Bariatric Revision Surgery

Transcription

1 Bariatric Revision Surgery Ethicon Endo-Surgery Los Angeles, California January 23, 2010 This program is presented by Ethicon Endo-Surgery. Welcome to this OR-Live webcast presentation on bariatric revision surgery. During the program, it s easy for you to request more information. Just click the buttons on your webcast screen. Now let s join the surgeons. Hello and welcome to this live webcast presentation. We are coming to you from Los Angeles, California. I m Dr. Kelvin Higa. I m a bariatric surgeon from Fresno Heart and Surgical Hospital in Fresno, California. Joining me are two very distinguished surgeons who need no introduction; Dr. Allen Wittgrove, who is the inventor of the laparoscopic gastric bypass from Scripps Memorial Hospital in La Jolla, California, and Dr. Rosenthal from the Cleveland Clinic in Florida. Welcome gentlemen. Welcome. The topic of today s presentation is revisional bariatric surgery. During this program, we ll be narrating and discussing video segments of a recent surgery. We will also open the presentation up to questions later in the program. If you would like to send us a question now or at any time during the webcast, just click the Ask a question button on your webcast screen. Okay. So the first tape is concerning a patient who has had an open vertical ring gastroplasty. It was done many years ago, and the patient now presents with solid food dysphasia, weight recidivism, reflux. And we decided to take this patient and perform a gastric bypass and do it laparoscopically. So this patient has had an open procedure in the past with what was known in the past as a stomach stapling, and we re going to do a gastric bypass. So let s roll the tape. This is an edited video of course. This patient had an open vertical ring gastroplasty many years, a very respectable operation that had pretty good results, and then, of course, recidivism of weight, reflux, solid food intolerance, and we felt it best, in this case, although it s not the only option, but in this case, we felt it best to take her to a gastric bypass. Can I ask you a question, Kelvin? Sure. You said this is a ring gastroplasty and food intolerance. What if this patient would be malnourished, would you consider just taking down that ring and see if the patient can eat. Or do you believe that this patient should get a gastric bypass up front? I think in that case I would probably do a gastric bypass up front because the disease still exists. Even though there s some dysfunctional eating caused by our intervention, I think it s better to still treat the disease, and we d leave a feeding tube in the remnant, and I don t think we re going to lose ground that way.

2 I would agree with that. I think that even to the point of perhaps putting a feeding tube in the jejunum, but most of the time just a feeding tube in the gastric remnant is fine, but I agree to convert them and then take care of their malnutrition after that. And most of the time all of our revisions, even if they had an open surgery, we still approach laparoscopically. Do you guys are the same? Absolutely. Sure. I think there s some advantage. I mean obviously the advantages of doing laparoscopic bariatric surgery are there, and I really think it s accentuated on some of the revision operations. So we don t really shy away from that. Do you think that all surgeons should practice the same way. I don t think all surgeons should do revisions, so I don t think all surgeons should do it the same way. Because revision surgery is more technically advanced. It s higher risk for the patient. And so I think there are a lot of surgeons that would choose not to do the revisions and, and I think that s fine. I think, you know, a person s got to know their limitations and their sense of where their comfort zone. And if they re not comfortable doing revisions, I don t think that s a sign of weakness. I think that s fine. They should just refer them to a place that does do that. If I may -- if I may. Go ahead. When we talk about revisions, I think we should define what s a revision. It could be a reversal. It could be a revision. It could be conversion. I think when you are reversing, for instance, a jejunoileal bypass to a gastric bypass or to a natural anatomy, probably the open approach would be chosen first in my practice. When you revise and convert, cut the pouch smaller, redo the GJ, or convert like you re doing something here, BBG to a bypass, I think laparoscopy is the way to go. But if I might say one more thing to what Allen just said, revisional surgery pays a price. That s the take-home message; it is not the same thing to redo an operation than to do it primarily. Yeah. Well I m going to talk a little about the technical aspect of this operation because, you know, fist of all, when we gain access after an open operation, we usually come in laterally in the left upper quadrant. We use optical trochars. We don t do insufflations. And usually that s pretty free, and we take down the anterior down wall adhesions. In this case we got lucky. So there wasn t a lot of adhesions. And the first thing I do is we have to get to the hiatus. And so you can see over here the caudate lobe. And for me the caudate lobe, once I see that, and the right crus of the diagram, then I feel a lot safer, because now I can protect the vena cava. I can protect the esophagus. And a lot of times, we don t even need a liver retractor because the adhesions keeps the liver up out of the way. So I think it s really important on these (INAUDIBLE) divisions to really define the hiatus and get the hiatus dissected out. And you would be surprised how many patients have hiatal hernias. So we can agree and let the audience understand that if you do these procedures, the hiatus should always be exposed and a hiatal hernia be excluded. Well I think that s true.

3 Yeah, I would agree with that. I think unless, you know, it s the extraordinary, I think then that s the exception to the rule. But I think the rule should be that you need to feel very comfortable with the hiatus and exposing that and getting into this particular plane. I m using the Harmonic ACE here. I generally don t use unipolar cautery anymore. I haven t in a number of years. And just for me, this is the device that really helps me do this kind of dissection, and I like to do a division with as little (INAUDIBLE) as possible. But as you can see in just a second here, I left IN a clip of what happens when you don t listen to your own advice. So here we re coming on the lesser curve, and I m coming in below the ring, which is over here, and I want to get behind the stomach, and here we go with some blunt dissection. You see a little blood there. And so I ignored my own rule and got a little bleeding. I left this in because it s an important point. When we get bleeding, especially in these areas, not to just panic but to just get control, look at it, and then we used some bipolar cautery here. Do you guys use unipolar still? I do use unipolar. I use -- we kid about it in my operating room. I use whatever the tech puts in my hand most of the time because they ve worked with me so long they know what I m supposed to be using. So I use scissor dissection, Harmonic, and unipolar. But I do, I use regular cautery a lot. You use a lot of scissor, don t you Raul? Well, yeah. I m more afraid about using any kind of energy source, being the ultrasonic or monopolar or bipolar if I don t see what I m burning. I think if I don t see what I m burning, I use blunt technique and cold scissor. When I m sure what I m burning then I go for the Harmonic scalpel and prosonic energy. Yeah. I m worried about these patients that three days later might develop a perforation because of a injury, internal injury from whatever source you just used. I think it s is very important point -- take-home point. Because you know a lot of times, especially in revisions, we re going through tissues that can t really define the anatomy. And if you re not sure what the anatomy is, then to burn a hole in it, no matter what kind of energy source you re using, it can be a bigger opening than you think, and so scissor dissections still should be used in surgical armamentarium. Here you have transected to the stomach. I ve come from medial to lateral and I ve transected below the ring. You can see the ring right here, and I ve come in below and you can see the staple line. Whoever did this operation did a pretty darn good VVG, I think. The anatomy is good. Ironically the better the operation, the harder it is to revise it. When you see some of these large pouches you can come in the staple line. But here I ve come in below just so we can get behind here and see things well. We re up staging our staple lines to green cartridge, of course. I m going to bring this across and -- Can you see the old staple line there? Yeah. The old staple line is going to be hidden in this over here. Yeah. It s over there, I think, yeah. Because a lot of times that (INAUDIBLE) sort of imbricates on itself. Right. And if this were a gastric bypass revision we d sort of take down all those adhesions. In that case, I probably would use scissor dissection. But we ve come to respect the Harmonic and the heat it makes, so we often cool it off without thinking. But, you know, I use it for every operation from appes to gallbladders and things like that. How about reinforcing the staple lines, Kelvin, by buttressing or over sewing or doing nothing?

4 I ve tried just about everything. We re going to use some old fashioned buttressing technique later. I ll show you at the end of this when we do a Roux-Y. I don t buttress it with anything. I feel as though the staple devices are -- especially the newer ones, you can see the staple line almost set upright now with the new flex staple lines, the Echelon, and I think that those staple lines are well orchestrated and devised, and so I think they can do that better than I can put in sutures quite honestly, so I don t reinforce it. I agree with that, because I think the problem we have with stapling on a revised stomach is thickness of the tissue and the ability of those staples to close. So whatever you re going to put in between those two blades is going to make that thickness even higher and greater and not allow the staple to close. So I don t buttress for revisional surgery, but I do over sew staple lines because our linkage rate is much higher when we do reoperations than when we do primary procedures. Here you over sew your primary procedures. No. I buttress those. Yeah. Well the thickness of the tissue is really important, and it s nice to have a variety of staple cauteries to use. Here we had just passed by, I wanted to make sure that we saw to the extent which we do this posterior dissection, division, so we don t get into this particular problem. You can see I m sort of struggling up here trying to get that stapler right where I want it to be, for whatever reason, and you will see why in a second. But I thought I did a pretty good posterior dissection and not to leave any fundus. You know, the whole idea to do revision surgery isn t to compromise that operation. We want to make as perfect an operation as we can, as if they didn t even have the primary operation. Don t you agree? Absolutely right. And I think this is a good example, not only in revision surgery but in primary surgery. That posterior fundus oftentimes can wrap around there. It can get into a space that if you don t really look at that don t, dissect it out the right way then you can make your pouch too big, and so here, looking back behind again to really see what s in folding, yeah, so you can see what tissue you really want to take. So if it doesn t feel right, don t fire it. You have to make sure it is right before you commit yourself and especially up in this area. You know when you don t dissect this out, who knows where the G junction is. And you certainly don t want to staple off the lower esophagus. Talking about knowing where the G junction is, do you use any kind of tubes to identify the G junction? Well the best tube is an endoscope; right? The best thing to see it. And a lot of times before we put in an Lavacuator tube here, we ll go ahead and do endoscopy, and then internally we ll know exactly where the Z line is and we can mark it, so that it s not always obvious after have a lot of scar tissue in this area. Now here we re taking down gastric medially, and this is a pretty good argument. You can see this is pretty goody visualization, so when you re doing your sleeve, do you often go medial to lateral or lateral to medial, Raul? I like to go first for the short gastric vessels. The reason why is it gives you access to the posterior wall (INAUDIBLE) indigenous to the pancreas to better identify the ring, to help you identify the G junction, and then you can go with stapling of a pouch much easier than when you re doing it the other way around. Now here I m over sewing the gastric remnant staple line and using a 2.0 monofilament suture because it runs well, and whether you do this or not is really individual. I ve seen these staple lines if there s a bowel obstruction I

5 can see those things hiss, so I generally just reinforce it whether it s good or not. We don t have any studies say if it s actually better or not. I ll accept that. Yeah. I think we all need to understand that some of this is our own fetish and we do it for ourselves, and sometimes there s surgical literature that documents the best way to do it and sometimes there s not. You know, it s our own personal preference and practice. Now we ve done the pouch. You know, this is just a standard bypass. Now we re coming across proximal jejunum. I don t use a stapler coming across the mesentery. You can see it s a 60 stapler but I only use part of it because I use the Harmonic device because for me it s just more hemostatic. And most revision surgeries, it really depends on the operation, but we like to measure things and so we put rulers in and things like that. You ve got to make sure you take them out. Yeah. We do have a ruler count, so we try to take them out. Well I must say that regarding the running of a bowel, it s very important to do that, and we re going to get into discussion of length of the limb. I learned from Dr. Wittgrove that it s sometimes -- rarely by but you re going to have patients with a small bowel that s not longer than 200 or 300 centimeters. Correct. So how do you choose the length of the limb, Kelvin? Well this is a proximal bypass, so we re just trying to make it 100 standard length limb. But if it were -- let s say we were going for malabsorption or the patient had a malabsorptive procedure, we d measure the entire bowel from one end to the other. We d have to do that dissection. If there are any adhesions, we d take them down. But we d want to know the entire bowel length before we start chopping it up. You do that routinely in your primary bypasses? Primary bypasses, no. Primary bypasses, we just measure the rule them and the common channel is ill-defined length. I think that biliary pancreatic limb is something that we also need to agree how long that is going to be. I m sometimes puzzled by surgeons that come up to you in meeting and say, Hey, how long is your biliary pancreatic limb? I say, Well, I choose to do 50. Oh, I go 150 down. And that counts. That counts, and the longer they are the more malabsorption we re going to have to, you know, to nutrients. So I think it s very important to understand what we are doing when we count bowel and how long these limbs are going to be. Well the other factor with that is if your anesthesiologist is giving medication that paralyzes the bowel, that affects the limb lengths as well, so if they give anticholinergic medication, then your limb is going to be different than if they don t give anticholinergic medication. This looks like a Fobi pouch. Is this your reinforcement? Well we are in L.A. This is exactly right. This is similar to a Fobi pouch without the ring, because he already had a ring and it didn t work, so we took it out. So this is -- I m reinforcing the entire staple line with the Roux limb. Now I ll usually over sew it if I don t reinforce it. In this case it just seemed nice to bring up the small bowel to sew the entire thing. And we used a monofilament posterior running suture and then we re making the (INAUDIBLE). So the stomach, even though it hadn t been stapled before, you can see how thick and edematous it is. It s just not normal tissue.

6 I think we can expect higher bleeding, higher leak rates from this no matter what technique we use, even if it s hand sewn or using a stapler. I wanted to point out something just the other -- you may not have seen that before. It s called a mesenteric closure. We re closing the mesentery. Have you ever seen that before? This is a discussion like doing a cholangiogram or not to close the mesenteric defect or not. I think that for the sake of the audience, you might choose to do it or not. But you always have to be vigilant about internal hernias happening. And as you would know, Kelvin, from your own experience, you closing them, you see internal hernias. So I think the take-home message is when the patient comes to the emergency room with abdominal symptoms, (INAUDIBLE) pain, they have to bent, no matter if you close them or not, you have to think this person has an internal hernia until otherwise demonstrated. Well that s true. But our rate went from almost 10 percent high at one time down to less than 1 percent. True. But let s not forget, Kelvin, that you choose a retrocolic/retrogastric route, which is a more herniogenic route. I personally do the anticolic/antigastric. Don t divide the mesenterium. When they do herniate, they don t strangulate. When they do obstructions, they don t strangulate. They develop obstructions, but the defects are large, the bowel slips in and out, and I now can work. But so far we ve been very, very aggressive in dealing with these patients. When they come to the emergency room with abdominal pain, the physician should immediately think about this being an internal hernia. Well can we agree that we should close a hiatal hernia? I agree. All hernias have to be fixed, not only for revisional surgery, for primary procedures. Yeah. I think it s very important, no matter which procedure you do, you should be fixing these hiatal hernias. Do you have to fix it posteriorly? Well this is important. The preoperative screening also plays a roll. If you re going to scope these patients or do upper GIs, which I think you should, you re going to see the magnitude of that hernia. And if it s a large hernia, the classic repair for hiatal hernia is you have to dissect posteriorly, close that crest, and if it s a large one, yes, you have to. If it s a small little area anteriorly, you might want to do just a suture anteriorly and you can move on. Now if you notice, Raul, this is an anticolic bypass. Can you believe that? Congratulations. Welcome to the club, Kelvin. Well think that there s no hard and fast rules. I ll go anti or retro. Most of the time we will go retrocolic because of the efficiency reasons. The other thing that we want to point out -- I think it s important. I think you guys will agree -- is that post-op endoscopy is essential when you approach revision surgery. I think all bariatric surgeons should know how to do endoscopy personally. But certainly if you re going to do revision, it s imperative. There are times that you can t tell how big your pouch is, you don t know where the esophagus stops, and I think it s really imperative that you know how to endoscopy in operating room.

7 Before we get to Allen s video, we have some questions from our audience that I would like to ask both of you. And one more detail that you finish with your video, Kelvin, to drain or not to drain. I know you may not drain primary procedures. How about revisions, would you drain or no? I always drain my revisions. I went through a time where I didn t drain them, and knowing that I was just going to have to re-operate, put a drain in and establish mineral feedings, but the leakage rate is significant. And we can control that fistula with a drain and not re-operate, then that s the way we ll go. So we drain a hundred percent. And how long do you leave the drain in? Seven days. Seven days. Allen, drain or no drain, and how long does it stay in? I always drain. It stays in at least two days. If the patient looks great, no real drainage, then I ll take it out at two days. Otherwise I leave it in until I think that it doesn t need to be in. So we have consensus, always drain. Always drain. I leave it two weeks. Two weeks. Two days, seven days, and two weeks. Let s move onto the questions. Let s talk -- one more thing about gastrostomy tubes or no gastrostomy tubes? I personally feel as though we should always use gastrostomy tubes in revisions, essentially a hundred percent of the time, and I think it s an insurance policy that we should all take out. I agree. I think if we have discussed that there are so much more complications in reoperations than in primary procedures. A gastrostomy in a difficult surgery should always be left behind. Now if the case goes really smooth or is good anastamosis, even if it s called a revision, let s not forget that gastrostomies can also cause complications. So if you have a good stomach to leave a gastrostomy, fine. But don t force it. Leave a gastrostomy under tension because you re going to have a major problem post-operatively. Kelvin, gastrostomies or no? I would agree with what you said. I agree with both of you. I think it s never a bad idea to leave a gastrostomy tube. I ve seen complications gastrostomy tubes, so we use it depending on our judgment at the time. Let me ask you a question. Anna is asking us. She had a gastric bypass done six years ago. She was 300 pounds, she s now 158. But lately she starts to put on. She gained 50 pounds, how can she keep her stomach small, and would you consider her for a re-operation? In other words, what would you re-operate, Kelvin? Well, this is a very complicated issue, and to me, the most difficult revision operation, not only to think about doing a revision but what to do is after gastric bypass. And the whole concept of stomach stretching, I think, we need to talk about. Because I don t think it s the stomach stretching so much as the patient is adapting to a new situation, able to eat more and more that s going through, things like that. I d like to add one more variable to that. Stomach stretching, patient non-compliant, and a bad surgeon. Because I ve seen stomachs that by no way the patient could have stretched that were left behind. That patient left the

8 operating room with a gigantic pouch, and in the past, this happened a lot. Hopefully we re going to see that less and less. But, Allen, what would you tell Anna? How can she keep her stomach small and her weight down? Would you take her to the operating room? I think we have to look at why patients have failed or the operation has failed the patient, and we need to make that distinction. I think that if the patient is no longer really maintaining those lifestyle changes, then it s really the patient s fault, not necessarily the operation s. And I think Anna might need to revisit some of the rules of the program, so follow up with the program is really very important. On the other hand, if her pouch is really a bigger reservoir than what we would like it, and I agree wholeheartedly with you Raul, I think that most of these really large stomachs that we re seeing were created as to big a pouch, and then they expand out over time. If you make a very small pouch, it can t expand over time the same way. Obviously, patients are going to be able to eat more at one, two, six years than they can at one, two, six months, but still, they need to make the same correct choices. They have to make lifestyle changes. And in Anna s situation, we have to figure out if it s her choices that are wrong or the operation that s wrong. So here s the question then. Obviously, I don t think any of us would operate on someone who s maintained this kind of weight loss just yet. Right. When do you intervene? Do you intervene only when they ve regained all of their weight back, or do you intervene on their upslope, or when would you intervene? I think the recurrent of medical conditions are the first must while you should be re-intervening, not only with surgery, re-intervening with nutritional counseling, psychological counseling, getting this patient into your office and (INAUDIBLE) more aggressively. But when a patient recurs, diabetes, hypertension, sleep apnea, you need to help this person. These are killers. You know what s real interesting. I think we need to point out that although revision surgery is universally much more hazardous, more complications, Bob Roland showed in his life-long work that the resolution of comorbidities occurs at a higher rate than, say, the primary operations, which is pretty interesting. Yeah. And I certainly agree that if you look at why we re-operate on people, it s not necessarily for weight alone, so if somebody s only regained 40 percent of their weight that they ve lost in total, that may be the right time to reintervene depending on what happened with her operation or what s happening to them medically, so that s what we need to look at. One more question from the audience before we go to Allen s video. The caller is asking, what is the approach we have for gastrojejunal marginal ulcers in patients that failed medical treatment? So the patient comes with the ulcer, with the pain and the pain and the vomiting, and you keep scoping that patient, and the ulcer is still there. So, Dr. Higa, what are the parameters that you look in that patient? Why can this ulcer come and what would you do? Well the first thing is, let s eliminate the obvious things like smoking and end stage and things like that. Let s just assume the patient just has a marginal ulcer. And by and large that patient needs a re-operation. We re going to look for gastrogastric fistulas. We re going to look for those patients that such a chronic ulcer that there s no longer any tissue. It s a complete circumferential ulcer that s never going to heal. Even if it heals a little bit it s always going to come back. And so I mean I m with Allen, the pouch is usually too large, there s too much acid there, and we re going to downsize and revise that entire system. Look for the hiatal hernia.

9 You resect the pouch but you redo the gastrojejunoscopy. Oh, absolutely. And I think the best way is to simply chop off that Roux limb, let it die back, dissect out the hiatus, and then redo everything and try to make that as perfect as possible, leaving the gastrostomy tube, leaving in the drain, at least seven days. What would you do about the recurrent ulcers? Yeah. You know they re either -- it s almost always either the pouch is too big, so there s too much acid, or the patient s smoking or drinking, or there s a gastrogastric fistula. So if the patient s drinking or smoking, you almost can t do much about that until they stop that. But even when they stop that behavior, you re still left with an ulcer that s not going to heal, as Kelvin just talked about. So most of those patients need to be revised. Yeah. If some colleague is thinking about doing a vagotomy for these patient, I personally think that vagotomies are a little bit hysteric for these type of ulcerations. Stomach and small bowel don t get along. If you have an ulcer that keeps coming, your options are in a big pouch you trim it. In a fist fistula, you take down that fistula. You might do a remnant or not. And if it keeps coming, and you really don t know where it s coming from, you may consider reversing the gastric bypass. Sure. Or converting to a sleeve. Or converting to a sleeve gastrectomy. But first just reverse it, because converting to a sleeve sometimes it s the same procedure a little bit too much. It s rare these days I ll see modern laparoscopic bypass that, you know, with an ulcer that won t heal that s not a technical issue though. Correct. So I think we can go to Allen s video. Yeah. My video at this time, this is an individual who had had a prior gastric bypass. You will see at the beginning of the video that there is some mesh that was placed because of a hernia. This individual had been operated on several times. She had had a gastric bypass, standard proximal gastric bypass. She had had a perforated marginal ulcer, and then that was re-operated on, and she had had, then, another perforated ulcer. They had operated on that. She had had yet a third perforated ulcer. That was treated with interventional radiology. And so she came to me really with obstruction, chronic pain, and poor nutritional state. So our first address was to let this last perforation kind of get over, so we were going to let her out from this last perforation at least six months so that hopefully there wouldn t be as much tissue reaction and then get her in the best nutritional state that we could get in. Here you see that there was a lot of adhesion formation. Obviously, she had some four upper abdominal operations, including three perforations of ulcers. So she had a lot of inflammatory response there. We try to mobilize the liver and the medial aspect of the stomach, the lesser curvature, and just as Kelvin was talking about with his video, I feel much better when I find the lobe of the liver and then the adjacent crus of the diagram, so that s what we re going after right here in order to identify area of the anatomy that -- if we injure that, we re going to be in real trouble because the patient doesn t tolerate it well. So the part of the anatomy that s the most important, from my standpoint, is that of the hiatus and the lower esophagus. If we get into the body of the stomach, it s not a big deal. If you get into the fundus of the stomach, it s not a big deal. But if you get into the diagram, if you get into the esophagus, then it becomes a real big deal.

10 So here we re dissecting posteriorly. This is, obviously, is a lot of edematous tissue. This is back behind the stomach where she had the perforations, and there s actually a fistula formation between the pouch at the area of the gastrojejunostomy and the remnant stomach, so we re having to take out even more stomach than I ordinarily would in this particular lady. I like to mobilize the greater curvature and so we ll -- this is the whole inflammatory mess really. You ll see this is part of the small bowel coming up to the -- this is defunctionalized stomach, and then we re going to take the defunctionalized stomach, the greater curvature on up. Allen, can I ask you a question because this is very important? You will find on and off when you do these procedures you get in there and you see that complex inflammatory mass, remnants, anastomoses, ural alimentary limb, and you mentioned before who should be doing the surgery. And I don t want the audience to believe that we arrogant. But you have to be ready to convert a retrocolic to an anticolic. You need to sometimes redo the G-J, because if you have to resect that remnant, that alimentary small pouch, so you really need to have good help in the operating room and be experienced in doing these types of procedures. You agree? Because here you have to resect the remnant, the alimentary limb, the gastrojejunostomy. You might end up with a small pouch. Absolutely. And it can become a nightmare. And in this, you can see in the posterior pouch here, you can see all these clips that were used as well. So if you run a stapler across here you can foul the stapler. You really have to be ready to do almost anything in revision types of surgery, and you need to understand what your back-out position needs to be if, in fact, you can t be successful in the operation that you d like to perform. Kelvin, would you do if Allen finds now that the alimentary limb is 50 centimeters in length after resecting it? You would have to move the (INAUDIBLE) anastomosis. Yes. You d have to -- you know, I think for these, even if you have the old op note, even if you talk to the previous surgeon, which is always a good thing. It s always a good thing to call up your colleague and ask what was done, what are you doing differently. But then we -- unless we just work on the proximal end and there s no malabsorption, we ll measure out the entire limb length from one end to the other. And that s for future reference, because we may be there again doing something else. I think revision surgery begets more revision surgery sometimes. But aren t you worried, Allen, about moving that anastamosis and working more on the small bowel with all those loops of bowel attached to the mesh, adhesions? I mean you came here to do a gastrectomy. Now you re going to end up revising the whole gastric bypass. Is that a concern for you? It s always a concern, and we realize that she had mesh. And we understood also that she had a small hernia adjacent to the mesh, so we had to fix that too. All these things were put into the context of her having chronic pain, recurring ulcers with perforations, and now an obstruction from the significant inflammatory response. So this wasn t taken lightly, but it s one of those things that we didn t have a lot of other options for. Was her pouch too big? The pouch was very big, yeah. Even after she had had part of the pouch resected down with one of the perforations, they had actually resected part of the pouch. What they I don t think really understood in this particular individual was that she had a huge pouch above the diagram through the hiatal hernia, so she had too big of a pouch below the diagram, but she had almost as much of that up above the diagram as well, so her pouch was really very big.

11 Now, Kelvin and Allen, both of you, I have a question from one of our callers in the audience. When do you do a remnant gastrectomy? Is it that easy? Would you say everyone with a gastrogastric fistula needs it? Well I did a series of vertical-banded gastroplasty revisions years ago, in the mid 90s, and we found if we didn t resect the portion of the staple line, a portion of the remnant stomach, then we had about a third of the patients get re-gastrogastric fistula. So if we take out part of that stomach, then it essentially went to zero. I want to point out, this is -- I m showing here that I m going -- I m going to take all of this tissue above the staple gun here, because right above the staple device is where that gastrogastric fistula was. And so under most circumstances, I would probably leave a little bit more stomach than this, but in her, I had to make sure that I got all the way up to this part here because that was where her fistula happened to abide. So, Kelvin, how about remnant gastrectomy, when do you think we should do that? Most of the time we ll do remnant gastrectomy. It depends on the situation. Sometimes we have a fistula, it s not really a fistula from a leak, it s from the original operation. They didn t go high enough with their vertical staple line and left a little bit of, you know. Then in that case I ll just staple that off and not do a remnant gastrectomy. Just to get to this point, you end up sacrificing a lot of the stomach, just so you can see things real well. Allen, I think this is exactly the way I would approach this situation, coming in behind and really making sure I knew exactly where things are. What should be the right opening of the pouch? We have a question from Renee? How large should be your gastrojejunoscopy, which I assume that s her question? I make a gastrojejunoscopy the same way every time because I use a circular stapler and it s 12 millimeters in size. I think it s important for us to understand that probably early on, the size of the gastrojejunoscopy is important from a restrictive standpoint. But they all get bigger over time. And there s nothing that really has been shown that after the patient has been out a year or two years or more that they need to have that type of restriction, that there are a lot of patients who have maintained a 75-percent excess body weight loss or more, and they have a two- or three-centimeter anastamosis. So the size of the anastamosis has never really been shown to be critical in the overall weight loss and maintenance of the weight loss. Kelvin. Well, I make my gastro-j the same size every time because I hand sew it to a millimeter, so it s exactly the same size as Allen s, but just a little different approach. And I agree with everything he said. But I think Lloyd McLain, when he scoped all of his patients at one year found that a lot of them that dilated that pouch didn t necessarily regain weight. One issue though is with sometimes when people have intractable bumping or hypoglycemic episodes. Allen, don t you think that sometimes that s one time when size might matter? It may. You know, I think the evidence is still out on that. It may be a factor. I think that if they have bad dumpling then it s lifestyle changes that they need to institute most of the time and more protein. I also think that the natural history of a pouch and of an anastamosis over time, they will dilate. Food is a natural dilator. And I always tell patients we operate on your stomachs not on your brains. To maintain the weight down, you need not on a good operation but you also need to be compliant and change your lifestyle. Your anastamosis can be very small and your pouch very small, but if you don t stay away from processed food and carbohydrates, you probably are going to fail in the long term regardless. I have another question from our audience and that is, overall what do you think is the failure rate of your gastric bypass? Kelvin, how many of you gastric bypasses regain weight, fail to lose their weight, and come back and say, Dr. Higa, I would like you to do an operation? None of my patients fail. They all come from Florida, really.

12 Oh, Florida, yeah. Just kidding. Seriously, you know, we re talking about an operation that we don t really understand very well for a disease we know even less about. Somehow these operations affect this disease in a very effective way for a variety of reasons, and I think overall, if across the board, we can expect maybe 10 to 15 percent of patients who have had either open or laparoscopic bypasses needing something done in the future, whether it s for ulcers, weight recidivism, something along the way. 50 percent, Allen. Yeah, we looked at this deed and we found that the average excess weight loss in our group with the operation done as you see it here actually with the small pouch, circular stapler of 21, circular stapler, the whole bit, and follow in our program, because I think the -- we can t negate the importance of a multi-disciplinary program because the disease is a multidisciplinary disease. The factors are significant, both physiological and psychological, and so you have to do it within the within a program. So within that context, we found that the average excess weight loss in my group of patients was about 75 percent out at five years. The distribution is such that we had about 12 percent of the patients that had not lost 50 percent of their excess body weight. So that s the group that we were most concerned about, and it s for various reasons. A lot of individuals, you know, it s lifestyle changes that they re not willing to make. It s choices that they just cannot come to grips with. And so psychological changes, we use some Phentermine at times. There s different reasons and different ways of treating it. Can I ask you a technical question, Allen? Sure. This pouch looks small even for your standards. I mean you make a small pouch. Is this smaller than the usual pouch, or is this pretty much what you do? No, this is pretty much what I do. And your marginal ulcer rate is like zero. Zero. Yeah, it s really -- it s essentially zero. I did go up a little bit higher perhaps in this particular case, as we went up. Because I wanted to make sure that I got up above -- you couldn t tell really on this edited video, but there was some inflammatory changes that were just a little bit lower, and so I went up above that because I wasn t exactly sure how that would heal. So this is a little bit smaller than my usual pouch, but essentially the same way as I usually do it. Now let me ask you another question that we have from the audience. You have a patient with a bypass the pouch is small, the anastamosis is small. The patient is three hours out of surgery and has lost only 30 percent of excess body weight. The patient is compliant, psychologically, what would be the procedure that you would choose? In other words, do you believe in this gastric bypass? Would you consider converting this to a BPDDS, Kelvin? I would consider all of the above. You know, that is a very difficult question to answer. It s almost an impossible question to answer based on the information you gave, because that type of decision requires, you know, maybe four or five office visits and counseling, really getting to know the patient. Is it satiety? What s happened in their life? What s going on? And I would consider any of those revisions, distal bypass, consorting to a duodenal switch, or nothing actually. Sometimes the right answer is not to operate. Allen?

13 I don t do distal bypasses. I did a series of over 500 biliopancreatic diversions and we found that we had ha lot of difficulty with malabsorptive procedures, so I don t recommend them, and I know that there are patient that have them done and surgeons that advocate, but it just doesn t work in my particular setup, my program with my patients followed the way we follow them. So when I have a patient like that, I insist that they see my psychologist, the psychologist that works with my program. I think it s important to know which psychologist the patient s seeing so that they get the requirement information, and I know the information that Dr. Rito instills in patients. I think, as Kelvin said, I believe that it takes several office visits for us really to understand what s going on with the patient, the dynamics in their life, in their family, and then I would advocate at times, using some of the medications like Phentermine to try to get people to get off of that particular dime and maybe get some assistance in their weight loss and then can see the light at the end of the tunnel. So I don t think that it all has to surgical at all. I agree. I would add to all of this that if the patient doesn t have serious comorbidity illnesses, we are not weight loss surgeons. We are going to try obesity and the comorbidities and if a patient fails to lose what he or she expected, however the comorbidity are resolved, to me that is a success, and I will monitor this patient, try to stay on medical treatment, observation, but not jump into doing major surgery and converting proximal to distal or BPDDS. You have to be very, very careful. I have more questions from the audience I think are very important, and I think we have ten more minutes. Banding: We know, at least in my experience and most publications we ve seen, 10 to 15 person of bands have to be revised or removed. Assuming you have a patient that failed banding, comes to your office and says, Dr. Higa, I would like you to do a bypass on me. Would you consider that, doing in a step approach? Would you first take the band and then do the bypass or the sleeve or the BPDDS, or would you do that all during the same operation, Dr. Higa, Dr. Wittgrove? Well, first of all, I think that we see a lot of these patients, and rather than jump into converting that patient over, which is still pretty morbid. It s not that easy to reverse a band that s put in. We really try to figure out whether or not they have used that band properly. So just like a bypass, we re going to put them into a program. We re going to try to optimize and evaluate the anatomy and see if we really come up against that wall that s not going to go any further. Then as long as it s not an erosion, if the band is perfectly functional, we will attempt to do a primary conversion to another operation. If there s any issue at all, then I think it s safer to stage that, just take the band out, take down the adhesions, cut that pseudo capsule around the stomach, and then come back another time. Allen. I agree with that. I think that when you re looking at banding operations, we know that historically the bands, on an average, if you look at the FDA study, for example, the excess body weight loss for a band is 40 percent or so. So if you look at it from a weight loss standpoint, it s less than a bypass, primarily because patients don t get the same kind of feedback as they do with bypasses. If you look at it from a metabolic standpoint, so for diabetes, diabetes doesn t resolve the same with the band as a bypass. Bypass is a much more powerful metabolic operation. So if a patient hasn t done well with a band, I agree, we need to try to allow them to do as best they can with a band. And again, if they don t get satiety with that, I would add some Phentermine with that particular individual to try to augment it so that they can get as much power out of the operation and any other therapy short of revision. That being said, since I don t think that it s the same metabolic operation, I m a little bit faster at jumping to a revision with a band than I am with a bypass. Yeah. If I may add to what Allen and Kelvin just said. I think you have to take into consideration the patient as a whole; the age of the patient, how long the band was in there, what the BMI is, and be very careful with the sleeve

14 gastrectomy. Don t think now that the sleeve gastrectomy is a solution for all the problems in bariatric surgery. If you choose to do a sleeve gastrectomy in a failed band, from European experience, it seems like a two-step approach would be better, and you are tempted as a surgeon when you get in there, everything looks good anatomically, you have good tissue, you can do it in one step as well. I think in the very heavy patient, diabetic that failed the band, I would do a -- bypass sleeve might be taken into consideration with a lower BMI. In our experience, and we hopefully are going to be presenting that pretty soon in our annual meeting, the bypass does much better as a conversion and procedure for failed banding than sleeve gastrectomy. You know, one thing I think there s some patients tuning in on this, and I just want to caution patients to searching out for the surgeon and the operation you may think you want. Obviously if a surgeon only does only one operation, that revision is going to include that operation. And truthfully what you want is to search out the experts like those sitting next to me who are experienced in a lot of different operations so that you can kind of get a good -- they can give a good analysis of what they think you should have, rather than just what you may think you have. Would you agree? I think that it is important to understand what not only the patient want to get out of it but what the surgeon wants to get out of it, and so to try to mesh those two things into an operation that s the safest for the patient or no operation if that s the safest and best. Again, I would like to reemphasize what Raul talked about. With revisions, most of the time we re re-operating because of a problem, and the problem is not weight regain. That s not -- the problem s not the weight as much as its diabetes or hyper tension or sleep apnea or some other perforation or fistula or it s the operation problem. And so the weight is completely secondary for all these issues. And I agree to everything that was said here. I would like to emphasize another point, which is dealing with insurance. I think insurances still do not understand what revisions, re-operations mean, and as Allen mentioned and Kelvin mentioned, a lot of these patients have problems, and problems are not choices. When a patient comes with a marginal ulcer, with bleeding, with gastrogastric fistulas, that patient needs surgery, that patient needs help, because these are sometimes lethal complications, debilitating complications. It is different with a patient that has no diabetes, no hypertension, and knocks on the door and says, Well I d like to lose another 40 pounds, because they re worried about it. That s the patient that we should put on a program, but the other ones. And I mentioned that because I recently dealt with a 21-year-old girl that had a short gut syndrome from an internal hernia. In fact, she had a bypass done with closure of mesentery defects and lost most of her small bowel. From Fresno. No, no, nom didn t come from Fresno. But long story short, this patient was on TPN and getting septic and septic, and I had this medical director that said, Well but we approve only one bariatric procedure. I was saying, But, doctor, this is not bariatrics. This is a complication. This is short gut syndrome. This patient needs a reoperation. So I think this is important also for those who are in the audience who are dealing with insurance and approvals, and hopefully a medical director that is listening to that. I hope they got invited to listen. They should look into reoperations because this is a very, very, very important field for their patients. Okay. No more questions? There are no more questions at this point.

15 No more questions? Well I have a few for you guys. I mean we re talking about ethics in medicine, about reoperations, and we re talking about the difference between compliance and responsibility. I mean on the one hand we ve talked about how surgeons may not leave the optimal anatomy, even though we have no idea what the optimal anatomy should be. We talk about patients and their compliance as if patients have a choice a lot of time to change their lifestyle to, you know, completely turn around their entire lives. I mean how realistic is that to have someone change your -- you know, not just what they eat, how they eat, their kids eat, their family, that sort of thing. In my experience, that s not easy. And I think that the public is also, including ourselves, doctors, ignorant about the obesity disease. I think we don t understand the obesity disease as it is. And doctors tell their patients, Well, if you want me to change your hip or do you re hernia, you have to lose 50 pounds. It s like saying Rosenthal, I want you hair to grow back or to grow five inches. It s not going to happen. So you need to help that patient to get there. And it s not easy for them to lose the weight just because we tell them that. And it s not always compliance. The obesity disease, as such, also has to do with metabolic rates. Sometimes our patients go through bands, through sleeves, through bypasses, and they still don t get to lose what we want them to lose. So it s a delicate problem. We need to do more prospective studies, controlled studies to understand the obesity disease as such. Well I think we need to -- if we re going to blame anything, let s blame the disease primarily, then we ll blame our ignorance for not understanding it so much. And we can share the blame of patient behavior and some of the other society things that have come along. Well, you know, it is a disease, and I think it s important for all of us, our colleagues, and for society in general to understand that it s a multi-factorial disease that we re dealing with and that many of the metabolic factors that enter into with diabetes and the like, those cause weight gain as well. So not only the patients come in and they suffer with the disease of morbid obesity, but then they re on five different medications, and probably four of those medications cause them to gain weight or hold onto the weight. So the patients are kind of behind the eight ball to begin with, and then we put several more eight balls in front of them that don t allow them the opportunity to lose weight, and then get healthier, we need to emphasize get healthier. So the whole program is in place to, first, have a good surgery, but then try to allow the patients to adapt their lifestyle, have psychological support, have support groups, have online support, whatever is necessary for that particular individual to hopefully get the best results that they can get out of it. I think some of the most interesting data right now showing that some of the pollutants in our air are also causing weight gain, and so that may be part of the reason that we hadn t seen this epidemic to this degree until now. And now if you re so genetically encoded, the air that we breathe even is harmful to people with that genetic imbalance. We re talking about a lifelong incurable illness, why wouldn t we expect certain failure rates, certain recidivism after primary treatment; correct? Absolutely. And as what you were saying, Raul, it s unconscionable for insurance companies not to authorize a revision operation, especially if there are complications. That s a good call to action. That s right. Well unfortunately we are about out of time. I would like to thank you for joining us for what I hope was an informative program. I would also like to extend special thanks to Ethicon Endo-Surgery for sponsoring this important series of webcast for surgeons. If you missed any of the program or would like to view it again, the