As a result, bariatric surgeons are performing increasing proportions of revisional procedures on our operating lists. Despite the massive positive impacts bariatric surgery has on both the physical and mental health of people, there are certain drawbacks with every type of weight loss procedure. Some of these issues are mild and manageable, however the quality of life of many people is affected to the degree where they require re-operations (revisional bariatric surgery) to improve their wellbeing. Gastric Bands Australia, more than other parts of the world, has seen gastric bands become the predominant bariatric procedure performed over the previous decade. Over 100,000 people in Australia have received a gastric band since 1994. Many people with gastric bands have either had a great deal of success followed by complicated band issues, or have never really succeeded in losing as much weight as they initially hoped for. Sometimes the distortion of the gastro-oesophageal anatomy can produce symptoms that manifest themselves many years later. The common problems seen are band slippage, pouch or oesophageal dilatation, and excessive scar formation beneath the band. The options available to patients in this setting include; removal of the band, attempt at repositioning the band to a more functional position, or removing the band and converting to another weight loss procedure. Removing the band and release of the sub-band scar tissue invariably leads to immediate symptom relief. Simply removing the band however, is likely to lead to weight regain, often to the patient’s initial pre-band weight in the vast majority of patients. Some patients may be amenable to an attempt at repositioning the band or placing a new band in a more satisfactory functional position. This often works well however there exists a significant re-failure rate with this option. Patients electing this avenue may have multiple failures long term and extremely variable weight loss results. Band removal and conversion to another bariatric procedure is becoming increasingly common. The most common options are conversion to a gastric bypass or a sleeve gastrectomy. Band removal and conversion to a gastric bypass can be performed safely in the same procedure in the majority of cases, saving the patient an additional general anaesthetic and operation. Sometimes the scarring or distorted anatomy as a result of the band necessitates removal of the band and a delay of about two months before later conversion to a bypass. Conversion to a sleeve gastrectomy is also possible, however those who do this generally delay the sleeve gastrectomy, due to the higher risk of a combined procedure. The risk of a leak of the staple line is the major concern; this has more serious physiological effects on the patient in the sleeve setting relative to the bypass in which case it is usually self-limiting due to the roux limb effect. Gastric bypass is generally accepted to be the most effective option to induce further weight loss after a failed gastric band. Evidence demonstrates better long-term weight loss, improved food tolerance, and a better quality of life with gastric bypass relative to sleeve gastrectomy following removal of a band. The agreement among international consensus meetings is that a conversion of a band to a bypass is the preferred operation. Sleeve Gastrectomy Sleeve gastrectomy has become the predominant bariatric procedure in Australia since 2010. Its popularity has arisen due to its fewer long-term side effects relative to the gastric band, however it too does have issues, which poses a risk of re-operations. Historically the sleeve gastrectomy was developed as the first operation of a two-step bariatric procedure. The first step involved creating the sleeve, then a second operation usually six to twelve months later involved converting the sleeve into a gastric bypass or duodenal switch procedure. It was noted that after the first step many patients were happy with the modest amount of weight loss created by the sleeve and this technique was further refined to make it a more effective definitive procedure. As longer-term data becomes evident, we are now beginning to see many patients developing late symptoms relating to the sleeve, most commonly reflux at the gastro-oesophageal junction. This reflux can be incapacitating and can severely affect the quality of life of these patients. The reflux in this scenario relates to the high intraluminal pressure of the sleeve, compared to the highly compliant stomach that has been removed. This is a different mechanism to the weakened gastro-oesophageal sphincter seen in non-sleeve patients and therefore merely attempting to repair a hiatal weakness at the diaphragm is not reliably helpful. Some patients may develop a late stricture of the sleeve. This is usually amenable to balloon dilatation, however sometimes patients requires multiple dilatations, and often require temporary stenting. Often a sleeve can twist, or become torted around the lesser omentum causing problems with eating General Hea lth 16 Pindara Magazine Autumn 2015
Pindara Private Hospital Magazine - Issue Four
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