INCISION-LESS SURGERY: FOR WEIGHT REGAIN AFTER GASTRIC BYPASS

By admin on July 20, 2009 at 10:37 am

I’ve completed my training in a cutting edge technology-and it’s incision-less. Please pardon the pun.  A novel company called USGI has been developing a system to reduce the pouch size from within the pouch itself. It became available in January 2009, and I was selected among a small number of surgeons in the United States to offer this to my patients. I believe it will have a permanent place in the world of weight loss surgery.

I have been performing endoscopy (a lighted scope with camera is inserted into the mouth and guided into the stomach) for over two decades. Through the scope, we have detected peptic ulcers and have treated bleeding, removed polyps as well as large pieces of food that may get stuck, dilated up obstructions with balloons, as well as sealed leaks and perforations with stents. Never before, until now, have we had the opportunity to truly sew within the stomach itself or the gastric bypass pouch.

After several years of performing gastric bypass, we have come to recognize that 5% of our patients may regain some weight. It may not be immediate. Often times it is not apparent until 18 months or several years after surgery. Some patients may only gain a few pounds but some may regain 20 or more pounds. Having the benefit of fluoroscopy (x-ray machine) in the office with the ability to do immediate barium swallows, I have the opportunity to examine these pouches.

Sometimes I find these pouches to be dilated to much larger than when I created it at the time of the original surgery. Because I have often enjoyed an honest relationship with my patients we have shared and discovered the root causes of these dilated pouches. After over 3000 patients, I believe a pouch will dilate in size as a result of three main causes:

• OVEREATING. I ultimately aim to get all patients “full” with 4 oz of food or less. We as human beings sometimes test our limits so we may stretch the pouch out with time. I once had a patient who said she “stops eating when it hurts so much, I can’t stand it”. Eating slowly allows us to listen to our “signals” that we’re full. Thus, chewing our food 25 times and giving ourselves at least 20 minutes to eat. Eating too quickly does not allow us time to listen to these “signals” so we tend to over eat. At the time of surgery, I create a pouch that is 20 cc’s or smaller-that’s about the size of an egg.
• DRINKING AND EATING AT THE SAME TIME. For the same reasons described above.
• DRINKING CARBONATION. Our bodies are 98.6 F or the equivalent of a hot summer day in Dallas. The fizz that we enjoy is carbon dioxide gas or CO2. 98.6 plus CO2 equals a bottle rocket of pressure internally in these pouches causing radial expansion over time.
• POUCH WAS MADE TOO BIG TO BEGIN WITH. This was obviously not the patients fault. I perform a lot of revision surgery and some patients will come to me from other practices with a pouch that was made too big at the original time of surgery.

There are other causes for weight regain such as poor nutrition choices and lack of exercise. That’s why support is important. However, after significant pouch dilation occurs, it will be very difficult to achieve weight loss or maintain your current weight because it may take double the amount of food to feel full. 8 oz meals 3 times a day could lead to tremendous caloric intake that is hard to overcome with proper nutrition and exercise.

For this reason, ROSE was invented. It’s an acronym for Restorative Obesity Surgery. It allows a second chance for patients to shrink down the size of their dilated gastric bypass pouch back to its original size. It will also decrease the size of the opening at the bottom of the pouch, or stoma, as it attaches to the intestine. A dilated stoma can lead to weight regain as well as dumping syndrome. When this becomes dilated, for the 4 above stated reasons, ROSE can shrink or “restore” the size of the pouch and stoma to approach that of its original size. This can allow a patient to start losing weight again.

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As you can see, an endoscope is passed from the mouth into the pouch. All of the operating tools are passed through this scope so the procedure is taking place in the pouch itself with no incisions being made on the surface of the abdomen. Tissue “anchors” made of nitinol create a pleat of stomach tissue the way you create pleats or hemlines in pants. Nitinol is a permanent flexible inert metal. This is the first time a permanent solution has been offered to restore pouch size through a scope. Other operating systems like Stomaphyx came first but did not allow us the ability to take a full thickness “bite” of stomach tissue; thus, our concern that stomaphyx may not lead to permanent pouch reduction.

Postoperatively, the patient is discharged the same day. Sore throat is the most common complaint. Everyone was capable of returning to work the next day, and there were no life threatening complications like perforating the esophagus or stomach in over 120 cases since January 2009.

A patient should know that other options exist for pouch reduction. These include placing a lap band around the dilated gastric bypass pouch as well as surgically cutting the pouch back to a small size and re-creating a small stoma.

If you or someone you know is regaining weight after gastric bypass, make an appointment to see us and examine the options available. We’ll see if you are a candidate for ROSE as well as reviewing your health and considering medical options to weight loss.

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