Aspectos paar decidir una conversión
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![Revision of RYGBP (Weight loss failures) (Weight loss failures) ,[object Object],[object Object],[object Object],[object Object],10 V Congreso Internacional de Cirugia Bariatrica y Metabolica Mendoza Argentina May 19 & 20, 2011 Advanced Laparoscopic Surgery Associates Medical Group](https://image.slidesharecdn.com/aspectospaardecidirunaconversin-110719155258-phpapp01/85/Aspectos-paar-decidir-una-conversion-1-320.jpg)
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Aspectos paar decidir una conversión
- 3. “ Since all types of bariatric operations can be defeated, it is virtually impossible to assign all of the “blame” for poor weight loss to the patient. Moreover, many of these patients suffer from obesity-related comorbidities and physical disability. Because morbid obesity is highly resistant to all methods of nonsurgical treatment, it seems unethical to categorically deny the opportunity for patients to have revisional surgery.” Robert Brolin WHY PERFORM REVISION SURGERY?
- 8. 19±9 lb 23±17 lb ±5 lb
- 14. The Pouch
- 15. Pouch Reduction Preservation of GJ Complete Revision
- 18. 2-year follow-up
- 20. Banded gastric bypass superior?
- 26. The Bypass
- 27. Limb Length Studies Study Limb Length BP Roux BMI EWL Inabnet 2005 1 year F/U 50 100 100 150 <50 NS Chobin 2002 5 year F/U 30 75 150 250 <50 >50 NS MacLean 2001 4-6 year F/U 10 100 40 100 <50 >50 NS S Brolin 1992 5 year F/U 15 30 75 150 >50 S
- 30. Annals of Surgery • Volume 244, Number 5, November 2006 “ The gastric bypass limb length does not impact long-term weight loss.”
- 31. No correlation between limb lengths and weight loss after proximal “Fobi/Capella”
- 32. J Gastrointest Surg. 2002 Mar-Apr;6(2):195-203
- 33. 66 GBP 49 D-RY 75cm common channel 12 T-RY re-stapled 5 Loop GBP standard RY (150cm Roux) 48 %EWL 51 %EWL 58.8 %EWL Annals of Surgery • Volume 248, Number 2, August 2008 Single surgeon experience 151 patients over 22 years 55% followup @ 5 years; 28% followup @ 10 years
- 37. Improvement and/or Resolution Buchwald et al. JAMA 2004; 292:1724-1737 Brolin 2008 100% 94% 92% 100% Arthritis 97% Condition Buchwald 2004 Diabetes 84% Hypertension 75% Hyperlipidemia 94% Sleep Apnea 87%
- 42. Obesity Surgery 1992 Achieved BMI 31 kg/m 2 for revisions 79% > 50% EWL
- 44. “ None of the patients undergoing revision of a previous RYGB to a nonmalabsorptive RYGB achieved successful weight loss.” Standard Distal weight loss 68 ± 7 lb 115 ± 12 lb p < .001 satisfaction 78% 90% NS > 50% EWL 45% 52% NS
- 47. Personal Experience Variable Mean ± SD Sample size (n) 212 Female:Male 64:8 Age (years) 46.6 ± 8.12 Initial BMI (kg/m 2 ) prior to first RYGBP 53.2 ± 11.4 BMI (kg/m 2 ) @ time of revision 41.6 ± 7.7 % EWL prior to revision 32.5 ± 20.5 Mean time to revision (years) 8.4 ± 4.59 Advanced Laparoscopic Surgery Associates Medical Group
- 48. Revision Procedures Group 1 Static band (Fobi/Capella) Group II Revision gastroplasty only Group III Adjustable gastric band Group IV Distal ➔ proximal gastric bypass & revision gastroplasty Group V Distal gastric bypass Advanced Laparoscopic Surgery Associates Medical Group
- 49. Results Performance Performance ANOVA & Bonferroni Post Hoc Tests p-value by paired T-test Variable GROUP 1 Fobi GROUP II Revision only GROUP III AGB GROUP IV Distal -> Prox GROUP V Distal TOTAL p-value Followup (years) 2.3 ± 0.96 3.0 ± 2.16 1.3 ± 0.44 3.4 ± 2.13 2.6 ± 0.98 2.6 ± 1.70 NS % EWL before revision 35.4 ± 19.56 32.3 ± 14.66 43.7 ± 11.06 31.2 ± 14.85 40.8 ± 12.86 34.4 ± 16.56 NS % EWL after revision 63.5 ± 17.28 62.2 ± 20.25 60.0 ± 24.79 73.4 ± 25.74 62.0 ± 21.36 63.7 ± 19.62 NS Absolute % EWL 28.1 ± 15.71 29.9 ± 12.02 16.3 ± 14.01 42.2 ± 32.4 21.2 ± 16.06 29.3 ± 16.85 NS p-value < 0.001 < 0.001 < 0.001 < 0.040 < 0.001 < 0.001 Advanced Laparoscopic Surgery Associates Medical Group (5) removed
- 50. Overall Performance p-value determined by Paired T-test % EWL prior to revision 34.4 ± 16.56 % EWL after revision 63.7 ±19.62 Absolute % EWL 29.3 ± 16.85 p-value < 0.001 BMI prior to revision 41.6 ± 7.74 BMI after revision 34.9 ± 7.32 Absolute change in BMI 6.7 ± 7.53 p-value < 0.001 Advanced Laparoscopic Surgery Associates Medical Group
- 51. Patient Satisfaction percent Completely satisfied 80,6% Unsatisfied 19,3% Inadequate weight loss 6,4% Weight recidivism 6,4% Unrealized expectations 6,4% Advanced Laparoscopic Surgery Associates Medical Group
- 52. *Flum et al: Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. JAMA 2005;294:1903-8. Higa K, Ho T, Boone K. Laparoscopic Roux-en-Y gastric bypass: technique and 3-year follow-up. J Laparoscopic & Adv Surg Tech 2001, 11: 377-382 1.9% Mortality among MCARE pts* 0.8% 0 1.4% Brolin Higa-VBG Higa-GBP Higa-Primary Morbidity 21,8% 46,6% 26% 14,8% Mortality 1,3% 0,2%
- 53. Complications *Higa K, Ho T, Boone K. Laparoscopic Roux-en-Y Gastric Bypass: Technique and 3-Year Follow-Up. J Laparoscopic & Adv Surg Tech 2001, 11: 377-382. Advanced Laparoscopic Surgery Associates Medical Group Primary* Brolin Higa Stenosis 4,9% 2% 6% Leaks 0,7% 6% 9,5% Hemorrhage 0,8% NR 2,4%
- 55. Personal Approach weight recidivism abnormal anatomy revise pouch good anatomy add AGB inadequate weight loss good anatomy satiety no surgery poor nutrition good nutrition distal bypass (if compliant) reversal
- 56. AGB after open GBP
- 58. THANK YOU
Notas do Editor
- By the time El Greco arrived in Rome, Michelangelo and Raphael were dead, but their example continued to be paramount and left little room for different approaches. Although the artistic heritage of these great masters was overwhelming for young painters, El Greco was determined to make his own mark in Rome defending his personal artistic views, ideas and style. [16] He singled out Cor reggio and Parmigian ino for p articular prai se, [17] but he did not hesitate to dismiss Mich elan gelo's Last Judgment in the Sistine Chapel ; [f] he extended an offer to Pope Pius V to pain t over the whol e w ork in accord with the new a nd stricter Catholic thinking. [18] When he was later asked what he thought about Michelangelo, El Greco re plie d that &quot;he was a good man, but he did not know how to paint&quot;. [19] And thus we are confronted by a paradox: El Greco is said to have reacted m ost strongly or even condemned Michelangelo, but he had found it impossible to withstand his influence. [20] Michelangelo's influence can be seen in later El Greco works such as the Allego ry o f the Holy League . [21] By painting portraits of Michelangelo, Titian, Clovio and, presumably, Raphael in o ne o f his works ( The Purification of the Temple ), El Greco not only expressed his gratitude but advanced the claim to rival these masters. As his own commentaries indicate, El Greco viewed Titian, Michelangelo and Raphael as models to emulate. [18] In his 17th century Chronicles , Giulio Mancini included El Greco among the painters who had initiated, in various w ays, a re-evaluation of Michelangelo's teachings. [22]
- Inabnet: 1 year Chobin: 5 years MacLean:43-76 months Brolin: 5 years
- Brolin: 5 years MacLean: 43-76 months
- 1 year
- 5 year f/u
- follow-up 55% @ 5 years; 28% @ 10 years