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

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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.
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