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IFSO 2012

IFSO report: the future of gastric bypass

Khaled Gawdat said that banding a micro gastric bypass makes the weight loss "more powerful and sustained".
Khaled Gawdat: 12-year experience banding gastric bypass
Enrique Lanzarini investigates the anti-diabetic mechanism in gastric bypass
Karl Miller: mental training and the nodal point
Jacques Himpens discusses how to repair a failed gastric band

A session at IFSO’s 27th World Congress in New Delhi, India, concentrated on the latest modifications and developments to the laparoscopic Roux-en-Y gastric bypass.

Khaled Gawdat introduced the findings from a prospective non-randomised study examining the safety and efficacy of using a band to prevent the dilatation of the micro-pouch in the gastric bypass operation. Following 294 patients for up to 12 years, Gawdat said that the weight loss was more powerful and more sustained at all year points.

The 294 patients were placed into two groups. The first, consisting of 97 patients, had a traditional non-banded Roux-en-Y gastric bypass, while the second group of 197 had a micro-bypass with a Sapala-Wood style micro-pouch. 16 cases were excluded, after their pouches were judged to be too large, or post-operative factors altered their weight loss.

At one year, the banded patients had lost an average of 90% of their excess body weight, compared to 60% for the non-banded patients. Both groups regained weight modestly over the next nine years, at which point the banded patients had an average of 80% excess body weight loss and the non-banded patients had lost 46%.

Morbidity and mortality were similar between the two groups; there were two deaths and seven leaks in the course of the study.

Enrique Lanzarini reported on his study of the mechanism by which gastric bypass resolves diabetes, investigating whether the resection of the stomach in a bypass with gastrectomy played a role in metabolic control.

Lanzarini divided 50 patients into two groups, the first of which received a conventional non-resective LRYGB, and the second of which had a LRYGB with a resected stomach.

Follow-up concentrated on metabolic control, measuring weight, BMI, fasting glycemia, HbA1c, c-peptide and lipids. However, Lanzarini et al did not find any statistically significant differences between the groups for any of the variables, suggesting that the metabolic effect of the gastric bypass with gastrectomy was not caused by the resection of the stomach.

Karl Miller used his presentation to advocate mental training and the nodal point technique for surgery, abstracting each surgical technique into a series of discrete actions, which can then be practiced before the actual operation. Drawing analogies to sports and aviation, where precision and skilled movement is necessary in high-pressure situations, Miller emphasised that being mentally prepared for an operation is a vitally important step.

Jacques Himpens’ presentation discussed his techniques for addressing a failed gastric bypass, concentrating on problems involving insufficient weight loss and unacceptable weight regain.

The normal track for a RYGB, said Himpens, was for the patient to lose weight for two years, followed by a modest regain, which ultimately plateaus. However, there are a number of phenomena that can confound this series of events.

A gastro-gastric fistula can nullify a gastric bypass. Himpens suggested a treatment of a resection along with fundus resection.

A failure to follow up, said Himpens, can result in unacceptable weight regain. Unless they are in effective follow-up with the surgeon, a patient will revert to previous poor eating habits.

A patient has two ways of bypassing a bypass – eating too frequently (polyphagia) and eating over-large meals (hyperphagia).

When using surgical options to treat the effects of hyperphagia, Himpens first investigated the gastrojejunal sleeve, which did not result in significantly higher excess weight loss, and the laparoscopic redo of the initial bypass, which led to poor weight loss and high complications. He settled on the Fobi ring, which led to significantly higher weight loss than before.

Himpens said that he treats plyphagia with a distal bypass – conversion to normal anatomy, followed by a duodenal switch. With his own modified “European School” technique, he managed 59.4% excess weight loss; however, he noted that his experience of 19 cases had led to a 21% complication rate.

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