Annual ASBS Revisions Course

Annual ASBS Revisions Course

Special Feature

By Amir Mehran, MD, FACS, Assistant Clinical Professor of Surgery, Director of Bariatric Surgery, UCLA. Dr. Mehran reports no financial relationships relevant to this field of study.
This article was peer reviewed by Peter Crookes, MD, FACS

The annual asbs "approaches to bariatric Revision Surgery" was held at the San Francisco Hyatt on November 10 and 11, 2006. Sponsored primarily by Ethicon Endo-Surgery, it boasted well known faculty members who discussed various aspects of revisional bariatric surgery. The course was primarily geared towards experienced bariatric surgeons who, in turn, used this opportunity to discuss some of their upcoming difficult revisional cases.

The first day began with Dr. Jeff Allen discussing the management of adjustable gastric band (AGB) complications. Armed with several video clips and pictures, AGB slippage, tube breakage, erosions, mega-esophagus, and other complications were reviewed in detail. In contrast to most of the attendees, in revisional AGB cases, Dr. Allen was a proponent of keeping and reusing the original AGB or, at the most, just replacing it with a new one. He also briefly spoke about using the AGB as an additional restrictive procedure following failure of the gastric bypass.

In contrast to Dr. Allen, Dr. Jacques Himpens painted a gloomier picture of the AGB. A past proponent of this procedure, Dr. Himpens stated that he now spends a considerable amount of time reversing what he termed a dysphagia operation. Based on a patient's age, comorbidities, and eating patterns, he follows a specific algorithm in deciding between a gastric bypass and biliopancreatic diversion with duodenal switch. This is in contrast to the US experience where most surgeons convert AGB failures to the former. He, too, used several intraoperative videos and pictures to demonstrate the difficulties a surgeon faces during these procedures, and challenged the notion of AGB's easy reversibility. The importance of dividing the restrictive underlying gastric wall pseudocapsule was emphasized too by various faculty members

Banding the gastric bypass with either adjustable or nonadjustable material was a popular topic discussed throughout the meeting. Dr. Mal Fobi discussed his banded gastric bypass techniques in detail, both for initial and revisional surgeries. His group reported improved results with a banded gastric bypass, as a large number of failures are due to dilated gastrojejunostomies. With a band placed superior to this anastomosis, portion control will always be maintained. The use of mesh vs silastic material was discussed, with preference being given to the latter. Until FDA approves a currently available commercial product, Dr. Fobi recommended using a 6 or 6.5 cm silastic tubing to do the job, which might also reduce the currently quoted 2% erosion rate. Whereas there were disagreements about banding the initial gastric bypass, most of the attendees and faculty members agreed on its utility for revisional surgeries, as well as placement of a feeding gastrostomy tube.

Management of a failed gastric bypass was indeed the major topic for the rest of the day. Drs. Robert Brolin, Raul Rosenthal, and Jacques Himpens discussed their approaches to these patients in detail. Despite disagreements as to the best approach or technique, there was a uniform consensus amongst everyone that with the exception of gastroplasty revisions, no matter what reoperation is done, the return is less than expected. In other words, trimming a dilated pouch, revising a widened gastrojejunostomy, increasing or adding malabsorption, etc., all lead to less than expected weight loss results. This is especially true as the number of revisions increase.

This concept led several attendees to argue against multiple revisional surgeries in patients who will always find a way to defeat any surgery. Despite interesting differences in opinion on how to approach each patient and how many times will they try before giving up, there was uniform agreement amongst the faculty that the approach has to be tailored to each individual patient and the reasons why they failed in the first place. The faculty members further emphasized the importance of a documented and detailed consent process, as well as liberal use of preoperative imaging studies and endoscopies.

The second day was dedicated to malabsorptive operations, such as the biliopancreatic diversion with duodenal switch (BPD/DS) and the distal gastric bypass. Dr. Douglas Hess provided a very good review of his practice's experience with these patients. It was interesting to see that a subgroup of patients managed to eat their way even through the formidable BPD/DS. The necessity for a very aggressive follow-up protocol was emphasized, as noncompliant patients can rapidly spiral downwards secondary to nutritional deficiencies. Everyone in the faculty and audience had taken care of such train wrecks and shared similar stories. The importance of not rushing into any type of non-urgent surgery was emphasized, as was the critical role of a prolonged course of nutritional supplementation by any means possible. Dr. Himpens even suggested a laparoscopic feeding tube placement, should TPN prove insufficient.

The seminar concluded with 2 live revisional surgery broadcasts by Dr Higa from his operating room in Fresno. Moderated by Dr. Himpens, various helpful tricks in converting an AGB to gastric bypass were demonstrated during the first case, such as using the AGB as a retractor to the very end and staying right on top it to avoid injuries to the stomach or esophagus. Technical pearls and pitfalls of converting a previous VBG to a RYGB were reviewed during the second case, during which, he also performed a choledochoduodenostomy for ampullary stricture.

By the end of the seminar, both the attendees and faculty members felt they had learned a lot from the course and would make changes to their current practices. Furthermore, everyone agreed that revisional surgery should not be attempted until a surgeon has done at least 50 regular cases, either laparoscopic or open.