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Apollo EndoSurgery Symposium

Revisional surgery: why surgery fails

The reasons for re-intervention are either for unsatisfactory weight loss or complications and that revisional surgery has been shown to be effective in providing good additional weight loss, although it can result in significant morbidity

At the recent European Obesity Summit in Gothenburg, Sweden, Apollo Endosurgery hosted a symposium, which included presentations on revisional surgery, long-term outcomes, low BMI patients, band complications and the banded bypass.

The rise of bariatric surgery has led to an increasing number of re-interventions for failed bariatric procedures and approximately 10-25% of patients undergoing bariatric surgery will require revisional surgery (Gagner M, Gentileschi P, de Csepel J, et al. Laparoscopic reoperative bariatric surgery: experience from 27 consecutive patients. Obes Surg 2002; 12:254-260), but the reasons for revisional surgery and types of interventions are varied in nature and remain to be defined, according to a presentation by Professor Natan Zundel, Vice-Chairman Department of Surgery, Florida International University, FL.

Natan Zundel

He began his presentation by stating that the reasons for re-intervention are either for unsatisfactory weight loss or complications and that revisional surgery has been shown to be effective in providing good additional weight loss, although it can result in significant morbidity (Outcomes of Revisional Procedures for Insufficient Weight Loss or Weight Regain After Roux-En-Y Gastric Bypass. Obes Surg. 2012 Nov;22(11):1746-54).

A systematic review by an ASMBS Task Force (Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force.Surg Obes Relat Dis. 2014 Sep-Oct;10(5):952-72) sought to identify procedure-specific indications and outcomes for re-operative procedures. It found that reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention and complication rates are generally reported to be higher after reoperative surgery, compared to primary surgery. The Task Force concluded that indications and outcomes for reoperative bariatric surgery are procedure-specific but the current evidence does support additional treatment for persistent obesity, co-morbid disease and complications.

“Despite a 15 percent increase in total bariatric procedures in the US between 2011-2013, the number of revision stayed at a constant 6%,” said Professor Zundel. “But then increased to 11.5% in 2014. So what is the problem and why did this increase occur?”

To answer some of these questions, the First International Consensus Conference on Revisional Bariatric Metabolic Intervention (RBMI) meeting was held in June 2015 to study, interpret, and discuss available evidence in order to develop and publish expert consensus on the following topics:
• Identifying appropriate candidates for RBMI
• Identifying interventions that provide benefit for patients and under what circumstances
• Define next steps in order to obtain and evaluate collective data regarding RBMI
• Explain what evidence is lacking in the scientific literature and what work needs to be done in order to address these deficiencies
• Discuss nomenclature for various procedures/interventions in RBMI

“Over 30 international experts participated in the presentations and discussions. Based on the paucity of available data, little consensus was obtained on most topics,” he explained. “The heterogeneity and complexity of the problem makes it virtually impossible to design or fund randomised trials, so it was unanimously agreed that standards should be established for each procedure and outcomes from RBMI should be mandatorily submitted to a registry.”

According to Professor Zundel, there is /lack of information for both health care professionals and patients. After bariatric surgery, he said it was clear than patients and physicians should focus on diet, exercise and behaviour modification and that, “Postoperative care, nutritional counselling, and surveillance should continue for an indefinitely long period.”

Predictive factors

In addition, he explained that several predictive factors have been identified as the causes of insufficient weight loss after surgery including poor surgical technique (gastric pouch size, limb size), pre-operative weight loss, socioeconomic aspects, depression, behavioural factors, poor nutritional compliance, lack of physical activity T2DM (insufficient weight loss) and oral hypoglycaemic agents (Factors related to weight loss up to 4 years after bariatric surgery. Obes Surg. 2011 Nov;21(11):1724-30).

He also said that pre-operative teaching on the patients' surgical option could also improve surgical outcomes, as this provides an informed and better patient selection for bariatric surgery and helps the patients understand the various surgical options, and makes their decision easier (Impact of preoperative teaching on surgical option of patients qualifying for bariatric surgery. Obes Surg. 2004 Oct;14(9):1241-6).

He added that post-operatively, patients must also understand the importance of adequate nutrition, increasing physical activity in their daily lifestyle (exercise regimen), stress management and setting realistic goals, and attending support groups (Behavioral Predictors of Weight Regain after Bariatric Surgery. Obes Surg (2010) 20:349-356).

Finally, he touched on the issue of cultural norms of self-acceptance in terms of weight and beliefs of fat being healthy and the importance of cost-effective societal interventions such as a tax on unhealthy food and beverages, front-of-pack traffic light nutrition labelling and prohibition of advertising of junk food and beverages (Ther Adv Gastroenterol (2013) 6(1): 77-88). He also added that more research is needed to understand the impact of physician BMI on obesity care by improving the quality of obesity-related training in medical school, residency or continuing medical education (Impact of physician BMI on obesity care and beliefs. Obesity (2012) 20, 999-1005).

“Bariatric surgery plays a crucial role in treating obese patients and their comorbidities,” he concluded. “But we must remember that bariatric surgery is just one component o of a much wider patient-centred approach to treat obesity.”

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