Complications: Non-compliant or ???
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Revision Bariatric Surgery is Surgical Treatment for Failed or Otherwise Complicated Weight-Loss Operations There are several reasons why patients may seek out revisional bariatric surgery. For many patients, a single operation to treat obesity is sufficient to produce durable, long-term weight loss without complications. For some patients, however, a weight-loss procedure may yield less-than-optimal results, either through inadequate weight-loss, inadequate resolution of co-morbidities, or by medical complications specifically related to their weight-loss surgery. You may have heard the adage, "if the only tool one has is a hammer, every problem ends up looking like a nail". In the practice of revision bariatric surgery, one needs to make every tool in the toolbox available, and be open to the concept of using new tools as they are developed, as well as understanding the diversity of problems and being able to invent new tools as each situation demands. The decision to undergo revisional bariatric surgery is one not to be taken lightly, and, as in any other operation, that decision hinges on weighing the risk against the benefit. Revision bariatric procedures are inherently higher risk than first-time bariatric procedures. They are typically longer procedures, often (but not always) through open incisions, with greater blood loss, and a higher incidence of leak and infection. The higher leak rate is thought to be a result of microscopic changes in blood flow to the stomach, induced by the original surgery. Whereas the results of a revision bariatric procedure are fairly predictable when treating medical complications of weight-loss surgery, the results of revision procedures to further weight-loss are less so. It has been observed that the weight-loss results of revision surgeries do not seem to be as good as if the operation was performed as a first-time procedure. This phenomenon is metabolic in nature; the body appears to undergo metabolic adaptation to the first bariatric operation making subsequent weight-loss more difficult, and patients who are particularly metabolically stubborn are more likely to fail a first-time weight-loss procedure in the first place. Given these factors, revisional bariatric procedures are best approached on a highly individualized basis, tailoring weight-loss surgery to the patient's unique and specific needs.
Weight Regain/Inadequate Weight Loss This is the most common reason for patients to consider revisional bariatric surgery. A certain operation may be expected to yield a certain amount of average weight-loss for the "average" patient, but not all patients are "average". A particular patient may not be suited for adapting to the lifestyle required for success for a particular operation; a particular operation may not be suited for the patient's particular metabolism; a particular operation may not maintain its original anatomy over time. All these are reasons why a bariatric operation may fail. The first consideration is determining whether it is the patient or the operation that has failed. Sometimes patients lack insight into how to make their particular operation work optimally. Getting "back on track" with proper aftercare and support may be all such patients need. Many times, however, a patient's body may be particularly resistant to losing weight after a period of weight regain, which may limit their ability to lose - for a second time - the weight that they had previously lost. In many instances it is the operation that has failed the patient, whether it be for "mechanical" or for "metabolic" reasons. Mechanical reasons for failure encompass those instances where the anatomy of the original operation has changed over time. A pouch may stretch out and enlarge; the outlet of a gastric pouch may dilate to a larger diameter; a gastro-gastric fistula may form between a gastric pouch and the bypassed stomach; the absorptive capacity of the intestine may increase beyond that expected; a band may have slowly slipped, resulting in less restriction. In these cases, re-construction of the original surgical anatomy may restore the original conditions that allowed the patient to lose weight in the first place. Re-trimming of a dilated gastric-bypass pouch is one such approach, or a re-trimming of a stretched-out vertical sleeve gastrectomy. Placing a band around a dilated gastric-bypass outlet often makes a suitable remedy for a dilated outlet. Re-stapling broken down staple-lines of gastroplasty procedures has been advocated in the past, but are probably best addressed by conversion to a different bariatric operation, given the high failure rate of gastroplasty operations long-term. And then there are those cases of metabolic failure, where the operation fails to meet the metabolic needs of the patient. Success after surgery is often more than a simple matter of watching what one eats; there is a metabolic component to obesity as well, which explains why some people are able to eat massive amounts of food and remain lean, while others are stuck in the rubric of "once on the lips, forever on the hips". "Metabolic failure" is a case of the operation failing the patient. Whereas remedial operations for "mechanical failure" aim to restore the previous anatomy, operations to address "metabolic failure" involve a paradigm shift directed at converting the patient to a more metabolically-active operation. One example of this paradigm-shift thinking would be revising a patient with a stretched out and dysfunctional Gastric Bypass pouch to a Duodenal Switch, as opposed to re-trimming the pouch to restore it to its original size. For more information on these procedures, see the "Specific Revision Considerations" portion of this section. Inadequate Resolution of Co-morbidities Inadequate resolution of co-morbidities is another reason for consideration for revision/conversion surgery. These considerations are usually related to the causes of metabolic failure, as inadequate resolution of co-morbidities usually parallels inadequate weight-loss, and co-morbidities are intimately linked to metabolism. These cases parallel the approach to metabolic failure cases, and often involve a conversion to a more metabolically active procedure. For more information on these procedures, see the "Specific Revision Considerations" portion of this section. Some patients have medical complications as a result of their weight-loss operations that require revision surgery. Some of these revision procedures parallel the "mechanical" vs. "metabolic" paradigm outlined in the previous section, whereas others require reversal of the original procedure while preserving weight loss. Conditions potentially requiring revision include ulcer, stricture, severe dumping, malnutrition, over-malabsorption, metabolic bone disease, iron deficiency/anemia, vitamin deficiency, vitamin-D deficiency, and thiamine (vitamin B-1) deficiency. For more information on these procedures, see the "Specific Revision Considerations" portion of this section. Revision Bariatric Surgery: Specific Revision Considerations Patients may require revisional bariatric surgery after LapBand surgery for a variety of reasons. Band slippage may be a slow chronic condition, or an acute surgical emergency. In either event, the band fails to function as it should. Remedial options potentially include band removal, repositioning, or replacement, depending on the cir****tances. Removal of the band, of course, leaves the patient with the possibility of weight regain, potentially requiring additional surgery. Band erosion is another potential complication of LapBand surgery. This is a condition where the band wears a hole into the stomach, rendering the band relatively ineffective. Patients may notice a single episode of vomiting blood as the initial sign of band erosion. The most common presenting symptom is an infection around the port site. This occurs as a result of saliva leaking through the hole in the stomach, tracking along the band tubing, and subsequently infecting the tissues under the skin around the port. Treatment consists of removal of the band. This leaves the patient without a weight-loss operation, making weight regain likely. My recommendation in these instances is to convert the patient to a Vertical/Sleeve Gastrectomy based procedure, such as Vertical/Sleeve Gastrectomy, Duodenal Switch, or VERGITO. These procedures can be performed with a minimal amount of cutting through the area of erosion, which is a weakened part of the stomach made more prone to leak as a result of the erosion. LapBand failure is another reason for seeking revisional bariatric surgery. LapBand is essentially a restrictive procedure, and not all patients are metabolically tuned to be able to lose the necessary amount of weight with LapBand. Other patients are simply unable to maintain the appropriate eating behaviors that success with LapBand demands, which can result in counterproductive, maladaptive eating patterns, leading to weight regain and failure. Conversion to any other weight-loss procedure is possible, but it is these cases where a paradigm-shift in thinking away from restrictive procedures to more metabolically active procedures is most likely to yield the best results. There is a fair body of evidence that a well-managed LapBand is nearly as good as a Gastric-Bypass over time, as both rely on the maintenance of restrictive eating through similar size pouches long-term. Conversion to a Gastric-Bypass procedure may therefore yield only marginal benefit, while putting the patient at significant risk of leak. For those patients who still want nothing more than a restrictive procedure, conversion to Vertical/Sleeve Gastrectomy makes an excellent option. Their results will still be limited by the metabolic limitations of their bodies and of the surgery, but there are several ways in which Vertical/Sleeve Gastrectomy may yield better results than LapBand over time. For those patients willing to undergo more involved procedures, proceeding to Duodenal Switch or VERGITO, which build from the platform of Vertical/Sleeve Gastrectomy, make excellent choices. These procedures invoke metabolic mechanisms to maintain weight loss, without relying merely on restriction, and take the patient one step beyond where they were with the original LapBand surgery. Patients with Gastric Bypass are candidates for revision surgery for two general reasons: failure (weight gain/inadequate weight loss) and medical complications. Sometimes medical complications of Gastric Bypass may result in failure as well. The causes of failure may be either mechanical or metabolic, with consideration of the patient's eating behaviors as well. Adhering to the principle of "making the best of what you've got", the first step in evaluating a post-Gastric Bypass patient with weight-loss failure is to take a careful inventory of their food intake. Keeping a detailed food diary is the best way to begin to make such an assessment, and patients are often surprised to see what their actual daily intake is. We may have a general idea of what our food intake consists of - what we believe we are eating - only to look back on an accurate food diary and be confronted with the truth. If patients are off track with what they should be doing from a dietary standpoint, getting them back on track is the next step. What happens next is variable: some patients are able to get back on track and back to where they were; some patients get back on track with their eating without success at weight-loss; some patients are never able to resume appropriate eating behaviors, which does not necessarily mean that the patient is "non-compliant". There may be a mechanical reason for patients having to resort to maladaptive eating behaviors, such as what occurs when a patient with an anastomotic stricture falls into the "soft-calorie syndrome" out of necessity, because soft foods are the only foods that can be tolerated without vomiting. We must also realize what it means to be "compliant" with a Gastric-Bypass. What constitutes "appropriate" eating for a Gastric Bypass patient would be a most unusual pattern of eating for the rest of humanity; some people just aren't cut out for that sort of thing, even with the help of a small gastric pouch, and not necessarily due to any character flaw, either. Reasons for mechanical failure of Gastric-Bypass include gastro-gastric fistula, pouch dilation, and anastomotic dilation. Gastro-gastric fistula is where the stomach pouch grows back and re-connects to the bypassed stomach. This can occur as a consequence of a pouch leak, where the resulting local inflammation from the leak disrupts the staple line of the bypassed stomach where it lies next to the pouch. More often, though, gastro-gastric fistula formation is a result of a less acute, slower process. Regardless the cause, gastro-gastric fistula allows food to pass from the pouch to the bypassed stomach, effectively partially reversing the Gastric-Bypass. Revision surgery for this condition may consist of closure of the fistula, restoring the original surgical Gastric-Bypass anatomy. Conversion to a Vertical/Sleeve Gastrectomy based procedure is an option as well, especially if there are reasons other than mechanical failure to explain the patient's weight gain. Pouch dilation is a condition where the stomach pouch stretches out and enlarges; anastomotic dilation is where the connection between the stomach pouch and the intestine stretches out. Both conditions result in allowing the patient to eat more than what would be required to remain successful. Re-trimming the pouch to make it small again is one approach to treating pouch dilation. Surgical banding and endoscopic fixation are two approaches to treat an enlarged anastomotic connection. These approaches to pouch and anastomotic dilation are both directed at restoring the anatomy of the Gastric-Bypass procedure back to what it was prior to stretching out. Another approach is to make a paradigm shift and convert to a more metabolically active procedure such as Duodenal Switch. Other Vertical/Sleeve Gastrectomy based procedures are options as well, especially if the patient's Gastric-Bypass is complicated by nutrient malabsorptive issues, such as osteoporosis and anemia. Conversion from Gastric-Bypass to Duodenal Switch is the most definitive revision procedure for inadequate weight-loss or weight gain after Gastric-Bypass. This approach addresses the issues of metabolic failure and maladaptive eating as causes of failure. This conversion may be done laparoscopically in many cases. A potential concern with this procedure is that of proper stomach function after surgery. The bypassed stomach is now brought back into use, and some patients may have had the nerves to the bypassed stomach cut during their original Gastric-Bypass procedure. This is rarely a problem, as the nerves seem to grow back as the bypassed stomach "wakes up" and resumes working again. Sometimes it may not be safe to re-connect the gastric pouch to the bypassed stomach due to excessive scar tissue. If the patient has acceptable protein tolerance and satisfactory calcium metabolism, conversion to a Scopinaro-type Bilio-Pancreatic Diversion makes a very satisfactory option. Medical issues complicating Gastric-Bypass include marginal ulcer, stricture, and severe dumping syndrome. These conditions may often be treated conservatively, but when conservative treatment fails, revision surgery is indicated. Treatment for ulcer or stricture may involve resection of the ulcerated/strictured connection between the pouch and the intestine. Another approach is to convert to a Vertical/Sleeve Gastrectomy-based procedure, as stricture and marginal ulcer are conditions that arise as a result of the intrinsic physiology of Gastric-Bypass. This approach is favored for cases of severe dumping as well, as it is the inherent nature of the Gastric-Bypass itself that results in the condition. Rarely, reversal of Gastric-Bypass may be necessary to treat cases of malnutrition, including issues of vitamin and mineral malabsorption. Reversals for nutrient malabsorption may be accompanied by revision to a non-malabsorptive weight-loss procedure, allowing patients to stave off any weight re-gain that may otherwise result from the reversal of their malabsorption. Vertical Banded Gastroplasty (VBG) and Other "Stomach Stapling" Procedures Most patients with VBG and other "stomach stapling" procedures seeking revision surgery do so for two reasons: weight re-gain and maladaptive eating. Although some of these cases can be successfully treated by re-stapling and re-banding, most cases are best treated by conversion to a more definitive procedure. Given the stubbornness of many patients' bodies at losing weight after failure of a weight-loss procedure, conversion to a more metabolically active procedure brings patients out of the difficulty of trying to induce further weight-loss by relying on restriction alone. Revision to Duodenal Switch is one such example, and can often be performed laparoscopically. For patients with previous VBG, removal of the band during revision to Duodenal Switch is not always necessary. Given the variety of stomach-stapling procedures, and the various ways in which their anatomy may change over time, these cases are highly individualized in their surgical approach. The issues with revision of Mini-Gastric Bypass procedures are the same as for Roux-n-y Gastric-Bypass. Bile reflux is a potential condition unique to this type of Gastric-Bypass. Although this is an uncommon condition (and a concern more theoretical than actual), revision to Roux-n-y Gastric-Bypass is sufficient to treat this, and is a relatively straightforward conversion, and is done without having to disrupt the original connection between stomach pouch and intestine. While highly effective for many, some patients fail to lose adequate weight with Vertical/Sleeve Gastrectomy, and may seek revision surgery in order to induce further weight loss. Sometimes failure is a result of stretching of the stomach, and re-sleeving the stomach may suffice as a revision procedure. For others, adding metabolic and malabsorptive components onto the Vertical/Sleeve Gastrectomy "platform", such as Duodenal Switch and Ileal Transposition, may be indicated. Whereas most revision operations carry a higher risk than first-time bariatric procedures, revision of Vertical/Sleeve Gastrectomy to Duodenal Switch is less risky than performing Duodenal Switch as an all-at-once, first-time operation. Vertical/Sleeve Gastrectomy is one component of a Duodenal Switch procedure, so when converting to a Duodenal Switch procedure, a good portion of the operation has already been done, resulting in a lesser surgery than performing Duodenal Switch in its entirety. In addition to weight loss, stretching of the stomach may result in other difficulties as well. The stretching of the stomach tube may not be uniform along its entire length, resulting in parts of the stomach tube being more stretched-out than others. This may result in an “Hourglass Stomach", where the stomach has a large upstream portion separated from an enlarged downstream portion by an area of relative narrowing. This does not necessarily result in increased eating, but may result in uncomfortable, disordered eating. Patients usually experience reflux symptoms and a generalized difficulty eating. Depending on the constellation of the patient’s symptoms and meal volumes, surgical revision may take a couple of forms, but all result in a more direct passage of food from the upstream to downstream stomach. Anywhere from 2-5% of Duodenal Switch patients may be candidates for revision surgery. As our understanding of how best to balance the seemingly contradictory demands of weight-loss and malnutrition improves, the likelihood of a Duodenal Switch patient requiring revision surgery can be minimized, but not eliminated entirely. Inadequate weight-loss, excessive weight-loss, and malabsorptive/nutritional deficiencies comprise the most typical reasons for revision of Duodenal Switch. Excessive weight-loss and malabsorptive/nutritional deficiencies usually go hand-in-hand, and are some of the most straight-forward issues to surgically correct in Duodenal Switch patients. As in many endeavors, timing is everything. The overall malabsorptive effect of Duodenal Switch changes over time, with the intestine becoming more efficient at absorbing protein calories and nutrients. It is important to not revise a patient with malabsorptive complications too early after Duodenal Switch. An earnest attempt at conservative therapy should be instituted prior to revision, to allow time for the natural increase of absorptive capacity of the intestine to manifest itself. If revision is performed too early, patients risk excessive weight re-gain later on, after the intestine has fully adapted. Treatment for malabsorptive complications after Duodenal Switch generally involves adding intestinal length, a process known as elongation. Specific elongations of the common limb using the biliopancreatic limb are possible to obtain specific effects. A fairly common elongation procedure involves an elongation of both the alimentary limb and the common limb, which allows more surface area for protein absorption as well as starch and fat absorption. Increasing the capacity to absorb fat also increases the ability to absorb fat-soluble vitamins such as vitamin-D. Revision procedures to treat protein malnutrition and excessive weight-loss therefore have the added effect of increasing the capacity for fat-soluble vitamin absorption. The simplest procedure to increase both alimentary and common limb length involves a single small intestine connection, known as "entero-enterostomy", known quasi-affectionately by some as a "kissing-X". With elongation procedures patients are generally able to maintain some degree of weight-loss due to the "neuro-endocrine brake" effect, the same mechanism responsible for weight-loss following Ileal Transposition surgery. Ileal Transposition used as a method of intestinal elongation may be used to treat cases of calcium and iron malabsorption following Duodenal Switch. Unlike a conventional Ileal Transposition, when used in these instances the Ileal Transposition can be performed at the level of the duodenum, without having to re-connect the duodenum, which - after Duodenal Switch - is no small feat. Such "High Duodenal Ileal Transposition" procedures may use only a portion of the alimentary limb to accomplish the transposition, using the remainder of the alimentary limb for a "Parallel Ileal Transposition" at the level of the biliopancreatic limb, which is at that point incorporated back into the flow of food as a result of the High Duodenal Ileal Transposition performed upstream. This approach allows restoration of calcium and iron absorption without having to completely reverse the Duodenal Switch procedure. Occasionally patients have inadequate weight-loss, or weight regain after a period weight-loss, following Duodenal Switch surgery. Two conceptual approaches to this problem - assuming that a trial at non-surgical weight-loss has failed - are to reduce the stomach size and to shorten the common limb length. Results of these revisions are variable, and, in North America at least, surgically reducing stomach size seems to yield better results than common limb shortening. For patients suffering from osteoporosis as a result of weight-loss surgery, there are options for treatment. With any operation that results in bypassing the duodenum - such as Gastric-Bypass and Duodenal Switch - malabsorption of calcium occurs. The duodenum is the site of maximal absorption of calcium, which is why Gastric-Bypass and Duodenal Switch patients require calcium supplementation. Despite full supplementation, many patients still show signs of malabsorptive metabolic bone disease from calcium malabsorption. Calcium metabolism is monitored post-operatively by measuring blood levels of calcium, vitamin-D, and parathyroid hormone (PTH). It is important to maintain a normal vitamin-D level, as this vitamin is important in maintaining normal calcium levels. There are a few easily correctable situations that may result in inadequate calcium absorption after these procedures: taking the wrong form of calcium and taking iron supplements that interferes with calcium absorption. Not all forms of calcium are equally absorbable. Calcium citrate and calcium apatite are known to be easily absorbed. The most common form of calcium supplement - calcium carbonate - is actually poorly absorbed. Many bariatric surgical patients, though, are advised to take this form of calcium for their calcium needs. Although calcium carbonate is quite helpful in preventing kidney stones in bariatric surgical patients, it is a poor choice for preventing osteoporosis. Patients need to be on a form of calcium that they can absorb. Iron supplements are known to interfere with calcium absorption as well. It is generally recommended that iron pills and calcium pills not be taken within two hours of each other, which can make scheduling one's supplement routine rather difficult. Iron and calcium are both maximally absorbed in the duodenum, which is why metabolic bone disease and anemia often go together in Gastric-Bypass and Duodenal Switch patients. Many patients with iron deficiency will push their iron supplementation to the point that it interferes with their calcium absorption. In their attempt to raise their iron levels to normal, patients worsen their calcium deficiency, resulting in both anemia and osteoporosis. Many patients with iron deficiency require iron infusions when iron pills fail to do the trick. To many patients in this situation, this can be a cause of concern, but it is easier to treat iron deficiency this way than it is to treat calcium deficiency. If the choice is between taking iron pills while putting calcium absorption at risk, or receiving iron infusions while allowing calcium pills to be better absorbed, the clear choice is to take the iron infusions. Some patients continue to show signs of metabolic bone disease despite high-dose calcium supplementation and healthy vitamin-D levels. For these patients, reversal of their operation may be necessary. Ideally, reversal should be limited to that part of the operation that affects calcium malabsorption, without resulting in excessive weight re-gain. For Gastric-Bypass patients, conversion to Vertical/Sleeve Gastrectomy, with or without Ileal Transposition or Omentectomy, is an effective way to accomplish this. The result is the re-establishment of normal flow through the duodenum while adding the neuro-endocrine brake effect for weight-loss maintenance. For Duodenal Switch patients, a High Duodenal Ileal Transposition will accomplish the same effect without having to totally reverse the patient's operation. Although not the primary goal, revision bariatric surgery for metabolic bone disease also has the effect of improving iron absorption. The two classes of vitamins most likely to be deficient in weight-loss surgery patients are the fat-soluble vitamins (A, D, E, K) and certain B-vitamins (B-1/Thiamine, Folate, B-12). Given the effectiveness of oral supplements and vitamin injections, revision surgery to treat these conditions is quite uncommon. Fat soluble vitamin deficiencies are found mainly in Duodenal Switch patients, the most common deficiency being vitamin-D. Elongation of the common limb, as is done for malnutrition/protein deficiency, will usually remedy this problem.
For a comparison of the procedures our surgeons offer click here. Please note VERGITO and Vertical/Sleeve Gastrectomy will be added to chart soon. Duodenal Switch / Vertically Banded Gastric Bypass / Lap-Band / Vertical/Sleeve Gastrectomy / VERGITO / Laparoscopic Surgery
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6-7-13 band removed. No revision. Facebook Failed Lapbands and Realize Bands group and WLS-Support for Regain and Revision Group
on 6/16/12 2:51 am - Califreakinfornia , CA
http://vimeo.com/25570146
Transcript:
Hi, I'm Dr Mitchell Roslin, Chief of Bariatric Surgery at Lenox Hill Hospital in NY and Northern Westchester Hospital in Mt Kisco, NY. The title of this talk is, "Revisions: Does the Patient Fail the Procedure or Does the Procedure Fail the Patient?" This is a copy of a talk that I gave at the ASMBS in Orlando in 2011 and I was asked by many of the attendees at the session to see if I could record the talk and place it online.
The purpose of the talk is to try to explain some of the physiology behind bariatric procedures and weight regain or inadequate weight loss following bariatric surgery.
When I started doing bariatric surgery 17 years ago I really thought it was simple. I thought when we did a gastric bypass what we did is that we made the stomach smaller so that people were forced to eat less. Then we added an intestinal bypass so that some of what was eaten was passed into the fecal stream. I now know that bariatric surgery is far more complex. The stomach is far more than just a storage organ, it actually produces certain hormones that regulate hunger and satiety. As a result I think concepts like restriction (making the stomach small) or malabsorption (bypassing part of the intestine) are rather simplistic and instead we need to think of bariatric surgery as gastric and intestinal. What I've learned is that one of the major aspects of the gastric part of the operation is suppression of hunger, especially through the reduction of the hormone gherlin. In addition, instead of a malabsorptive component probably what the intestinal component of the operation does is it increases the work of digestion therefore increasing the metabolic rate.
Frequently, patients who haven't done well with the various bariatric procedures have been labeled as non compliant, or not following directions. One of the things we have to realize is that if it were simple to follow eating directions nobody would have ever required bariatric surgery. Another thing that we have to realize is that obesity is not a single disease. Obesity occurs where there is inadequate regulation or inadequate balance between the amount of energy taken in and the amount of energy that is expended. As a result, the defect can be anywhere in the process, so that any no two patients that we see may have the same defect, yet we all treat them similarly. So when somebody doesn't do well with an operation we tend to say that it's because they haven't followed the directions, or they are noncompliant. An alternative explanation is that the operation doesn't change or alter the physiology that caused their obesity and is not effective in their particular case. I think that if we're going to take credit for bariatric surgery causing weight loss and being the most effective treatment of obesity, when patients regain weight the operation also has to be a part of the burden. We have to realize that there may be a physiological reason for weight regain, not just behavioral changes and lack of compliance. The purpose of this talk is to try to explain what we've seen in the two most common procedures performed in bariatric surgery – laparoscopic adjustable gastric banding and gastric bypass.
As mentioned, obesity occurs when there is any breakdown in the negative feedback system that controls energy balance. Human energy intake is mainly controlled by hormonal factors There are several key hormones that control hungry, satiety, as well as early energy and long term energy requirements. Ghrelin which is produced primarily in the stomach is considered the hunger hormone. PYY which is produced mainly in the intestine is considered the satiety or fullness hormone. Insulin is the short term energy hormone and it works along with GLP. Leptin is the long term energy hormone and is mainly produced in fat cells. But even this is relatively simplistic and leptin and insulin actually complete sometimes for binding in the hypothalamus of the brain. As a result a lot of patients who are insulin resistant also have excess leptin but leptin cant tell the brain that you already have too much fat tissue. So there is a breakdown in that regulation. As opposed to the input for energy intake which is mainly hormonal, the output is mainly through the nervous system. When the body wants to conserve energy it increases the tone of the parasympathetic system, reducing the heart rate and the metabolic rate. And this is what occurs when people try to reduce their caloric intake. When the body wants to produce more energy it activates the sympathetic system. The bottom line is that energy balance is a rather complex process and a deficit anywhere either in the input or the output or the afferent or efferent system or as well as in the brain or central nervous system and the hypothalamus can cause obesity because of the energy imbalance.
**Video clip of Jassira, an OH'er talking about her LapBand and DS revision
After watching the previous video of the patient who struggled with the Lap Adjustable Gastric Band, and has done so well with the Duodenal Switch, it is obvious that there different physiologic factors that occur following the bariatric surgical procedures As mentioned the input for human energy intake is mainly hormonal. Laparoscopic adjustable bands don't reduce ghrelin or increase PYY thus its not surprising that a number of patients are still hungry following lap adjustible banding. Thus instead of giving patients labels like noncompliant, or suggesting that the patient failed the operation because they didn't work hard enough we need to understand the physiologic differences that our operations cause. And in addition we need to begin to gain insight into why the particular patient is obese and what their particular deficit is in energy imbalance. Unfortunately we're not able to do that at the present time and we continue to treat patients with these broad operations. But it is really important to realize that failing one bariatric procedure doesn't mean that you're going to fail another bariatric procedure, and there is a lot more than just restriction and malabsorption. The most important thing that we can offer our patients in bariatric surgery is hunger suppression.
While Lap Band appears to be an attractive alternative for many patients it also has many limitations. The advantage of banding is the fact that the operation is relatively simple. The complications and the risk of serious early complications are lower than other bariatric or stapling procedures. The disadvantage of lap adjustable banding is the results are more variable and approximately 20-25% of patients, if not higher, will be dissatisfied with their weight loss. A major reason is because that while can always increase the work of eating, making you chew more and eat slower, it frequently doesn't make patients less hungry. I often say a lapband is a diet with a seatbelt, and what I mean by this is that the band doesn't affect ghrelin levels, doesn't increase PYY hormone or PYY levels, and as a result really functions similar to a diet accompanied by a restrictive device. Many patients do well with the band and patients who are most likely to do well are also those that are most likely to do reasonably well on a diet. They are younger, they are more active, and they have lower BMIs, or are in the lower part of the morbid obesity scale. Patients that seem to do less well with LapBands include older patients, patients that have a BMI that approaches or above super morbid obesity, and there is now a suggestion from George Washington University that there may be ethnic differences, and African Americans seem to have lower overall weight loss as well as a higher failure rate. Thus patients that are determining what bariatric procedure they want to undergo need to understand the probability that they have a higher chance of having inadequate weight loss with a Lapband or a realize band, as well as a higher chance of requiring reoperation and extraction of the band. This is offset by a lower early serious complication rate. But people have to understand that not all patients that have a Lapband have hunger suppression and in fact a significant amount never ever have any reduction in hunger, or for that matter, satiety.
Thus the major issue with Lap Adjustable Banding is inadequate weight loss. Another thing that frequently occurs s that we make the band tighter hoping to achieve restriction and force a smaller amount to be eaten and patients to be less hungry. And what we are successful in doing is creating a high pressure zone where patients don't get hunger suppression and they continue to eat and we see dilation in the esophagus and changes in the motility of the esophagus itself. So when you look at the Xray on the left side of this diagram you see tremendous dilatation of the esophagus above the level of the band. When fluid is removed you can see that the esophagus becomes smaller and the band wide open but there are still these scalloping figures in the esophagus which is a signal of a motility disservice. What you realize is that when you make the band tighter you make it harder to eat, you also make the esophagus work harder and you take the risk of having permanent motility disorders to the esophagus, but you don't necessarily make patients less hungry. The patient in this picture here actually came to me with the picture on the left because he started to regain weight because he was storing food in that large esophagus. So it is very, very important to understand the role of fills in Lap Adjustable Banding. The role of fills is to create some level of restriction but if that pressure gets greater than what the esophagus can pump, then there can only be harmful side effects to the esophagus. And just making bands tighter does not make all patients less hungry. Frequently on the internet we see something called the Green Zone, which is a place where people who have bands eat less and are less hungry. Unfortunately, on diagrams the Green Zone always exists, but clinically it is often very, very difficult to find a therapeutic window where patients eat less, are less hungry, and where we don't create a high pressure system that has an adverse effect on the esophagus.
Whereas inadequate weight loss or extraction are the main problems of Lap Adjustable Banding, gastric bypass is an outstanding weight loss operation. What I'm not convinced of is that it is a great operation for the maintenance of weight loss. An increasing problem in bariatric surgery is the number of gastric bypass patients that have regained weight 3-10 years following the operation. We've done an awful lot of research on this topic and are beginning to form an understanding of why we believe this occurs. Over the course of time what we see happening is food, or in this case contrast as shown in this diagram, passing immediately from the esophagus into the small gastric pouch, and then going straight into the intestines. The food doesn't remain in the pouch long because there is no restriction left between the gastric attachment and the intestinal bypass that was created. As a result as soon as the patient eats the food goes into the intestine. With this you get a rise in satiety factors followed by a rapid fall. Thus what we believe happens following gastric bypass is there is a return of inter-meal hunger so that when you actually question patients what you find is that while they can still eat less than they did prior to the operation but the problem is that they are hungry one to two hours after eating. If they eat foods that are higher in the glycemic index, or simple carbohyrdrates what happens is they have a very rapid insulin response followed by a low sugar, and this makes patients develop a maladaptive eating pattern. So what we are seeing is numerous patients with gastric bypass that have lost a considerable amount of weight, but approximately 30% of our post bypass patients we are seeing regain a significant amount of the weight that was originally lost.
Thus we believe the major problem in gastric bypass surgery is weight regain with a return of inter-meal hunger. As a result its been our hypotheses that better bariatric procedures would have a valve at the end of the gastric pouch. And we believe that the best vale is the pyloric valve which is the normal valve of the stomach which controls emptying of food in the normal stomach. There are two operations that now exist that allow us to preserve the pyloric valve. They are the Sleeve gastrectomy and the Duodenal Switch. In order to test this hypothesis we have designed a prospective trial that we received grant for that examines the weight loss as well as response to glucose challenge in sleeve gastrectomy, gastric bypass, and duodenal switch. This is the first 6 month data from that perspective trial. And you can see that all of the operations cause effective weight loss, with duodenal switch causing the most weigh loss in the first six months.
The purpose of the study though, was to compare the effects of a glucose challenge on the various operations that we perform. This shows data when glucose is given both preoperatively, as well as 6 months following from surgery. And what we do following the glucose challenge is we measure the insulin levels. What we can see is a vast difference between the different operations. With gastric bypass what happens at six months is that the insulin level goes down, but when challenged with glucose the insulin level actually goes up so high that it exceeds its preoperative value at six months. We don't see this in sleeve gastrectomy and duodenal switch. When you get such a rapid rise in insulin what happens next is a rapid fall in the sugar. And we believe this rapid rise in insulin followed by the rapid reduction in sugar glucose level leads to inter-meal hunger. Because we know when people become hypoglycemic in order to relieve the symptoms of the low sugar they become hungry and forced to eat. So we believe what is happening in gastric bypass is that since there is no valve there is rapid emptying and when there is rapid emptying there s rapid rise in the factors that determine fullness such as insulin as well as the other gut hormones, followed by a rapid fall. And when that rapid fall occurs patients become hungry. What is really fascinating is that we don’t see the same response in duodenal switch which also has an intestinal bypass.
This diagram shows the 6 month results for insulin levels. You can see that all the operations cause a reduction in fasting insulin level, which is very important and demonstrates an improvement in metabolic function. However, gastric bypass causes a rapid rise when stimulated with glucose, much greater than sleeve gastrectomy or duodenal switch. We believe that this rapid rise in insulin is a hallmark of a rapid emptying of food as well as the rapid distribution of nutrients to the intestine, and that this rapid emptying then leads to a rapid fall in glucose level and causes the inter-meal hunger that we think is responsible for a significant amount of weight regain following gastric bypass.
This diagram shows results that were determined in the RESTORE trial. The RESTORE trial was the first multi-center trial to look at endoscopic treatment for weight regain following gastric bypass. The idea was to try to reduce the anastomatic size so that patients could regain restriction. Unfortunately to date none of the endoscopic trials have been shown to be effective to provide long term weight loss. There are some suggestions that short term weight loss could be achieved. When we went back and looked at all of the data from patients that were eligible for the trial, and this means by definition that they have to have normal pouch following gastic bypass, no evidence of fistula, and an anastomatic size that was >2CM, which we estimated approximately 70% of post bypass patients would have. We found that the most significant factor that would determine weight regain was the time from surgery.. Thus we felt that this was evident that the weight regain was physiologic, and was steady and progressive over time, especially in patients that have an anastomatic size >2CM. When surgery is first done the anastomosis is made approximately 1.5CM, or slightly less. Unfortunately what we are finding in time is that in time the anastomosis spreads to a greater size. What we found looking at the data from the RESTORE trial is that once it got to 2CM, it didn't make a difference if it was 2CM or 3CM, there was already a loss of restriction and weight gain was steady and progressive. We believe that means that this is going to be very, very difficult to treat by an endoscopic procedure.
While weight regain following gastric bypass is becoming a much more common clinical problem, with the average patient regaining approximately 30% of the weight they lost and approximately 20-30% regaining a significant amount more, the options for patients remain limited.
They include
1) obviously dietary adjustments but many patients feel that we are kind of like Indian Givers, because at one point in time they had no hunger, they had early satiety and now they are hungry all the time.
2) An increasingly investigated option is endoscopic suturing but there is no long term data.
3) Band over bypass works for certain patients, but has many of the same problems that primary banding has
4) the most aggressive option is to convert the operation to a Duodenal Switch but this is a rather large operation, requires multiple anastomosis, and is an option that we reserve to patients that have considerable problems because of their weight regain.
Thus it is important to realize that:
Our operations have limitations and that inadequate weight loss and weight regain cant just be blamed on the patient.
Bands have no effect on Ghrelin, PYY, or GLP.
Gastric bypass has no valve and this can lead to inter-meal hunger.
The fact that the weight gain is steady and progressive over time I think is indicative that it is physiologic
We believe that increased insulin secretions after glucose challenge in bypass is indicative of the rapid emptying that occurs and the cause of inter-meal hunger.
Additionally, failing one operation should not preclude consideration for another bariatric procedure.
Obesity is a chronic disease and therefore we are going to have to be prepared to treat our patients on a long term basis and realize that bariatric surgery is not a cure for obesity but merely a control mechanism.
We need to critically analyze our procedures
My opinion is that pyloric preserving procedures such as the sleeve gastrectomy and especially the duodenal switch, and maybe future variations of these procedures will replace gastric bypass as standard.
on 6/16/12 7:16 am - Califreakinfornia , CA
I remember one specific night, I think it was one or two days before I went in to see my lap band surgeon.
It was in the middle of the night, and I awoke in a panic, while running to the bathroom because my airway was obstructed, and I couldn't breath. I bent over the toilet while forcing both of my fists into my stomach in an upward motion. I was able to dislodge the object which turned out to be a blob of bloody mucosa. After having held my breath for so long, I immediately & uncontrollably started swallowing big gulps of air... I couldn't stop ( and I tried ) I swallowed until I started throwing up.
Long before that actually happened to me, I kept experiencing " bee stinging " like sensations along with tenderness and burning at my port site. Sometimes I would lean against the kitchen counter while washing dishes and it would hurt so incredibly bad. I visited the E.R. countless times, had MRI's, CT SCANS, barium swallows, endoscopy's etc...
They never could find anything wrong with me, and they began to treat me as a drug seeker... Like it's not bad enough I had to suffer all that pain. I was now going to be treated like a drug addict, which only added insult to injury, which in turn made me one angry ***** to have to deal with.
Sooo a day or two after the obstructed airway incident, I was seen at my bariatric surgeons office, where they completely unfilled my band, and tried to get me to drink some water...ummmm nope, not gonna happen. I was in pain and I wasn't going to take another chance on the night time obstruction incident happening again. I hardly had any fluid in the band to begin with, and my port area was still hurting.
He directly admitted me to the hospital across the street, where I stayed for 6 days. On Monday night they did an endoscopy, Tuesday I got the results which said my band looked GREAT and was in perfect position, Wednesday morning my surgeon poked his head in about 8:00 AM and told me I would be going into surgery later that afternoon, because " My band had slipped "
Wait what
ME: Okay, so if you're gonna take my band out, can you revise me to a sleeve please ?
Surgeon : NO !
ME : okay
Well at least my band was finally coming out
okay...so I better call someone and tell them I'm having surgery this afternoon...oh...I'll call my daughter and she can call everybody else for me.I was still on the phone with my daughter when they showed up with a gurney to wheel me into surgery...and then I woke up with a sleeve.
They told me this while I was in recovery, " Lisa, wake up, SURPRISE you have a sleeve "
Hospital records later confirmed an erosion.
Ok so in this link it states a 50% failure rate for the lapbands. You can not tell me that 50% of lapbanders are noncompliant................but yet 50% of those that have the other WLS's are not!
Dr. Garth Davis- 50% Lapband failure rate
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