2. “Those who cannot remember the
past are condemned to repeat it.”
George Santayana
Bariatric Surgery: A History of Failure
3. 1454-1502: Bariatric Procedures Should
Include Both Small Gastric Pouch and Gastric
Bypass for Maximum Effectiveness
Bariatric Surgery: A History of Failure
Dr. Rutledge
Director
Center for Laparoscopic Obesity Surgery
Email: DrR@clos.net
702-714-0011
http://minibypass.wordpress.com/
http://www.facebook.com/DrRutledge
http://twitter.com/DrRR
http://www.youtube.com/user/DrRRutledge
5. Jaw wiring in treatment of
obesity
Lancet. 1977 Jun 11;1(8024):1221-2. Rodgers S, Burnet R, Goss A, Phillips P,
Goldney R, Kimber C, Thomas D, Harding P, Wise P.
17 patients with severe (median percentage above ideal weight 100%) and
resistant obesity underwent jaw wiring.
There were no major complications and patients tolerated the procedure and
subsequent minor inconveniences.
All patients lost weight at a rate (median 25-3 kg in six months)
comparable with that of intestinal bypass surgery and one
achieved and maintained her ideal weight.
Two-thirds of the patients, however, regained some weight after the wires
were removed.
Jaw wiring is a simple effective procedure which can be
carried out in most hospitals, and has a place in an
integrated approach to obesity.
6. Maintenance of weight loss in
obese patients after jaw wiring
Br Med J (Clin Res Ed). 1981 March 14; 282(6267): 858–860.
Maintenance of weight loss in
obese patients after jaw wiring
In this study jaw wiring was used to limit food
intake.
...
patients were followed for 4-14 months after
removal of jaw wires and regained a mean
of only 5.6 kg of the 31.8 kg lost while their
jaws were wired.
"This procedure compares favourably with
other treatments for severe obesity."
7. Bariatric Surgery: A History of
Failure
Jaw Wiring
BioEnterics Intragastric Balloon (BIB)
8. BioEnterics Intragastric
Balloon (BIB)
Int J Obes (Lond). 2006 Jan;30(1):129-33. BioEnterics Intragastric Balloon (BIB):
a short-term, double-blind, randomised, controlled, crossover study on weight
reduction in morbidly obese patients. Genco A, Cipriano M, Bacci V, Cuzzolaro M,
Materia A, Raparelli L, Docimo C, Lorenzo M, Basso N. Department of Surgery Paride
Stefanini, University La Sapienza Medical School, Rome, Italy. alfredo.genco@uniroma1.it
The results of this study show that
treatment of obese patients with
BioEnterics Intragastric Balloon is a safe and effective
procedure.
In association with appropriate diet it is significantly
effective in weight reduction when compared to sham
procedure plus diet.
9. BioEnterics Intragastric
Balloon (BIB)
Obes Surg. 2008 Dec;18(12):1611-7. Epub 2008 Jun 21. Evidence-based review of
the Bioenterics intragastric balloon for weight loss. Dumonceau JM. Division of
Gastroenterology and Hepatology, Geneva University Hospitals,Geneva, Switzerland
Reviewed clinical studies performed with the Bioenterics
intragastric balloon (BIB) to promote weight loss.
Thirty studies were included [18 prospective (5 randomized), 12
retrospective], totaling 4,877 patients.
Only one of three controlled trials found a significantly higher
weight loss with the BIB vs the sham procedure
In nonrandomized studies, weight loss with the BIB averaged 17.8
kg, BMI changes of 4.0-9.0 kg/m(2).
10. Bariatric Surgery: A History of
Failure
Jaw Wiring
BioEnterics Intragastric Balloon (BIB)
Vertical Banded Gastroplasty
11. High revision rates after
laparoscopic vertical banded
gastroplasty
Surg Obes Relat Dis. 2009 Jan-Feb;5(1):94-8. Epub 2008 Jul 21.High revision rates after laparoscopic
vertical banded gastroplasty. Marsk R, Jonas E, Gartzios H, Stockeld D, Granström L, Freedman
J.Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska
Institutet, Stockholm, Sweden.
486 patients
The median follow-up was 3 years
104 patients, 21% required revision
12. Bariatric Surgery: A History of
Failure
Jaw Wiring
BioEnterics Intragastric Balloon (BIB)
Vertical Banded Gastroplasty
Lap Band
13. Bariatric Surgery Failures: PubMed Search
“failed gastric banding” >> 100 Articles
1: Elnahas A, Graybiel K, Farrokhyar F, Gmora S, Anvari M, Hong D. 9: Burton PR, Brown WA. The mechanism of weight loss with laparoscopic
Revisionalsurgery after failed laparoscopic adjustable gastric banding: a adjustable
systematic gastric banding: induction of satiety not restriction. Int J Obes (Lond). 2011
review. Surg Endosc. 2012 Aug 31. [Epub ahead of print] PubMed PMID: Sep;35 Suppl 3:S26-30. doi: 10.1038/ijo.2011.144. Review. PubMed PMID:
22936440. 21912383.
2: Deutsch GB, Gunabushanam V, Mishra N, Sathyanarayana SA, Kamath 10: Berende CA, de Zoete JP, Smulders JF, Nienhuijs SW. Laparoscopic
V, Buchin D.Laparoscopic vertical sleeve gastrectomy after open gastric sleeve
banding in a patient gastrectomy feasible for bariatric revision surgery. Obes Surg. 2012
with situs inversus totalis. J Minim Access Surg. 2012 Jul;8(3):93-6. PubMed Feb;22(2):330-4. Review. PubMed PMID: 21866377; PubMed Central PMCID:
PMID: 22837597; PubMed Central PMCID: PMC3401724. PMC3266499.
3: Meesters B, Latten G, Timmermans L, Schouten R, Greve JW. Roux-en-Y 11: Hedberg J, Gustavsson S, Sundbom M. Long-term follow-up in patients
gastric undergoing open gastric bypass as a revisional operation for previous failed
bypass as revisional procedure after gastric banding: leaving the band in restrictive procedures. Surg Obes Relat Dis. 2011 Jun 30. [Epub ahead of
place. print]
Surg Obes Relat Dis. 2012 Feb 10. [Epub ahead of print] PubMed PMID: PubMed PMID: 21865097.
22440668. 12: Runkel N, Colombo-Benkmann M, Hüttl TP, Tigges H, Mann O, Sauerland
4: Deylgat B, D'Hondt M, Pottel H, Vansteenkiste F, Van Rooy F, Devriendt D. S.
Indications, safety, and feasibility of conversion of failed bariatric surgery Bariatric surgery. Dtsch Arztebl Int. 2011 May;108(20):341-6. doi:
to 10.3238/arztebl.2011.0341. Epub 2011 May 20. Review. PubMed PMID:
Roux-en-Y gastric bypass: a retrospective comparative study with primary 21655459;
laparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2012 Jul;26(7):1997- PubMed Central PMCID: PMC3109275.
2002. 13: Goitein D, Feigin A, Segal-Lieberman G, Goitein O, Papa MZ, Zippel D.
Epub 2012 Jan 19. PubMed PMID: 22258299. Laparoscopic sleeve gastrectomy as a revisional option after gastric band
5: Hii MW, Lake AC, Kenfield C, Hopkins GH. Laparoscopic conversion of failure. Surg Endosc. 2011 Aug;25(8):2626-30. Epub 2011 Mar 17. PubMed
failed PMID:
gastric banding to Roux-en-Y gastric bypass. short-term follow-up and 21416182.
technical 14: Bhasker A, Gadgil M, Muda NH, Lotwala V, Lakdawala MA. Revisional
considerations. Obes Surg. 2012 Jul;22(7):1022-8. PubMed PMID: 22252745. bariatric
6: Vijgen GH, Schouten R, Pelzers L, Greve JW, van Helden SH, Bouvy ND. surgery for failed gastric banding in Asia: a review of choice of revisional
Revision procedure, surgical technique and postoperative complication rates. Asian J
of laparoscopic adjustable gastric banding: success or failure? Obes Surg. Endosc Surg. 2011 Feb;4(1):26-31. doi: 10.1111/j.1758-5910.2010.00062.x.
2012 Epub
Feb;22(2):287-92. PubMed PMID: 22094368; PubMed Central PMCID: 2010 Nov 17. PubMed PMID: 22776171.
PMC3266497. 15: Greenbaum DF, Wasser SH, Riley T, Juengert T, Hubler J, Angel K.
7: Scheffel O, Weiner RA. Therapy of stenosis after sleeve gastrectomy: Duodenal
stent and switch with omentopexy and feeding jejunostomy--a safe and effective
surgery as alternatives--case reports. Obes Facts. 2011;4 Suppl 1:47-9. Epub revisional
2011 operation for failed previous weight loss surgery. Surg Obes Relat Dis. 2011
Apr 13. PubMed PMID: 22027291. Mar-Apr;7(2):213-8. Epub 2010 Nov 10. PubMed PMID: 21215708
8: Abu-Gazala S, Keidar A. Conversion of failed gastric banding into four
different bariatric procedures. Surg Obes Relat Dis. 2012 Jul;8(4):400-7.
Epub
14. Bariatric Surgery Failures: PubMed Search
“failed gastric banding” >> 100 Articles
"Recent data from Marmuse on
adjustable bands and BMI>50,
who says that
“At ten years, only 11% of patients
(nine of 80) have successful bariatric results
(%EWL>50%)
and we were forced to
remove the gastric band in 52.2% of patients (47 of 90)
because of complications,
regardless of the initial operative technique"
Michel
Gagner
15. Bariatric Surgery: A History of
Failure
Jaw Wiring
BioEnterics Intragastric Balloon (BIB)
Vertical Banded Gastroplasty
Lap Band
Sleeve Gastrectomy
16. Sleeve Gastrectomy Failure:
Just When We Thought We Had the Perfect Operation
Sleeve gastrectomy and the risk of leak: a systematic
analysis of 4,888 patients.
Surg Endosc. 2012 Jun;26(6):1509-15. Epub 2011 Dec 17. Aurora AR, Khaitan L, Saber AA. Department of Surgery,
University Hospitals Case Medical Center, Cleveland, Ohio
" The risk of leak is low at 2.4%." !!
Himpens, in an article by Deitel et al, presented his early
five-year results after sleeve gastrectomy he reported a
disappointing 37 and 23 percent inadequate weight loss
and second procedure rates, respectively.
17. Bariatric Surgery: A History of
Failure
What are the COSTS?
Jaw Wiring
BioEnterics Intragastric Balloon (BIB)
Vertical Banded Gastroplasty
Lap Band
Sleeve Gastrectomy
18. RNY & VBG
Fail to Cut Healthcare Costs
• Bariatric surgery programs in VA medical
centers.
• 847 were propensity matched to 847
nonsurgical control subjects from the
same 12 VA medical centers.
• Bariatric surgery was NOT associated
with reduced health care expenditures
Arch Surg. 2012 Jul 1;147(7):633-40.
Health expenditures among high-risk patients after gastric bypass and matched controls.
Maciejewski ML,
19. Costs of Failure
American Society for Metabolic and Bariatric Surgery Bariatric Outcomes Longitudinal Database
Gastric banding 22,947 pts in BOLD by 2009
If 100% Fail:
22,947 * (US$ 29 000) = 665 million U.S. dollars
If 50% Fail
22 947 * (US$ 29 000) * 50% = 332 million U.S. dollars
1/3 Billion Dollar Debt for Failed Bands
20. Spectrum Bariatric Surgery
Duodenal Bypass
Restrictive Bilopancreatic Diversion
JI Bypass
Balloon VBG
Jaw Wiring Sleeve
Band
Gastrectomy-Like Malabsorbtive
Alone => Weak Poor Success / High Failure
Rates
21. Outcome after gastrectomy in gastric
cancer patients with type 2 diabetes
Jong Won Kim, etal, Gangnam Severance
Hospital, Yonsei University College of Medicine,
Seoul 135-720, South Korea
World J Gastroenterol. 2012
January 7; 18(1): 49–54.
METHODS:
403 gastric cancer patients with T2DM were studied, who
underwent gastrectomy between May 2003 and
September 2009.
A review of medical records and telephone interviews was
performed in this cross-sectional study.
22. Outcome after gastrectomy in gastric
cancer patients with type 2 diabetes
BMI % Reduction
Gastrectomy
Partial 8.2%
Near Total 14.2%
Duodenal Bypass
No Bypass 7.6%
Bypass 11.4%
23. Outcome after gastrectomy in gastric
cancer patients with type 2 diabetes
Diabetes Improvement/Resolution:
Gastrectomy
Partial 40%
Near Total 60%
Duodenal Bypass
No Bypass 37%
Bypass 52%
24. Bariatric surgery: a systematic review and
network meta-analysis of randomized trials.
Obes Rev. 2011 Aug;12(8):602-21. doi: 10.1111/j.1467-789X.2011.00866.x. Epub 2011 Mar 28.Padwal R, Klarenbach S,
Wiebe N, Birch D, Karmali S, Manns B, Hazel M, Sharma AM, Tonelli M.Department of Medicine, University of
Alberta, Edmonton, Alberta, Canada.
31 RCTs involving 2619 patients; BMI Decrease
• Jejunoileal bypass [ -11.4 kg/m(2) ]
• Mini-gastric bypass [-11.3 kg/m(2) ]
• Biliopancreatic diversion [-11.2 kg/m(2) ]
• Sleeve gastrectomy [-10.1 kg/m(2) ]
• Roux-en-Y gastric bypass [-9.0 kg/m(2) ]
• Vertical banded gastroplasty [-6.4 kg/m(2) ]
• Adjustable gastric banding [-2.4 kg/m(2) ]
26. IFSO Varianational Committee Survey
Results (Preliminary)
Experience with 39,000 cases in the prior year
Lap Band is a "Poor" Surgery
RNY & Sleeve Surgeons have "lots" of leaks
MGB Surgeons Answered More Correct than Non-
MGB Surgeons
29. Spectrum Bariatric Surgery
Duodenal Bypass
Restrictive Bilopancreatic Diversion
JI Bypass
Balloon VBG
Jaw Wiring Sleeve
Band
Gastrectomy-Like Malabsorbtive
Alone => Weak Poor Success / High Failure
Rates
30. Conclusions
High Failure Rate after Bariatic Surgery that is Restrictive
/ Gastrectomy alone
These Failures Represent HUGE Future Debt
(Billions of Dollars) to our patients, families and their
children
History of Bariatric Surgery/Gastric Cancer Data Shows
Greatest effectiveness for operations that combine
Restrictive/Gastrectomy anatomy with
Duodenal Bypass
