ANZ J. Surg. 2014; 84 (Suppl. 1) 1–6
Bariatric Surgery Program Abstracts
BT01 WHAT IS BEST PROACTICE 2014 – LAGB Paul O’Brien Monash University, Victoria Optimal outcomes after LAGB are dependent on best preparation, operation and aftercare. In preparation the patient must be well-informed in order to provide their part of the partnership. The placement of the band should be a safe, gentle day procedure. Precise placement, removal of the anterior fat pad, good fixation and appropriate filling are needed. Consider mesh port fixation – it saves time, avoids pain and is easier to access in the office. Good aftercare is critical. Have frequent initial visits, seeking the ‘Green Zone’. Provide consultations, not ‘fills’. Push the rules regarding eating, which can be summarised as ‘Eat a small amount of good food slowly’. Maintain a good data management system, which provides targets and group reports so your patients know where they are going and whether they are getting there and you know if you and your team are getting there also. There are no ‘normal’ symptoms after LAGB. If food is sticking or there is heartburn or reflux, one of three things is happening. Most commonly, the patient is eating too fast or taking too big a bite. Educate them. Next, you have made the band too tight. Loosen it a fraction. Finally, there may be a proximal enlargement. Identify it on barium meal and consider a 1 month trial of fluid out. If it persists or returns, fix it. Revision is safe day patient procedure. BT02 SLEEVE GASTRECTOMY Rudolf Weiner KH Sachsenhausen, Germany Sleeve gastrectomy (SG) is currently one of the most common obesity procedures performed worldwide. Initially described in 1999 as the first component of the biliopancreatic diversion with duodenal switch (BPD-DS), it is now accepted as a stand-alone intervention. Although theoretically a simple procedure, it can be followed by life-threatening complications. Prevention and management of these complications require the adoption of a standardised peri-operative protocol and timely interpretation of abnormal post-operative findings. Deviation from a normal post-operative clinical course or abnormal blood tests (elevation of inflammatory parameters or a drop in haemoglobin) or radiological studies should raise suspicion of complications. An integrated teamwork approach is necessary to interpret abnormal signs and results and to instigate prompt management. Post-operative complications can present either early or late. Early complications include staple line leakage and bleeding. Endoscopic stenting and/or surgical revision are usually needed to manage leakage. Haemodynamic instability due to staple line bleeding necessitates surgical revision. Late post-operative complications include leakage (which may present as free intraperitoneal leakage, abscess formation or development of fistula), sleeve stenosis (which may be associated with other proximal complications including leakage) or perigastric haematoma.
We video present here a safe and a feasible simultaneous trimming of the dilated gastric pouch and the dilated anastomosis. Methodology: Patient presentation in chronological events: • In 2009, a 29-year-old Caucasian female presented with a weight of 120 kg and a BMI of 39. Had a LAGB (laparoscopic adjustable gastric band) procedure. Lost her weight to 104.2 kg but also developed severe reflux. Band was deflated and patient put on weight back and reached to 120 kg. Patient underwent a LRYGB. • Reflux went away and patient was better and started losing weight again. In 2013 presented with weight going up to 89 kg. Gastrograffin swallow showed gastric pouch dilatation. Patient planned for revision of bypass. At the operation the findings were of dilatation of the Gastric pouch with concurrent dilatation of the jejunum and the anastomosis. Decision made to trim the dilated gastric pouch and the anastomosis with addition of the fixed ring. Postop Gastrograffin swallow showed no dilated pouch and an intact anastomosis. Results: A technically safe procedure for revision of a failed RYGB. Conclusion: Concurrent trimming of the dilated gastric pouch and anastomosis may be considered in a select group of patients as a safe procedure without compromising the GJ anastomosis. BT05 STUDY LOOKING AT WEIGHT LOSS AFTER SLEEVE GASTRECTOMY Zhiyun Chen, Costantine Karihaloo, Martin Epstein and Claire Morbey John Hunter Hospital, Newcastle, New South Wales, Australia Introduction: Sleeve gastrectomy is an increasingly popular form of weight loss surgery, with reports suggesting weight loss outcomes equivalent to gastric bypass in the medium term. Significant weight loss is seen in the first 6 months after surgery. There are concerns that this may reflect sarcopenia, or loss of fat free mass (FFM). We examined changes in body composition after surgery using dual-energy X-ray absorptiometry (DXA). Methods: Consecutive patients presenting for surgery in 2011 were offered DXA pre-op and 6 months post-op. Patients underwent surgery in the routine fashion, and all received intensive dietetic support in the pre and post-operative period. Results: Twenty-seven patients (23 female) aged 25–58, mean weight 121 kg (100–146), mean BMI 45 (38–58) were recruited. There were no operative complications. At 6 months the average weight loss was 29.6 kg (17–44), with mean %EBWL 52.2 (31–88). Overall average fat loss was 21 kg and FFM loss was 11.3 kg. The average ratio of fat: FFM loss was 2.1. In older and in diabetic patients this ratio was 1.6. Average fat loss was 9.2 kg in the trunk and 4.5 kg in the legs; muscle loss was 5.6 kg in the trunk and 1.2 kg in the legs. Diabetics lost less fat in the trunk (3.8 vs 10.7 kg). Older patients lost more muscle in the legs (8.2 vs 4.1 kg). Conclusion: Early weight loss after sleeve gastrectomy can be associated with sarcopenia. This should be considered especially in the older and diabetic populations. BT06 RATIONALES AND OUTCOMES OF CONVERTING LAGB TO RYGB IN BMI
Bariatric Surgery Program Abstracts
BT01 WHAT IS BEST PROACTICE 2014 – LAGB Paul O’Brien Monash University, Victoria Optimal outcomes after LAGB are dependent on best preparation, operation and aftercare. In preparation the patient must be well-informed in order to provide their part of the partnership. The placement of the band should be a safe, gentle day procedure. Precise placement, removal of the anterior fat pad, good fixation and appropriate filling are needed. Consider mesh port fixation – it saves time, avoids pain and is easier to access in the office. Good aftercare is critical. Have frequent initial visits, seeking the ‘Green Zone’. Provide consultations, not ‘fills’. Push the rules regarding eating, which can be summarised as ‘Eat a small amount of good food slowly’. Maintain a good data management system, which provides targets and group reports so your patients know where they are going and whether they are getting there and you know if you and your team are getting there also. There are no ‘normal’ symptoms after LAGB. If food is sticking or there is heartburn or reflux, one of three things is happening. Most commonly, the patient is eating too fast or taking too big a bite. Educate them. Next, you have made the band too tight. Loosen it a fraction. Finally, there may be a proximal enlargement. Identify it on barium meal and consider a 1 month trial of fluid out. If it persists or returns, fix it. Revision is safe day patient procedure. BT02 SLEEVE GASTRECTOMY Rudolf Weiner KH Sachsenhausen, Germany Sleeve gastrectomy (SG) is currently one of the most common obesity procedures performed worldwide. Initially described in 1999 as the first component of the biliopancreatic diversion with duodenal switch (BPD-DS), it is now accepted as a stand-alone intervention. Although theoretically a simple procedure, it can be followed by life-threatening complications. Prevention and management of these complications require the adoption of a standardised peri-operative protocol and timely interpretation of abnormal post-operative findings. Deviation from a normal post-operative clinical course or abnormal blood tests (elevation of inflammatory parameters or a drop in haemoglobin) or radiological studies should raise suspicion of complications. An integrated teamwork approach is necessary to interpret abnormal signs and results and to instigate prompt management. Post-operative complications can present either early or late. Early complications include staple line leakage and bleeding. Endoscopic stenting and/or surgical revision are usually needed to manage leakage. Haemodynamic instability due to staple line bleeding necessitates surgical revision. Late post-operative complications include leakage (which may present as free intraperitoneal leakage, abscess formation or development of fistula), sleeve stenosis (which may be associated with other proximal complications including leakage) or perigastric haematoma.
We video present here a safe and a feasible simultaneous trimming of the dilated gastric pouch and the dilated anastomosis. Methodology: Patient presentation in chronological events: • In 2009, a 29-year-old Caucasian female presented with a weight of 120 kg and a BMI of 39. Had a LAGB (laparoscopic adjustable gastric band) procedure. Lost her weight to 104.2 kg but also developed severe reflux. Band was deflated and patient put on weight back and reached to 120 kg. Patient underwent a LRYGB. • Reflux went away and patient was better and started losing weight again. In 2013 presented with weight going up to 89 kg. Gastrograffin swallow showed gastric pouch dilatation. Patient planned for revision of bypass. At the operation the findings were of dilatation of the Gastric pouch with concurrent dilatation of the jejunum and the anastomosis. Decision made to trim the dilated gastric pouch and the anastomosis with addition of the fixed ring. Postop Gastrograffin swallow showed no dilated pouch and an intact anastomosis. Results: A technically safe procedure for revision of a failed RYGB. Conclusion: Concurrent trimming of the dilated gastric pouch and anastomosis may be considered in a select group of patients as a safe procedure without compromising the GJ anastomosis. BT05 STUDY LOOKING AT WEIGHT LOSS AFTER SLEEVE GASTRECTOMY Zhiyun Chen, Costantine Karihaloo, Martin Epstein and Claire Morbey John Hunter Hospital, Newcastle, New South Wales, Australia Introduction: Sleeve gastrectomy is an increasingly popular form of weight loss surgery, with reports suggesting weight loss outcomes equivalent to gastric bypass in the medium term. Significant weight loss is seen in the first 6 months after surgery. There are concerns that this may reflect sarcopenia, or loss of fat free mass (FFM). We examined changes in body composition after surgery using dual-energy X-ray absorptiometry (DXA). Methods: Consecutive patients presenting for surgery in 2011 were offered DXA pre-op and 6 months post-op. Patients underwent surgery in the routine fashion, and all received intensive dietetic support in the pre and post-operative period. Results: Twenty-seven patients (23 female) aged 25–58, mean weight 121 kg (100–146), mean BMI 45 (38–58) were recruited. There were no operative complications. At 6 months the average weight loss was 29.6 kg (17–44), with mean %EBWL 52.2 (31–88). Overall average fat loss was 21 kg and FFM loss was 11.3 kg. The average ratio of fat: FFM loss was 2.1. In older and in diabetic patients this ratio was 1.6. Average fat loss was 9.2 kg in the trunk and 4.5 kg in the legs; muscle loss was 5.6 kg in the trunk and 1.2 kg in the legs. Diabetics lost less fat in the trunk (3.8 vs 10.7 kg). Older patients lost more muscle in the legs (8.2 vs 4.1 kg). Conclusion: Early weight loss after sleeve gastrectomy can be associated with sarcopenia. This should be considered especially in the older and diabetic populations. BT06 RATIONALES AND OUTCOMES OF CONVERTING LAGB TO RYGB IN BMI
