Perch il Bandaggio Gastrico Perch ancora il Bendaggio
Perchè il Bandaggio Gastrico Perché ancora il Bendaggio Gastrico? Fabrizio Bellini Chirurgia Briatrica e Metabolica Desenzano
Perchè il Bandaggio Gastrico All over the world more than 800. 000 Gastric Bands have been placed! Why such a success…? According to the World Health Organization: “worldwide obesity has more than doubled since 1980 to over 500 million people and keeps increasing and the related costs to public health and the economy are skyrocketing…. . ” "Global obesity is a mega-investment theme for the next 25 years and beyond. "
Perchè il Bandaggio Gastric Band is still a major bariatric surgical procedure for obesity q q Safe : the lowest % of mortality Effective : - ≥ 50 % excess weight loss - Major co-morbidity benefits - Improved quality of life - Durable up to 15 years, so far “Gentle approach” - Minimally invasive - Adjustable Cost –Effective
Perchè il Bandaggio Gastrico No other Bariatric Surgical Approach has these peculiarities q Can be used in wide variety of patients, including adolescents q Highly reproducible laparoscopic technique q Short learning curve q Few complications with very low mortality rate q Adjustability q Total reversibility and all surgical options remain open q Acceptable results in terms of %EWL q Is an excellent first step procedure for the supermorbidly obese
Perchè il Bandaggio Gastrico Too many complications? ? Was the report from pioneer bariatric surgeons! q Relatively poor design of bands/ports (rigid, tiny, no cincunferential pressure. . . )
Perchè il Bandaggio Gastrico The materials has changed… marlex mesh, dacron vascular prosthesis, silicone covered mesh, Gore. Tex, silicon drains…….
Perchè il Bandaggio Gastrico
Perchè il Bandaggio Gastrico
Perchè il Bandaggio Gastrico Which technique, for the best results? Pars Flaccida Approach Perigastric Two steps The fusion of th “Flopping Band” Band setting “Stitched Band” e two techniqu e
Perchè il Bandaggio Gastrico Technical “guidelines” 1. Minimal dissection of the gastrophrenic ligament 2. The ”two-steps” technique 3. The band fixation 4. Gastro-gastric “Rossetti-like” stitch 5. The new life stile. The scrupulous follow up
Perchè il Bandaggio Gastrico 1. Minimal Dissection of the gastro-frenic ligament
Perchè il Bandaggio Gastrico 2. The “two steps” perigastric technique OLD TECHNIQUE “one step” The peri and retrogastric tunnel was performed in a single step with high risk of cauterization and gastric wall injury Perigastric approach NEW TECHNIQUE “ two steps” 1° step: retrogastric tunnel 2° step: perigastric tunnel
Perchè il Bandaggio Gastrico 2. The “two steps” technique The same of the “pars flaccida” First step Peculiar Second step No risk of damaging the gastric wall. No complications. SICOB 2013, Cagliari
Perchè il Bandaggio Gastrico 2. The “two steps” technique Why are we still performing the perigastric technique?
Perchè il Bandaggio Gastrico 2. The “two steps” technique Perigastric 5 -10% acute postoperative stenosis in Pars Flaccida Technique!! Pars Flaccida
Perchè il Bandaggio Gastrico 2. The “two steps” technique Perigastric - Correct band use - Homogeneous calibration Pars Flaccida - NO homogeneous calibration - Early risk of acute obstruction
Perchè il Bandaggio Gastrico 2. The “two steps” technique The “two step” is less familiar and not well-known, but can cover all different anatomical situation!! The perigastric technique is considered “abandoned” by many, but most surgeons have not even tried this approach in theirs gastric Band experience!
Perchè il Bandaggio Gastrico 2. The “two steps” perigastric technique No openings for Posterior Slippage!!! No possibilities for Posterior Slippage!!!
Perchè il Bandaggio Gastrico 3. Band Fixation Two stitches from the gastric fundus to the cardial region q Very near to the band q Gastro-gastric stitch No stitches on the left crus!!!
Perchè il Bandaggio Gastrico 3. Band Fixation Vomiting : the initial and the main cause of the BAND slippage!! With the stitches we reduce the slippage although the patient behaviour Band fixation > Band stability SICOB 2013, Cagliari
Perchè il Bandaggio Gastrico 3. Band Fixation q A. Bécaud, 58 non fixed Bands (Allergan) 2 acute slippages q J. M. Zimmermann, 35 non fixed Bands, (Allergan) 2 acute slippages Total: 93 cases, 4 acute slippages, 4. 3% 2008 a new study A. Bécaud, J. M. Zimmermann SICOB 2013, Cagliari
Perchè il Bandaggio Gastrico 4. Gastro-gastric stitch The “Rosseti-like stitch” avoids slippage of the gastric wall trough the band. The same as performed in the “Nissen fundoplicatio”
Perchè il Bandaggio Gastrico 5. The new life stile and scrupulous follow up Motivation and long-term commitment, are critical for successful weight reduction following LAGB. SICOB 2013, Cagliari
Perchè il Bandaggio Gastrico 5. The new life stile and scrupulous follow up We must be partners with our patients! Teaching the “ new eating behaviour “ q q q Small bite Good food Chew well Swallow Wait a minute Best Patient Care: Better Outcomes = Lower Exposure to complications SICOB 2013, Cagliari
Perchè il Bandaggio Gastrico Medical Nutrition Surgery Support Groups Psychology Nursing Education Exercise
Perchè il Bandaggio Gastrico “Bariatric and Metabolic Unit” Desenzano Dr F. Bellini 2002 3236 Heliogast System® “ Obesity Surgery Center” Policlinico Monza Dr P. Pizzi 2012
Perchè il Bandaggio Gastrico Mean BMI 3236 pts 70. 0 42. 9 60. 0 41. 2 50. 0 40. 0 30. 0 20. 0 10. 0 M F
Perchè il Bandaggio Gastrico BMI EVOLUTION 45 43 41 39 37 35 33 31 29 27 25 Pre op 6 months m f pts 41. 4 42. 2 3236 38. 2 37. 9 3110 12 18 24 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years months 34. 8 33 32. 9 31 31. 2 32 31. 6 30. 9 30. 2 30. 4 31 33 32. 8 30. 3 31. 2 30. 3 31. 6 31 29. 7 30 2993 2767 2412 2110 1754 1423 1010 655 354 199 98
Perchè il Bandaggio Gastrico % EWL TRAND 100 90 80 70 60 50 40 30 20 10 0 Pre op 6 months m f pts 0 0 3236 27 29 3110 12 18 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years months 42 50 51 55 55 54 53 52. 7 51 51. 6 50. 6 46 51 53 53 53 55. 7 53. 9 53. 4 52. 7 51. 9 51. 8 2993 2767 2412 2110 1754 1423 1010 655 354 199 98
Perchè il Bandaggio Gastrico 3236 Patients: 10 Years Results Major and Minor Complications Requiring SURGERY Number Slippage 137 (only anterior) Rate of Complications 4, 23% Surgical approach • Removal • Repositioning Number Rate of Reoperation 55 82 1. 69% 2. 53% Erosion 14 0. 43% Removal 14 0. 43% Psychological Intolerance 19 0. 58% Removal 16 0. 49% Incisional hernia 27 0. 83% Repair 25 0. 77% Port change/repositioning Catheter leak repair 41 1, 26 Repair 41 1. 26 Total 235 7. 26% Total 233 7, 20% 6, 6% • Removal • RYGBP: • BPD 1 74 11 2. 65% Unsatisfactory Results Lack of Compliance <25%EWL 201
Perchè il Bandaggio Gastrico Conclusion The “two-step” technique is not the perigastric technique as commonly thought!!!
Perchè il Bandaggio Gastrico Conclusion 1. The minimal dissection of the gastro-frenic ligament avoids slippage of the gastric fundus 2. The “two-step” technique is: technically simple avoids intimate posterior gastric wall dissection facilitates tight posterior band support dramatically reduces posterior slippage 3. The band fixation avoids early slippage and reduction of slippage percentage although the patient behaviour 4. The “Rossetti-like stitch avoids stomach slippage trough the band 5. The new Port with 360° accessibility, avoids problems with rotation/malposition
Learn from experience of others! Need not repeat mistakes…. . .
- Slides: 33