Perché ancora il Bendaggio Gastrico?

1. Perché ancora il Bendaggio Gastrico? Fabrizio Bellini ChirurgiaBriatrica e Metabolica Desenzano

2. 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."

3. Gastric Band is still a major bariatric surgical procedure for obesity • 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

4. No other Bariatric Surgical Approach has these peculiarities • Can be used in wide variety of patients, including adolescents • Highly reproducible laparoscopic technique • Short learning curve • Few complications with very low mortality rate • Adjustability • Total reversibility and all surgical options remain open • Acceptable results in terms of %EWL • Is an excellent first step procedure for the super-morbidly obese

5. Too many complications?? Was the report from pioneer bariatric surgeons! • Relatively poor design of bands/ports (rigid, tiny, no cincunferential pressure ......)

6. The materials has changed… marlex mesh, dacron vascular prosthesis, silicone covered mesh, Gore-Tex, silicon drains…….

9. Which technique, for the best results? Pars Flaccida Approach Perigastric The fusion of the two technique Two steps “FloppingBand” Band setting “StitchedBand”

10. Technical “guidelines” • Minimal dissection of the gastrophrenic ligament • The ”two-steps” technique • The band fixation • Gastro-gastric “Rossetti-like” stitch • The new life stile . The scrupulous follow up

11. Minimal Dissection of the gastro-frenic ligament

12. The “two steps” perigastric technique The peri and retrogastric tunnel was performed in a single step OLD TECHNIQUE “one step” with high risk of cauterization and gastric wall injury Perigastric approach 1° step: retrogastric tunnel NEW TECHNIQUE “ two steps” 2° step: perigastric tunnel

13. The “two steps” technique The same of the “pars flaccida” First step Peculiar Second step No risk of damaging the gastric wall. No complications.

14. The “two steps” technique Why are we still performing the perigastric technique?

15. The “two steps” technique Perigastric • 5-10% • acute postoperative stenosis • in Pars Flaccida Technique!! Pars Flaccida

16. The “two steps” technique Perigastric Pars Flaccida • Correct band use • Homogeneous calibration • NO homogeneous calibration • Early risk of acute obstruction

17. 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!

18. The “two steps” perigastric technique No openings for Posterior Slippage!!! No possibilities for Posterior Slippage!!!

19. Band Fixation Two stitches from the gastric fundus to the cardial region • Very near to the band • Gastro-gastric stitch No stitches on the left crus!!!

20. 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

21. Band Fixation • A. Bécaud, 58 non fixed Bands (Allergan) 2 acute slippages • 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

22. Gastro-gastric stitch The “Rosseti-like stitch” avoids slippage of the gastric wall trough the band. The same as performed in the “Nissenfundoplicatio”

23. The new life stile and scrupulous follow up Motivation and long-term commitment, are critical for successful weight reduction following LAGB.

24. The new life stile and scrupulous follow up We must be partners with our patients! • Teaching the “ new eating behaviour “ • Small bite • Good food • Chew well • Swallow • Wait a minute Best Patient Care: Better Outcomes Better Outcomes = Lower Exposure to complications

25. Medical Nutrition Surgery Support Groups Psychology Nursing Education Exercise

26. “Bariatric and Metabolic Unit” Desenzano Dr F. Bellini “ Obesity Surgery Center” Policlinico Monza Dr P. Pizzi 3236 Heliogast System® 2002 2012

30. 3236 Patients: 10 Years Results • Major and Minor Complications Requiring SURGERY

31. Conclusion The “two-step” technique is not the perigastric technique as commonly thought!!!

32. Conclusion • The minimal dissection of the gastro-frenic ligament avoids slippage of the gastric fundus • The “two-step” technique is: • technically simple • avoids intimate posterior gastric wall dissection • facilitates tight posterior band support • dramatically reduces posterior slippage • The band fixationavoids early slippage and reduction of slippage percentage although the patient behaviour • The “Rossetti-like stitch avoids stomach slippage trough the band • The new Port with 360° accessibility, avoids problems with rotation/malposition

33. Learn from experience of others! Need not repeat mistakes….. .