• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Bariatric Surgery: Options, Trends, and Latest Innovations
 

Bariatric Surgery: Options, Trends, and Latest Innovations

on

  • 4,130 views

 

Statistics

Views

Total Views
4,130
Views on SlideShare
4,121
Embed Views
9

Actions

Likes
3
Downloads
265
Comments
0

2 Embeds 9

http://parksmedicallegal.blogspot.com 6
http://medical.drferzli.com 3

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    Bariatric Surgery: Options, Trends, and Latest Innovations Bariatric Surgery: Options, Trends, and Latest Innovations Presentation Transcript

    • George S. Ferzli, MD Joel Ricci, MD
      • Dramatic increase during last 2 decades
      • 2/3 US individuals are overweight
      • 50% of these are obese
      • 5% morbidly obese
      • Rapid growth in BMI subgroups ≥ 35 and ≥ 40
      • Increase in comorbidities
      • 2.5 million deaths per year worldwide from comorbidities
      1. National Center for Health Statistics NHANES IV Report 2. Flegal KM et al: Prevalence and trends in obesity among US adults 1999-2000. JAMA 2002; 288: 1723-1727
    • Derived from Center for Disease Control and Prevention website www.cdc.gov
    • Derived from Center for Disease Control and Prevention website www.cdc.gov
    • Obesity associated conditions Diabetes Hypertension Sleep apnea Congestive heart failure Hyperlipidemia Stroke Coronary Artery Disease Osteoarthritis Gastroesophageal Reflux Disease Non-alcoholic fatty liver Psychological disturbances
      • BMI ≥ 35 kg/m²:
        • Risk of death ≈ 2.5 times greater than if BMI of 20-25 kg/m²
      • BMI ≥ 40 kg/m²:
        • Risk of death 10 times greater
      • Obesity
      • 2 nd leading cause of preventable premature death in US (smoking)
      • Calle et al. N Eng J Med, 1999; (15)341:1097-105.
      • Ali H, Mokdad AH, et al. JAMA 2004;291:1238-1245.
      • Relatively ineffective:
        • Diet with and without support organizations
        • Pharmaceutical agents
      • Only long-term options:
        • Bariatric surgery
        • Metabolic surgery
      • 1991 National Institute of Health Guidelines
        • BMI ≥ 40 or ≥ 35 with significant comorbidities
      • North American Association for the Study of Obesity and the National Heart, Lung, and Blood Institute. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults . Bethesda, Md: National Institutes of Health; 2000. NIH 00-4084.
      • Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292: 1724-37.
      • National Institutes of Health Consensus Development Panel. Gastrointestinal surgery for severe obesity. Ann Intern Med . 1991; 115: 956-961
      • First line of treatment
        • Calorie restriction
        • Exercise regimen
        • Behavior modification
        • Pharmacotherapy
      • Avg. weight loss ≈ 5% to 10% initial body weight at 3 to 6 months
      • Regain weight after 1 to 2 years
      1. Yanovski SZ, Yanovski JA. Obesity. N Engl J Med 2002;346: 591-602
      • Consensus Guidelines 2003
      • Surgical therapy should be considered for individuals who:
        • Have a BMI of greater than 40 kg/m²
        • OR
        • Have a BMI greater than 35 kg/m² with significant comorbidities
        • AND
        • Can show that dietary attempts at weight control have been ineffective
      Derived from American Society of Bariatric Surgery website: www.asbs.org
      • Bariatric Surgery
      Diet Exercise Behavior Modification “ Postoperative care, nutritional counseling, and surveillance should continue for an indefinitely long period.”
      • Obesity related to a metabolic or endocrine disorder
      • History of substance abuse or major psychiatric problem
      • Surgery contraindicated or high risk
      • Women who want to become pregnant within the next 18 months
      • National Hospital Discharge Survey Public-use data file and documentation. Multi-year data CD-ROM. National Center for Health Statistics, 1979-1996.
      • Nguyen et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg 2005; 140: 1198-202.
      • Griffen et al. The decline and fall of the jejunoileal bypass. Surg Gynecol Obstet 1983; 157: 301-8.
      • Shirmer et al. Bariatric Surgery Training: Getting Your Ticket Punched. J Gastrointest Surg 2007;11: 807-12.
      Period or Decade Incidence of surgery Reason for change Late 1970’s Early 1980’s 25,000 procedures per year
      • Innovative procedures
      • gastroplasty
      • loop GBP
      • jejuno-ileal bypass
      Late 1980’s 1990’s 5,000 procedures per year
      • Multifactorial:
      • High M&M
      • Ineffective long-term
      • Perceived failure
      • Surgeon experience
      2000’s 80,000 to 110,000 procedures per year
      • Multifactorial:
      • Laparoscopy
      • Long-term data
      • Centers of Excellence
      • Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292: 1724-37.
      • SjostromL, Lindros AK, Peltonem M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351: 2683-93.
      Study Type and size Effect on weight Effect on comorbidities Buchwald et al. Meta-analysis n = 22,094 pts Mean excess weight loss: 61%
      • Resolution of:
      • Diabetes: 70%
      • HTN: 62%
      • Sleep apnea: 86%
      Swedish Obese Subject trial (SOS) Prospective matched cohort n = 4,047 pts
      • At 10 years:
      • Med: 1.6% gain
      • Surg: 16% loss
      • Improved by surg:
      • Diabetes
      • Lipid profile
      • HTN
      • Hyperuricemia
      • Jejuno-ileal bypass
        • 70% excess wght loss
        • Reduced caloric intake
        • Malabsorption
        • Dehydration
        • Acidosis
        • Electrolyte abnormalities
        • Liver failure
        • Bacterial overgrowth
      • Griffen WO Jr, Bivins BA, Bell RM. The decline and fall of the jejunoileal bypass. Surg Gynecol Obstet 1983; 157: 301-8 .
      • Loop gastric bypass
        • Reduced capacitance
        • Aversive eating
        • Dumping syndrome
        • Alkaline reflux gastritis
        • Esophagitis
      • Horizontal gastroplasty
        • “ Gastric stapling”
        • 1970’s
        • Regained weight
        • Many pts left
          • GERD
          • Obesity
          • May seek re-operation for correction anatomy
      • Salmon PA. Salvage of failed horizontal gastroplasty by the addition of a distal gastric bypass. Obes Surg 1993;3:45-51.
    •  
      • “ Gold Standard”
      • 80% of bariatric proc.
      • Lap vs Open
      • Restrictive and Malabsorptive:
        • Reduced calorie intake
        • Macronutrient malabsorption
      • Pouch formation:
        • Small gastric pouch
        • 15-30 mL
        • Transect vs Stapling
        • Re-inforcement of staple line
      • Roux limb creation:
        • 15 to 100 cm distal to Ligament of Treitz
        • Jejuno-jejunostomy 75 to 150 cm down Roux limb
        • Long limb bypass: ↑ weight loss from malabsorption
      • Brolin RE. Long limb Roux en Y gastric bypass revisited. Surg Clin North Am 2005;85:807-17, vii.
      • Roux limb orientation:
        • Antecolic vs Retrocolic
        • Antegastric vs Retrogastric
        • Surgeon’s preference
        • Antecolic:
          • May lead to high tension gastro-jejunostomy
            • Ischemic strictures and ↑ bile leak rate
            • No literature supporting this hypothesis
          • No evidence of protection against internal hernias
        • Retrocolic:
          • Shorter
          • Creation of transverse mesocolic defect
      • Edwards MA et al. Anastomotic leak following antecolic versus retrocolic laparoscopic Roux-en-Y gastric bypass for morbid obesity. Obes Surg 2007;17:292-7.
      • Bertucci W, et al. Antecolic laparoscopic Roux-en-Y gastric bypass is not associated with higher complication rates. Am Surg 2005;71:735-7.
      • Carmody B, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 205;1:543-8 .
      • Gastrojejunostomy
        • Circular stapler
          • ↑ risk of wound infection (10%)
          • May be lower if protected stapler
        • Linear stapler
        • Hand-sewn
      • Drainage placement
        • Monitors for leak or post-op bleeding
        • Surgeon’s preference
      • Post op water-soluble contrast study
        • Evaluates for leaks before resuming po intake
      • Podnos YD, et al. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg 2003;138:957-61.
      • Dallal RM, et al. Back to basics – clinical diagnosis in bariatric surgery. Routine drains and upper GI series are unnecessary. Surg Endosc 2007;21:2268-71. Epub 2007 May 5.
      • Katasani VG, et al. Water-soluble upper Gi based on clinical findings is reliable to detect anastomotic leaks after laparoscopic gastric bypass. Am Surg 2005;71:916-8, discussion 918-9.
      • Brolin RE. Long limb Roux en Y gastric bypass revisited. Surg Clin North Am 2005;85:807-17, vii.
      • Higa KD, Ho T, Boone KB. Internal hernias after laparoscopic Roux-en-Y gastric bypass: Incidence, treatment and prevention. Obes Surg 2003;13(3):350–4.
      • Dallal RM, et al. Back to basics – clinical diagnosis in bariatric surgery. Routine drains and upper GI series are unnecessary. Surg Endosc 2007;21:2268-71. Epub 2007 May 5.
      Controversy Study Type and size Results Defunctionalized jejunum limb lenght Brolin et al. Prospective (n = 45) 22 pts: 75 cm length 23 pts: 150 cm length Mean f/u: 43 ± 17 m
      • Mean exc. wght loss:
      • 50% for short limb
      • 64% for long limb
      • No difference in complications
      • Internal hernia
      • Lap vs Open
      • Roux limb position
      • Mesocolic closure
      Higa et al. Retrospective (n = 2000)
      • Hernia site:
      • mesocolic: 67%
      • Jejunal: 21%
      • Petersen: 7.5%
      • Leaks or bleeding:
      • Drain placement
      • UGI series
      Dallal et al. Prospective (n = 352) No drains or UGI Small complication rate recognized from tachycardia
      • Popular in 80’s and 90’s
      • Less common than RYGB
      • Purely restrictive
        • Rapid sense of satiety
        • Reduced calorie intake
      • Pouch creation
        • Hole through anterior and posterior wall
        • Staple line to angle of His
        • Nondistensible band around distal neo-pouch
      • Randomized trials:
        • VBG vs RYGB
        • Better weight loss w/ RYGB
        • Similar operative risks
      • Replaced by Adjustable gastric band
        • Similar outcomes
        • Technically easier
      • Hall JC, Watts JM, O’Brien PE, Dunstan RE, Walsh JF, Slavotinek AH, et al. Gastric surgery for morbid obesity. The Adelaide Study. Ann Surg 1990;211:419-27.
      • Howard L, Malone M, Michalek A, Carter J, Alger S, Van Woert J. Gastric bypass and vertical banded gastroplasty – a prospective randomized comparison and 5 – year follow-up. Obes Surg 1996;5:55-60.
      • Dr. Cadiere 1992
      • Technically simple
      • Purely restrictive
        • Decrease hunger
        • Early satiety
        • Food aversion
      • Adjustment to stoma diameter
      • Pouch creation
        • “ Pars flaccida” technique
          • Proximal stomach dissection
        • Band placement and fixation
        • SQ port placement
      • Long-term follow up less studied
      • Proper adjustement of band is paramount
      • Scopinaro (Italy)
      • Significant weight loss
        • 75% excess weight loss
        • Maintained > 20 yrs
      • Super-morbid obesity
        • BMI ≥ 60 kg/m²
      • Restrictive
      • Malabsorptive
      • Decreased hunger
        • Hormonal changes: distal delivery of nutrients
      • Marinary GM, Murelli F, Camerini G, Papadia F, Carlini F, Stabilini C, et al. A 15 year evaluation of biliopancreatic diversion according to the Bariatric Analysis Reporting Outcome (BAROS). Obes Surg 2004;14:325-8.
      • Scopinaro N, Gianetta E, Adami GF, Friedman D, Traverso E, Marinari GM, et al. Biliopancreatic diversion for obesity at eighteen years. Surgery 1996;119:261-8.
      • Partial gastrectomy
        • 200 – 500 ml gastric pouch
      • Ileal transection
        • 250 cm above ileocecal valve
      • Gastro-ileal anastomosis
      • End-to-side ileoileostomy
        • 50 cm proximal to ICV
      • Alimentary channel = 200 cm
      • Common channel = 50 cm
      • 1988
        • Hess et al.
        • Marceau et al.
      • Longer common channel
      • Pylorus preservation
      • Restriction
      • Malabsorption
      • Decreases
        • Diarrhea
        • Dumping syndrome
        • Ulcerogenesis
      • Sleeve gastrectomy
        • 150 – 200 ml reservoir
        • Over 35 – 60 Fr bougie
      • Roux limb
        • 150 cm
      • Distal common channel
        • 100 cm
        • “ Duodeno-ileal switch”
      • Higher degree of difficulty
        • Multiple enteric anastomoses
      • Supersuper obese (BMI > 55 kg/m²)
      • 75% excess body weight loss
      • 2 stage procedure:
      • Regan JP, et al. Early experience with two stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 2003;13:861-4.
      • Cottam D, et al. Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Surg Endosc 2006;20:859-63.
      • Induced weight loss:
        • Improves comorbidities before 2 nd operation
      • Silechia et al:
        • 41 superobese pts
        • 2 nd stage operation
        • 60% resolved comorbidities
        • 24% resoved prior to 2 nd procedure
      • Avoids complications:
        • Anastomotic leak
        • Stricture
        • Internal hernia
      • Silechia G, et al. Effectiveness of laparoscopic sleeve gatrectomy (first stage of biliopancreatic diversion with duodenal switch) on comorbidities in super obese high-risk patients. Obes Surg 2006;16:1138-44.
      • Frezza EE, et al. Laparoscopic vertical sleeve gastrectomy for morbid obestiy. The future procedure of choice? Surg Today 2007;37:275-81.
      • OPEN
      • ↑ post op pain
      • Longer hospitalizations
      • ↑ wound complications
        • Infection
        • Hernias
        • Seromas
      • Return to work in 4-8 weeks
      • LAPAROSCOPIC
      • ↓ post op pain
      • Early mobility
      • ↓ Wound complications
      • 2-3 day hospital stay
      • Return to work in 1-3 weeks
      • Nguyen NT, et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg 2005;140:1198-202.
      • RYGB:
        • Avg. % excess weight loss = 70% at 1 year post op
        • Inversely related to preoperative BMI
        • 50% maintenance weight loss up to 15 years post op
      • Pories WJ, Swanson MS, MacDonald KG, Long SB, Morris PG, Brown BM, et al. Who would have thought it ? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;22:339-50, discussion 350-2.
      0 10 20 30 40 50 60 70 80 90 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Year Post-Op % EWL )
      • VBG vs LAGB
        • Similar % excess weight loss:
          • 38% at 12 months
          • 45% at 24 months
          • 54% at 36 months
        • European trials: LAGB up to 70%
      • Ren CJ, Horgan S, Ponce J. US experience with the LAP-BAND system. Am J Surg 2002;184(6B):46S-50S.
      • Belachew M, Belva PH, Desaive C. Long term results of laparoscopic adjustable gastric banding for the treatment of morbid obesity. Obes Surg 2002;12:564-8.
      • RYGB vs LAGB
        • Recent Italian randomized study
        • 5 year follow-up
        • RYGB: significantly lower weight and BMI
      • BPD or Duodenal switch
        • Greater weight loss in super-obese
        • 70% excess weight loss up to 25 yrs post op
        • Minimal rebound at 10 yrs post op
      • Angrisani L, et al. Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5 year results of prospective randomized trial Surg Obes Relat Dis 2007;3:127-32, discussion 132-2.
      • Prachand VN, et al. Duodenal switch provides superior weight loss in the super-obese (BMI > 50) compared with gastric bypass. Ann Surg 2006;244:611-19.
      • De Maria EJ, Schauer P, Patterson E, Nguyen NT, Jacob BP, Inabnet WB, et al. The optimal surgical management of the super-obese patient: the debate. Presented at the annual meeting of the Society of American Gastroenterology and Endoscopic Surgeons, Hollywood, Florida, USA, April 13-16, 2005. Surg Innov 2005;12:107-21.
      • Surgical patients vs Control subjects
      • Recent studies:
        • Mortality decreased by 40% in surgical group
        • Long-term death lower in surgical group
      • Multiple studies:
        • Weight loss and improved comorbidities
        • 30% to 85% Reduced Mortality
        • compared to nonsurgical care
    • Schauer, et al. Ann Surg 2000 Oct;232(4):515-29 N=104 1 year post op Number Pre-op % Worse % No change % Improved % Resolved Osteoarthritis 64 2 10 47 41 Hypercholesterolemia 62 0 4 33 63 GERD 58 0 4 24 72 Hypertension 57 0 12 18 70 Sleep Apnea 44 2 5 19 74 Hypertriglyceridemia 43 0 14 29 57 Peripheral Edema 31 0 4 55 41 Stress Incontinence 18 6 11 39 44 Asthma 18 6 12 69 13 Diabetes 18 0 0 18 82 Average 1.6% 7.8% 35.1% 55.7% 90.8% Improved or Resolved
      • Rapid decrease in serum blood sugar
      • Decrease in medication requirements
      • 66% to 75% complete resolution
      • Increased insulin sensitivity
      • Inhibits progression of disease
      • Swedish Obese Subject Trial:
        • Reduced relative risk by factor of 30 compared to medically treated population
      • Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292: 1724-37.
      • Pories WJ, Swanson MS, MacDonald KG, Long SB, Morris PG, Brown BM, et al. Who would have thought it ? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;22:339-50, discussion 350-2.
      • SjostromL, Lindros AK, Peltonem M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351: 2683-93.
      • 50% complete resolution
      • 25% reduced medications
      • Swedish Obese Subject Trial: 2 years post op
        • Decreased relative risk of new onset HTN = 10
      • Time interval for resolution not cleared
      • SjostromL, Lindros AK, Peltonem M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351: 2683-93.
      • 70% prevalence in gastric bypass pts
      • 80% improvement
      • No more CPAP
      • Decreased pCO2
      • Increased pO2
      • Dixon JB, et al. Predicting sleep apnea and excessive day sleepiness in the severity obese: indicators for polysomnography. Chest 2003;123:1134-41.
      • Sugerman HJ, et al. Gastric surgery for respiratory insufficiency of obestiy. Chest 1986;90:81-6.
      • Non-alcoholic fatty liver:
        • Resolution of steatosis
        • Improved liver contour
      • Osteoarthritis:
        • 50% reduced medication intake
        • Decreased joint stress from weight loss
        • Delayed operative joint intervention
      • Depression:
        • High prevalence in obese
        • Decreased medication use
      • Clark JM, et al. Roux-en-Y gastric bypass improves liver histology in patients with non-alcoholic fatty liver disease. Obes Res 2005;13:1180-6
      • Abu-Abeid S, et al. The influence of sugically-induced weight loss on the knee joint. Obes Surg 2005;15:1437-42.
      • Sarwer DB, et al. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg 2004;14:1148-56.
      • Surgical
        • Technical errors
        • Errors in judgment
        • Type of procedure
      • Metabolical
        • Malabsorption
          • Nutrients
          • Vitamins
      • Mason EE, et al. Causes of 30-day bariatric surgery mortality: with emphasis on bypass obstruction. Obes Surg 2005;71:9-14 .
    •  
      • 0.5% to 4% rate
      • DVT prophylaxis
        • HSQ
        • LMWH
      • High pre-op risk:
        • Heparin
        • Coumadin
        • IVC filters
      • Sapala JA, et al. Fatal pulmonary embolism after bariatric operations for morbid obesity: a 24-year retrospective analysis. Obes Surg 2003;13:819-25.
      • Prystowsky JB, et al. Prospective analysis of the incidence of deep venous thrombosis in bariatric surgery patients. Surgery 2005;138:759-63.
      • 0.5% to 1% rate
      • Obesity
      • Cardiac comorbidities
      • Pre-op stress testing
      • Long term benefit out-weights slightly increased risk
      • McCullough PA, et al. Cardiorespiratory fitness and short-term complications after bariatric surgery. Chest 2006;130:517-25 .
      • 2% to 4% incidence
      • Gastrojejunostomy
      • Gastric stapled line
      • Systemic symptoms
        • Tachycardia
        • Tachypnea
        • Fever
        • Hypoxia
        • Extreme anxiety
      • Hamilton EC, et al. Clinical predictors of leak after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc 2003;17:679-84.
      • Prevention
        • Intraoperative
          • Visual inspection
          • Water-tight seal
          • Re-inforce staple line
      • Recognition
        • Imaging
          • CAT scan
          • Contrast study
        • Exploration
      • Gonzalez R, et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg 2007;204:47-55.
      • Gonzalez R, et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg 2007;204:47-55.
      • 4% incidence
      • Acute
      • Chronic
      • ↑ Risk if anticoagulation
      • Prevention
        • Hemostasis
        • Reinforce anastomosis
      • Recognition
        • Physical Exam
        • Drains
        • Hgb/Hct
        • EGD
        • CAT Scan
      • 5% to 20% incidence
      • Less in laparoscopic vs open
        • Laparoscopic wounds heal faster
      • Risk factors in obese:
        • Thick layer of SQ fat -> liquefaction fat necrosis
        • Lower SQ tissue Oxygen tension
      • 5 to 20 days post op
      • Wound opening & packing
      • Revision of port site in LAGB
        • Rule out band erosion into gastric lumen
        • EGD
      • Podnos YD, et al. Complications after laparoscopic gastric bypass: a review of 3464 case. Arch Surg 2003;138:957-61.
      • Anaya DA, et al. The obese surgical patient: a susceptible host for infection. Surg Infect (Larchmt) 2006;7:473-80.
      • Kabon B, et al. Obesity decreases perioperative tissue oxygenation. Anesthesiology 2004;100:274-80.
      • Early and Late
      • Small bowel anastomosis
      • 2% to 8% incidence
      • ↑ with Laparoscopic approach
      • Adhesions: months to years post op
      • Internal hernias through defects:
        • Small bowel mesentery
        • Transverse mesocolon
      • Obstruction
        • Perforation of gastric remnant
        • Blow-out duodenal stump
      • Prevention
        • Closure of defects
        • Substantial anastomosis
        • Loop orientation
      • Recognition
        • Distention
        • Nausea & Vomiting
        • Contrast studies
        • CAT scan
      • Arshava EV, et al. Delayed perforation of the defunctionalized stomach ater Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2006;2:472-6, discussion 476-7.
      • Complete vs Partial
      • Type:
        • I: proximal roux limb
        • II: proximal bile limb
        • III: common limb
      • Cho et al.
        • 1400 pts
        • Antecolic-antegastric
        • 1.5% incidence of internal hernias
      • Cho M, et al. Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases. Surg Obes Relat Diseas 2006;2:2 87 – 91.
      • .
    •  
      • After gastric banding
      • Early post op
      • Band volume adjustment
      • Outlet obstruction
        • Small band size
        • Edema and inflammation
      • Non-operative management
      • If persistent: re-operation
        • Excision of perigastric fat under band
        • Replacement with larger size
      • Shen R, et al. Removal of perigastric fat prevents acute obstruction after Lap-Band surgery. Obes Surg 2004;14:224-9.
      • Patel SM, Shapiro K, Abdo Z, Ferzli GS. Obstructive symptoms associated with the Lap-Band in the first 24 hours. Surg Endosc 2004;18:51-5.
      • RYGB and BPD
        • Bypass pyloric sphincter
      • After meals (sweets)
      • Early: Osmotic gradient
      • Late: Reactive hypoglycemia
      • Lightheadedness
      • Dizziness
      • Sweating
      • Bloating
      • Diarrhea
      • Partial obstruction
        • Gastrogastrostomy
        • Gastrojejunostomy
      • 5% to 15% incidence after RYGB
      • 4 to 8 weeks after procedure
      • Postprandial nausea & vomiting
      • EGD
      • Pneumatic balloon dilation
        • < 15mm -> recurrent stenosis
        • 70% to 80% cure rate
        • Rule out ulcer
      • Persistent -> Operative revision
      • Schwartz ML, et al. Stenosis of the gastroenterostomy after laparoscopic gastric bypass. Obes Surg 2004;14:484-9.
      • Peifer KJ, et al. Successful endoscopic management of gastrojejunal anastomotic strictures after Roux-en-Y gastric bypass. Gastrointest Endosc 2007;66:248-52.
      • LAGB
      • Recent studies:
        • 25% incidence
        • < 1% need to remove band
        • Improved by deflation of band
        • Achalasia-type symptoms
      • If suspected:
        • Barium swallow
        • Band deflation
      • Early resolution of Sx
      • Dargent J. Esophageal dilatation after laparoscopic adjustable gastric banding: definition and strategy. Obes Surg 2005;15:843-8.
      • De Maria EJ, et al. High failure rate after laparoscopic adjustable silicone gastric banding for treatment of morbid obesity. Ann Surg 2001;233:809-18.
      • LAGB
      • 2% to 4% incidence
      • Obstructive symptoms
      • Band orientation change
        • Plain film
      • Posterior: perigastric technique
      • Anterior: “pars flaccida”
        • Less common
      • Deflation of band
      • Laparoscopic revision
      • Khourseed M, et al. Slippage ater adjustable gastric banding according to the pars flaccida and the perigastric approach. Med Princ Prac 2007;16:110-113.
      • Keidar A, et al. Band slippage after laparoscopic adjustable gastric banding: etiology and treatment. Surg Endosc 2005;19:262-7.
      • Months to years after LAGB
      • 1% to 2% incidence
      • Epigastric pain
      • Persistent port site infection
      • EGD:
        • Black foreign body in cardia region
      • Avoid plication sutures over buckle of band
      • 15% incidence in RYGB
      • Less common after Duodenal Switch
        • Gastro duodenal continuity
      • Epigastric pain
        • Heartburn
        • Upper GI bleeding
      • Risk factors:
        • NSAID’s
        • Large pouch
        • Non-absorbable sutures
      • EGD
      • Contrast study
        • Rule out gastro-gastric fistula
      • Rasmussen JJ, Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Surg Endosc 2007;21:1090-4.
      • Sacks BC, et al. Incidence of marginal ulcers and the use of absorbable anastomotic sutures in laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006;2:11-6.
      • Capella JF, et al. Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes Surg 1999;9:22-7.
      • Rapid weight loss -> Gallstone formation
      • 50% incidence
        • 10% symptomatic
      • Adjunt cholecystectomy
        • Cholelithiasis or cholecystitis at time or operation
      • Ursodeoxycholic acid:
        • ↓ incidence of gallstones post op by 30%
      • Post op anatomy:
        • Difficult management of pancreatitis, CBD stones
      • Sugerman HJ, et al. A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric bypass induced rapid weight loss. Am J Surg 1995;169:91-6.
      • Taylor J, et al. Is routine cholecystectomy necessary at the time of Roux-en-Y gastric bypass? Obes Surg 2006;16:759-61.
      • Ceppa FA, et al. Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2007;3:21-4.
      • RYGB
        • Transected/Occluded Lumen
      • Recanalization -> Fistula
      • 2% to 25% incidence
      • Risk factors:
        • Anastomotic leak
        • LUQ abscess
      • Long-term consequence:
        • Marginal ulcer
        • Suboptimal weight loss
        • Sudden weight gain
      • Carrodeguas L, et al. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Surg Obes Relat Dis 2005;1:467-74.
      • Gumbs AA, et al. Incidence and management of marginal ulcerations after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006;2:460-3.
      • GI contrast study
      • EGD
      • Indications for Rx:
        • Symptomatic ulcers
        • Suboptimal weight loss
      • PPI’s
      • Sucralfate
      • Surgical revision
      • Laparoscopic Remnant Gastrectomy
        • Cho et al.
        • 1400 pts w/ RYGB
        • 21 pts w/ GGF (1.5%)
        • 15 underwent LRG
        • No recurrence of GGF
        • No mortality
      1. Cho M, et al. Laparoscopic Remnant Gastrectomy: A Novel approach to Gastrogastric fistula after Roux-en-Y gastric bypass for morbid obesity. J Am Coll Surg 2007;4:617-24.
    • Carbohydrate Lipid Proteins Ca²+ Fe ²+ B 12 A, D, E, K
      • Restrictive:
        • Intolerance
        • Inadequate weight loss
        • Complications
      • Combined:
        • Enlarged pouch
        • Regained weight
        • Gastro-gastric fistula
      • Band deflation
      • Replacement size
      • Conversion to RYGB
      • Conversion to Duodenal Switch
      • Multiple Short Studies
        • Short follow up
      • Conversion is safe with significant weight loss and lower BMI
      • Decrease pouch size
      • Lengthen biliary limb
      • Distal jejuno-ileal anastomosis
        • Increases malabsorption
        • May increase weight loss
      • Mason EE, et al. Optimizing results of gastric bypass. Ann Surg 1975;182(4):405-14.
      • Fobi MA, et al. Revision of failed gastric bypass to distal Roux-en-Y gastric bypass: a review of 65 cases. Obes Surg 2001;11(2):190-5.
      • Metabolic Surgery
      • Surgical resolution for Diabetes?
        • Too fast to be accounted to weight loss alone
      • Duodenojejunal Bypass (DJB)
        • Non-obese Rat models
        • Complete resolution of diabetes
      • Intestinal bypass
        • Hormonal regulation
        • Foregut vs Hindgut hypothesis
      • Rubino F. Bariatric Surgery: Effects on Glucose Homeostasis. Curr Opin Clin Nutr Metab Care 9:497-507
      • Duodenum divided just below pylorus
      • Both limbs: 75cm
      • Gastrojejunostomy:
        • 50% hand-sewn
        • 50% stapled
      • Duodenojejunostomy:
        • 100% hand-sewn
      • Promising glucose control at 6 to 12 months
      • Non drug alternate maintenance for non obese diabetes
      • Resolution of:
        • Metabolic Syndrome
      • Endoscopic plication of the pylorus with laparoscopic gastrojejeunostomy
      • N.O.T.E.S
        • Endoscopic plication of the pylorus
        • Endoscopic transgastric gastric jejeunostomy
      • Human multicenter trials underway
      • Kantsevoy SV, et al. Technical feasibility of endoscopic gatric reduction: a pilot study in a porcine model. Gastrointes Endosc 2007;65:510-3.
      • Deviere J, et al. Safety, feasibility and weight loss after trans-oral gastroplasty (TOGA): first human multicenter study. Surg Endosc 2007;21(suppl 1): S303.
    •