revision except 3 (16.7%).94.5 % of cases were performed laparoscopic (n¼17). Surgical procedures included gastric band removal with either conversion to gastric bypass (n¼1, 5.5%) or sleeve gastrectomy (n¼3, 16.7%), conversion of sleeve to gastric bypass (n¼4, 22.2%; including 1 open surgery), conversion of vertical banded gastroplasty (VBG) to sleeve gastrectomy (n¼1, 5.5%), VBG to gastric bypass (n¼2, 11.1%). Candy Cane Resection with simultaneous revision of gastrojejunostomy (n¼4, 22.2%) and take down of Gastro-gastrostomy fistula with history of gastric bypass (n¼3, 16.7%). The mean operative time was 170(⫾75) minutes (median¼159) and mean post-revisional hospital stay was 3.6(⫾1) days (median 2 days). Mean follow up after the revisional surgery was 17.2(⫾3.6) months (median¼12 months). 2 patients (11.1%) had more than 4 years follow up after revision.Mean BMI and mean %EWL at 3, 6, 12, 24 and 48 months post-revision was 38.5(⫾2.1) and 31.9%, 37.8 (⫾2.8) and 40.2%, 33.2 (⫾2.1) and 55.4%, 31.6 (⫾2.6) and 66.2%, 30.2 (⫾8.5) and 93.3% correspondingly. The percentage of cases who succeeded to collectively lose more than 50% of their primary excess weight after revision was 58.8% (11 out of 17), 75% (9 out of 12), 83% (10 out of 12), 86% (6 out of 7) and 100% (2 out of 2) respectively at 3, 6, 12, 24 and 48 months after revision.No mortality was seen throughout follow up and complication rate was 11.1% (one pleural effusion and one stricture formation).Patients with comorbidities such as hypertension, diabetes mellitus, obstructive sleep apnea, psychiatric illnesses, GERD, dyslipidemia and osteoarthritis showed comparable results to their counterparts in comparison of weight loss success rates (p40.05) at all of the follow up periods except for patients with history or psychiatric illnesses just at the 3 month post revisional follow up (p¼0.03). Weight loss success rate although different between two races; however, it was not statistically significant. Comparing cases who underwent laparoscopic adjustable gastric banding (LAGB) at their primary operation (3 cases) who then
converted to other procedures later with all the other cases, they had significantly lower primary BMI (41.6 vs 54.7, p¼0.003), comparable minimum successful BMI (30 vs 36, p40.1) and again significantly lower BMI at the time of revision (35 vs 44, p¼0.007). More over all the %EWL at the time of revision and all the follow ups did not show statistically significant difference. However, the trend of weight loss among those who had revision from LAGB were more notable. Conclusion: There is an increasing demand for bariatric surgery and revisional operation in those with weight regain. In our experience, revisional bariatric procedures are safe and effective way to correct weight regain with low complication rates. The psychiatric conditions and related medications should be further evaluated for its effect on short term weight loss success rates.
A5211
SAFETY AND EFFICACY ASSESSMENT OF REVISIONAL BARIATRIC PROCEDURES: A SINGLE INSTITUTE EXPERIENCE Mohammed Alshehri1; Seyed Mohammad Kalantar Motamedi1; Adel Alhaj Saleh1; Amir Aryaie1; Tomasz Rogula2; Leena Khaitan2; Mujjahid Abbas2; 1University Hospitals Case Medical Center, Cleveland Ohio; 2University Hospital Case Medical Center, Cleveland OH Background: Obesity has increased significantly in the recent decades; more than one third of US, adults are obese. As bariatric surgical procedures are the only most effective treatment modality for obesity, more people are undergoing weight reduction operations. Hence, revisions of these bariatric procedures have also increased, either for complications or un-successful weight loss. We aim to evaluate the efficacy, feasibility, and safety of revisional bariatric procedures. Methods: A retrospective review of prospectively maintained database for all patients who underwent revisional bariatric procedures from January 2013 to December 2015 under IRB approval was performed. All procedures were performed by experienced high volume surgeons at a North American academic institution. Patients' records were reviewed for demographic data, symptoms, indication of surgery, pre and post revisional Body Mass Index (BMI), type of revision, and outcomes. Using chi squared test, complication rates, readmission rates were compared with the collective data of all primary bariatric surgical procedures performed in the same institution for the same period of time. We excluded patients with no follow up, band removal without conversion, hiatal hernia or internal hernia repair in patients with prior bariatric surgery. Results: Seventy-five (75) patients were included in this study (male: female ratio of 11:89 %). The mean age was 50 ⫾ 10 years. The mean BMI before revisional surgery was 36 ⫾ 1.2 and the mean duration of follow up before revision was 106 ⫾ 11 months. Indications for revisional surgery included symptoms like abdominal pain, reflux, dysphagia, weight regain, non-healing ulcer, gastric fistula and anastomotic stricture. The mean operative time was 173 minutes and mean hospital stay was 4 days. Laparoscopic approach was performed in 65 patients and open approach was used in 10 patients. Surgical procedures included gastric band removal and conversion to gastric by-pass in 2 patients (2.7%),
Background: Obesity is closely connected to non-alcoholic fatty liver disease (NAFLD) affecting the vast majority of patients. The most effective therapy for NAFLD is sustained weight loss, therefore bariatric surgery has successfully been utilized to reverse or prevent further progression of NAFLD. However, case reports have shown substantial deterioration of liver function and liver failure after performing radically malabsorptive bariatric operations as the jejunoileal bypass (JIB) and the biliopancreatic diversion (BPD). Clinically evident deterioration of liver function has not been reported in the currently established surgical procedures such as the Roux -en- Y gastric bypass (RYGB), one-anastomosis gastric bypass (OLGB) or sleeve gastrectomy (SG). The aim of our study was to evaluate major liver function impairment after bariatric surgery in patients treated at the Medical University of Vienna, Department of Surgery. Methods: Consecutive in- and outpatients after bariatric surgery within the preceding two years who presented with severe liver dysfunction were included in this case series. Results: In total, 7 patients (m:f¼1:6; median age 40a, range¼3066a) are reported. Deterioration of liver function occurred after RYGB (n¼5), OLGB (n¼1 (þ1/conversion into OLGB)) and even gastric banding (n¼1) after a median postoperative time of 6 months (range¼2- 24months). Clinical symptoms varied from fatigue (86%) to ascites (57%), hepatic encephalopathy (29%), and variceal bleeding (14%). Elevation of transaminases, impairment of coagulation parameters, thrombocytopenia and hypalbuminemia were present in 57%, 86%, 71%, and 100%, respectively. Liver cirrhosis was proven by biopsy in 3 out of 7 patients and a 100% steatosis was present in 1 of the patients. Median % excess weight loss (%EWL) was 113.3% (range¼81- 257%).In 5 patients bypass' (BP) length reduction or reversal was performed and led to an improvement of symptoms, determinable also by imaging, histology and blood exam. In one patient liver transplantation was needed, one patient died in septic shock and decompensated liver disease. Conclusion: To the best of knowledge this is the first description of liver failure/dysfunction after OLGB and gastric banding. Bypass reversal or elongation of the intestinal resorption length led to a rapid improvement of liver dysfunction. However, guidelines for handling bariatric patients suffering from a certain degree of liver pathology are lacking and the long-term outcome is still undetermined. As long as there are only speculations for the patho-mechanism of liver alteration, a meticulous preoperative evaluation including liver status, as well as a regularly scheduled post-operative follow-up for the early identification of liver impairment should be aspired in all patients.
A5209
MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE AND HIATAL HERNIA POST SLEEVE GASTRECTOMY: CARDIOPEXY WITH LIGAMENTUM TERES Salman Alsabah1; Shehab Akrouf2; Mohanad Al-Hadad1; Jonathon Vaz3; 1Royale Hyatt Hospital, Kuwait, Mesilla Kuwait; 2 Al-Amiri Hospital, Kuwait, Kuwait City Kuwait; 3Al-Amiri Hospital, Kuwait, Dasman Kuwait Background: This video demonstrates the management of Gastroesophageal Reflux Disease (GERD) post Laparoscopic Sleeve
S185
Gastrectomy (LSG). We present the case of a 26 year old female who underwent LSG 4 years ago. Her pre-operative weight was 116 kgs and her BMI was 44 kg/m2. Her post-operative weight was 59 kgs and her BMI was 22kg/m2. Post-operatively she had GERD and regurgitation and did not respond to medical treatment and dilatation. Endoscopy, barium swallow and CT scan revealed severe reflux, regurgitation with hiatal hernia. We discussed the treatment options as per our management of GERD protocol with the patient. She agreed to the ligamentum teres cardiopexy (LTC) technique which is currently being researched. In this video we demonstrate reproducible laparoscopic repair of hiatal hernia and cardiopexy utilizing ligamentum teres in 2 patients suffering from GERD and hiatal hernia. We discussed the option of gastric bypass with the patient as it is the standard of care in treating such complications, however after explaining both procedures the patient opted for LTC with the knowledge that if the procedure fails, she would require subsequently a gastric bypass.The video demonstrates step-by-step the technique of LTC repair which was successful in the short term follow up in both patients as evident in the post operative barium swallow which shows no hiatal hernia or reflex. At 6 months both patients had no symptoms of GERD. Conclusion: LTC combined with the reduction of the hernia is a good alternative treatment for GERD in patients with previous LSG following our algorithm. The use of intra-operative endoscopy is important in such procedures. Further studies with a longer period of follow-up are needed to address clinical efficacy and safety of the procedure
A5210
EVALUATION OF REVISIONAL BARIATRIC SURGERY IN PATIENTS WITH WEIGHT REGAIN Seyed Mohammad Kalantar Motamedi; Amir Aryaie; Mohammad Alshehri; Leena Khaitan Khaitan; Tomasz Rogula; Adel Alhaj Saleh; Mujjahid Abbas; University Hospitals Case Medical Center, Case Western Reserve University, Cleveland Ohio Background: Obesity is a worldwide increasing health problem. Bariatric surgery has been proven to be the most effective strategy to obtain long term weight loss for patients with morbid obesity. However, not all of the patients achieve the optimum desirable outcomes. Moreover among those who are primarily successful, weight regain is not unlikely specifically in the long run. Revisional bariatric surgery remains as an option for such patients to lose weight again. We evaluated the effectiveness of such procedures in a single institution. Method: A retrospective review of prospectively maintained database for all patients who underwent revisional bariatric procedures in a single academic institution from January 2013 to December 2015 under IRB approval was performed. Cases with history of inadequate weight loss or weight regain included for further evaluation. Patients' records were reviewed for demographic data, type of revision, body mass index (BMI) and excess body weight (EBW) at the time of initial bariatric surgery. In addition, percentage of excess body weight loss (%EWL) at the time of revision and in sequential follow-ups after revision were evaluated. We excluded patients with less than 3 months of post-revision follow up. Results: Eighteen patients were included in this study (Female n¼16, 88.9 %; White n¼12, 66.7%) with the mean age of
S186
Poster Presentations / Surgery for Obesity and Related Diseases 12 (2016) S76–S232
49.2 ⫾8.6 years. The mean BMI at primary bariatric surgery was 52.6 ⫾12.7. The mean duration between primary surgery and revision was 122 ⫾27 months (median¼102). Before regain weight, all patients had shown history of more than 50% weight reduction before revision except in two cases (%EWL of 37.6 and 42.6). Mean of their best %EWL was from 64.0(⫾25.4) down to mean BMI of 35.9⫾9.4. All cases had weight regain reaching the mean BMI (⫾SE) of 42.9 (⫾8.6) at the time of revisional operation. None of the patients had final %EWL of more than 50% at the time of revision except 3 (16.7%).94.5 % of cases were performed laparoscopic (n¼17). Surgical procedures included gastric band removal with either conversion to gastric bypass (n¼1, 5.5%) or sleeve gastrectomy (n¼3, 16.7%), conversion of sleeve to gastric bypass (n¼4, 22.2%; including 1 open surgery), conversion of vertical banded gastroplasty (VBG) to sleeve gastrectomy (n¼1, 5.5%), VBG to gastric bypass (n¼2, 11.1%). Candy Cane Resection with simultaneous revision of gastrojejunostomy (n¼4, 22.2%) and take down of Gastro-gastrostomy fistula with history of gastric bypass (n¼3, 16.7%). The mean operative time was 170(⫾75) minutes (median¼159) and mean post-revisional hospital stay was 3.6(⫾1) days (median 2 days). Mean follow up after the revisional surgery was 17.2(⫾3.6) months (median¼12 months). 2 patients (11.1%) had more than 4 years follow up after revision.Mean BMI and mean %EWL at 3, 6, 12, 24 and 48 months post-revision was 38.5(⫾2.1) and 31.9%, 37.8 (⫾2.8) and 40.2%, 33.2 (⫾2.1) and 55.4%, 31.6 (⫾2.6) and 66.2%, 30.2 (⫾8.5) and 93.3% correspondingly. The percentage of cases who succeeded to collectively lose more than 50% of their primary excess weight after revision was 58.8% (11 out of 17), 75% (9 out of 12), 83% (10 out of 12), 86% (6 out of 7) and 100% (2 out of 2) respectively at 3, 6, 12, 24 and 48 months after revision.No mortality was seen throughout follow up and complication rate was 11.1% (one pleural effusion and one stricture formation).Patients with comorbidities such as hypertension, diabetes mellitus, obstructive sleep apnea, psychiatric illnesses, GERD, dyslipidemia and osteoarthritis showed comparable results to their counterparts in comparison of weight loss success rates (p40.05) at all of the follow up periods except for patients with history or psychiatric illnesses just at the 3 month post revisional follow up (p¼0.03). Weight loss success rate although different between two races; however, it was not statistically significant. Comparing cases who underwent laparoscopic adjustable gastric banding (LAGB) at their primary operation (3 cases) who then
converted to other procedures later with all the other cases, they had significantly lower primary BMI (41.6 vs 54.7, p¼0.003), comparable minimum successful BMI (30 vs 36, p40.1) and again significantly lower BMI at the time of revision (35 vs 44, p¼0.007). More over all the %EWL at the time of revision and all the follow ups did not show statistically significant difference. However, the trend of weight loss among those who had revision from LAGB were more notable. Conclusion: There is an increasing demand for bariatric surgery and revisional operation in those with weight regain. In our experience, revisional bariatric procedures are safe and effective way to correct weight regain with low complication rates. The psychiatric conditions and related medications should be further evaluated for its effect on short term weight loss success rates.
A5211
SAFETY AND EFFICACY ASSESSMENT OF REVISIONAL BARIATRIC PROCEDURES: A SINGLE INSTITUTE EXPERIENCE Mohammed Alshehri1; Seyed Mohammad Kalantar Motamedi1; Adel Alhaj Saleh1; Amir Aryaie1; Tomasz Rogula2; Leena Khaitan2; Mujjahid Abbas2; 1University Hospitals Case Medical Center, Cleveland Ohio; 2University Hospital Case Medical Center, Cleveland OH Background: Obesity has increased significantly in the recent decades; more than one third of US, adults are obese. As bariatric surgical procedures are the only most effective treatment modality for obesity, more people are undergoing weight reduction operations. Hence, revisions of these bariatric procedures have also increased, either for complications or un-successful weight loss. We aim to evaluate the efficacy, feasibility, and safety of revisional bariatric procedures. Methods: A retrospective review of prospectively maintained database for all patients who underwent revisional bariatric procedures from January 2013 to December 2015 under IRB approval was performed. All procedures were performed by experienced high volume surgeons at a North American academic institution. Patients' records were reviewed for demographic data, symptoms, indication of surgery, pre and post revisional Body Mass Index (BMI), type of revision, and outcomes. Using chi squared test, complication rates, readmission rates were compared with the collective data of all primary bariatric surgical procedures performed in the same institution for the same period of time. We excluded patients with no follow up, band removal without conversion, hiatal hernia or internal hernia repair in patients with prior bariatric surgery. Results: Seventy-five (75) patients were included in this study (male: female ratio of 11:89 %). The mean age was 50 ⫾ 10 years. The mean BMI before revisional surgery was 36 ⫾ 1.2 and the mean duration of follow up before revision was 106 ⫾ 11 months. Indications for revisional surgery included symptoms like abdominal pain, reflux, dysphagia, weight regain, non-healing ulcer, gastric fistula and anastomotic stricture. The mean operative time was 173 minutes and mean hospital stay was 4 days. Laparoscopic approach was performed in 65 patients and open approach was used in 10 patients. Surgical procedures included gastric band removal and conversion to gastric by-pass in 2 patients (2.7%),