There were 250,000 new primary bariatric procedures this year in the USA. There is a 15% failure rate of gastric bypass; 25% failure for gastric banding; 5% for BPD/DS. There were 23,000 revision procedures in 2004 in USA.
Dr Schauer said that the cause of inadequate weight loss is multi-factorial and includes lifestyle, poor compliance and orthopaedic problems.
The reasons behind revision of gastric bypass include:
- Inadequate weight loss
- Anatomic problems (large pouch, marginal ulcers, persistent reflux)
- Malnutrition
He said that it is difficult to establish what represents success for a bariatric procedure: % Estimated Weight Loss <50% or <25%; BMI< 30 or <35; reduction or resolution of co-morbidities. He said that there is a need to set realistic expectations; understand patient anatomy, request patient to demonstrate compliance, assess intelligence.
Surgical tips from Dr Schauer included: Look for familiar landmarks; green staplers, reinforce anastomosis with sutures; beware of excessive traction of the liver; liberal use of NG tube; 15 mls gastric pouch; 50 cm BP limb - 150 cm roux limb.
Elements that may affect weight loss:
- Pouch size
- Intact staple line
- Diameter of gastrojejunostomy
- Extent of bypass (roux limb/BP limb)
Revisional strategies
- Reduce pouch size
- Narrow the gastrojejunostomy
- Excise a gastro-gastric fistula
- Lengthen of roux limb