The Skinny on he Role of Endoscopy in Bariatric Surgery

Patricia L Raymond MD FACG Rx For Sanity, Norfolk VA

Obesity is widespread.

Where does endoscopy fit in? pre op assessment endoscopic management of complications primary endoscopic bariatric in the futureNot addressing: selection criteria for bariatric surgery efficacy of bariatric surgery non endoscopic complications of bariatric surgery

Pre op bariatric surgery-controversial prevalence of upper gastrointestinal (GI) symptoms in patients with morbid obesity is higher than that of the general population  H pylori prevalence higher?  cannot get to excluded stomach post op for ulcers, MALT, or cancer American Society of Gastroenterology (ASGE) 2008 guidelines recommend screening EGD in bariatric patients who have symptoms of GERD or dyspepsia  Others recommend for all, even those without symptoms Retrospective study  448 bariatric patients undergoing screening EGD  141 (31%) had abnormal findings  18% resulted in change of medical management and 0.4% change surgical plans

Which endoscopies? EGD with biopsy for H pylori  urease breath or stool antigen tests, accuracy of 96 and 91%  serology assays sensitivity and specificity of greater than 95 percent in patients without atrophic gastritis or intestinal metaplasia  some payers require routine H. pylori screening before bariatric surgery Colonoscopy for all over 60 (Cornell University)

Barrett’s esophagitis Barrett’s esophagitis (BE) incidence in morbid obesity as high as 5.8% regression of Barrett’s esophagus following gastric bypass has been described (better than Nissan in obese patient with BE) 557 RYGBs  BE was identified in 12 (2.1%) of the subjects on routine preoperative endoscopy  Postop endoscopy showed regression of metaplasia in 42%  Need to continue BE surveillance post opNOTE: RYGB stomach remains for use for esophagectomy, VSGleaves no remnant stomach  VSG may be contraindicated in patients with Barrett’s

Bariatric Surgeries as of 2011 Roux-en-Y gastric bypass Vertical banded gastroplasty Laparoscopic adjustable gastric banding Sleeve gastrectomy Sleeve gastrectomy with duodenal switch

Roux-en-Y gastric bypass small stomach pouch only able to hold an ounce of food; over time, the pouch stretches to hold one cup body absorbs fewer calories since food bypasses the duodenum intestinal arrangement (Roux-en-Y) seems to change the release of GI hormones (improved metabolism, decreased Image from: Huang CS. Endoscopy in patients who have undergone bariatric surgery. In: UpToDate, Saltzman JR, Jones D (Ed), UpToDate, Waltham, MA, 2011. Used with permission. appetite)

Roux-en-Y gastric bypass Image from: Huang CS. Endoscopy in patients who have undergone bariatric surgery. In: UpToDate, Saltzman JR, Jones D (Ed), UpToDate, Waltham, MA, 2011. Used with permission.

Vertical banded gastroplasty purely restrictive procedure upper part of the stomach is partitioned by a vertical staple line with a tight outlet wrapped by a prosthetic mesh or band small upper stomach pouch gets filled quickly by solid food and prevents consumption of a large meal Image from: Huang CS. Endoscopy in patients who have undergone bariatric surgery. In: UpToDate, Saltzman JR, Jones D (Ed), UpToDate, Waltham, MA, 2011. Used with permission.

Vertical banded gastroplasty From Huang CS, Farraye FA, Endoscopy in the Bariatric Surgical Patient. Gastroenterol Clin N Am 34 (2005) 151–166

“Lap band” purely restrictive procedure tight, adjustable prosthetic band around the entrance to the stomach soft, locking silicone ring connected to an infusion port placed in the subcutaneous tissue. Image from: Huang CS. Endoscopy in patients who have undergone bariatric surgery. In: UpToDate, Saltzman JR, Jones D (Ed), UpToDate, Waltham, MA, 2011. Used with permission.

“Lap band” Image from: Huang CS. Endoscopy in patients who have undergone bariatric surgery. In: UpToDate, Saltzman JR, Jones D (Ed), UpToDate, Waltham, MA, 2011. Used with permission.

Sleeve gastrectomyMajority of the greater curvatureof the stomach is removed small capacity tubular stomach resistant to stretching due to the absence of the fundus few ghrelin producing cells (a gut hormone involved in regulating food intake). Image from: Huang CS. Endoscopy in patients who have undergone bariatric surgery. In: UpToDate, Saltzman JR, Jones D (Ed), UpToDate, Waltham, MA, 2011. Used with permission.

Duodenal switch partial sleeve gastrectomy with preservation of the pylorus Roux limb with a short common channel significant risks of long- term malabsorption and is used only for patients with very severe obesity (BMI >50 kg/m2). Image from: Huang CS. Endoscopy in patients who have undergone bariatric surgery. In: UpToDate, Saltzman JR, Jones D (Ed), UpToDate, Waltham, MA, 2011. Used with permission.

It would be far easier to lose weight permanently if replacement partswerent so handy in the refrigerator. Hugh Allen

Pulmonary embolism most common cause of mortality in the perioperative period after weight-loss surgery and can over 50 % of deaths

Post op bleeding 0.6 to 4.0 % higher rate laparoscopic versus open GBP surgical anastomotic and/or staple lines, and may be intra- or extraluminal, most commonly intraluminal. usually resolves without surgery, but may require transfusion and reversal of anticoagulation careful endoscopic examination and therapy for continued bleeding with high transfusion needs surgery for hemodynamic instability, intraluminal bleeding not amenable to endoscopic therapy (eg, staple line of the excluded stomach) or continued bleeding despite of normal coagulation

Endoscopy & late complications stomal stenosis marginal ulcers appliance erosion staple line disruption suture material

Stomal stenosis 6 to 20 % with RYGB , higher with LRYGB 20 to 33 percent with VBG several weeks post op with nausea, vomiting, dysphagia, gastroesophageal reflux, and eventually an inability to tolerate oral intake diagnosis by endoscopy or upper gastrointestinal series. endoscopic balloon dilation is usually successful, repeat dilation sessions may be required complication rate for dilation 3 % surgical revision (< 0.05 %) for persistent stenosis despite repeated dilations dilation for VBG may be unsuccessful (32%) due to the rigid nature of the prosthetic band

Stomal stenosis  Dilate to 10-12 mm, no greater than 15 mm  weight regain  Perforation  Recurrent stenosis options  glucocorticoid injection  stent  needle-knife electrocautery N Am 34 (2005) From Huang CS, Farraye FA, Endoscopy in the Bariatric Surgical Patient. Gastroenterol Clin 151–166

Marginal ulcer 0.6 to 16% Causes of marginal ulcers include:  foreign material, such as staples or nonabsorbable suture  NSAIDs  Helicobacter pylori infection  Smoking present with nausea, pain, bleeding and/or perforation diagnosis of a marginal ulcer by upper endoscopy treatment gastric acid suppression +/- sucralfate, treatment of H pylori if present

Marginal ulcer From Huang CS, Farraye FA, Endoscopy in the Bariatric Surgical Patient. Gastroenterol Clin N Am 34 (2005) 151–166

H. Pylori & marginal ulcerspreoperative testingand treatment of H. pylori significantly reduced the incidence of postoperative marginal ulcers(2.4% versus 6.8% in unscreened patients) http://www.bio.davidson.edu/people/sosarafova/Assets/Bio307/vinardone/page01.html

Band or mesh erosion band erosion 7 % of LAGB patients, occurs at a mean of 22 months after surgery 1 to 7 % of VBG, occurs one to three years after the surgery symptoms nausea and vomiting, epigastric pain. hematemesis from erosion of the lap band into the left gastric artery diagnosis endoscopic, treatment is surgical  Reports of endoscopic removal of eroded lap bands

What does band erosion look like?

Staple line disruption results in a fistula to the fundus in VBG occur in 27 to 31 of VBG, may be as high as 48% if assessed on routine postoperative endoscopy weight regain due to increased food consumption, since patients can eat around their restriction without feeling full surgical treatment is conversion to a RYGB or a BPD/Duodenal switch

Staple line disruption From Huang CS, Farraye FA, Endoscopy in the Bariatric Surgical Patient. Gastroenterol Clin N Am 34 (2005) 151–166

OMG Staple line disruption From Huang CS, Farraye FA, Endoscopy in the Bariatric Surgical Patient. Gastroenterol Clin N Am 34 (2005) 151–166

Trial endoscopic methods forfistulae or staple line disruption Expandable stent Full thickness staple Fibrin glue None are successful enough for general application at this time

Symptomatic suture material  pain, marginal ulcers, and obstructive symptoms (secondary to food entrapment/bezoar formation)  removal of foreign body only required if symptomatic  cut the suture material with endoscopic scissors and extract with biopsy or rat-toothed forceps  symptom resolution or improvement in over 80%

Look what we’re NOT looking at:Weeks 1 to 6 (Phase 1) Various/Continous - Bleeding Eating disorders - Anastomotic leaks Nutritional deficiencies - Obstruction Micronutrient deficienciesWeeks 7 to 12 (Phase 2) Psychosocial - Prolonged vomiting - Depression and sadness - Dumping syndrome - Effects of body changesMonths 4 to 12 (Phase 3) Cosmetic issues - Cholelithiasis - Small bowel obstruction - Band erosion - Band slippage

Complications specific toproceduresRoux-en-Y gastric bypass Lap band- Gastric remnant distension - Stomal obstruction- Ventral incisional hernia - Port infection- Internal hernias - Band slippage and gastric- Short bowel syndrome prolapse- Dumping syndrome - Port malfunctionJejunoileal bypass - Esophageal dilatation- Electrolyte imbalances- Renal failure- Cirrhosis

Todays beauty ideal, strictly enforced by the media, is a person with the same level of body fat as a paper clip. Dave Barry

Primary endoscopic bariatric duodenal electrical stimulation duodenal–jejunal bypass sleeve transoral guided staplers (TOGA) intragastric balloon treatment (BIB) gastric wall botulinum toxin

Duodenal electrical stimulation (DES) 12 healthy non-obese volunteers  feeding tube placed in the duodenum under endoscopy.  three ring electrodes at the end tip of the tube and the two distal electrodes were used for recording and electrical stimulation.  On two separate days, water intake test and GES with actual DES or sham randomly assigned No dyspeptic symptoms  DES may have a potential application for the treatment of obesity.

Duodenal electrical stimulation (DES)  Delayed gastric emptying Reduced maximum water ingestion by subjects  drink water at a 37°C temperature over a 5-min period until reaching the point of complete fullness

Various DES devices (under development) System and method for providing electrical pulses to the vagus nerve(s) to provide therapy for obesity, eating disorders, neurological and neuropsychiatric disorders with a stimulator, comprising bi-directionalSensor based gastrointestinal electrical stimulation for the communication andtreatment of obesity or motility disorders network capabilities UnitedUnited States Patent Application 2005022263, 2005 States Patent Application 20050049655 2005 Gastrointestinal stimulation device United States Patent 7054690, 2006

Duodenal–jejunal bypass sleeve duodenal–jejunal bypass sleeve  Endobarrier ™ (GI Dynamics™, Watertown, MA) commercially available in Chile, Germany, the United Kingdom, Netherlands; soon available in Australia. not approved for sale in the US and is considered investigational.  Trial underway at Carolinas Medical Center, Charlotte NC

Duodenal–jejunal bypass sleeve 41 study patients  30 underwent sleeve implantation, 11 diet control group.  All on same low-calorie diet during the study 26 devices were successfully implanted  Unable to implant in 4 .  4 removed before end of study  migration (1), dislocation of the anchor(1), sleeve obstruction (1), and continuous epigastric pain (1). Mean procedure time was 35 minutes (range: 12–102 minutes) for a successful implantation  17 minutes (range:5–99 minutes) for explantation.

Duodenal–jejunal bypass sleeve Adverse events universal  26 sleeve patients (100%) had at least one adverse event  mainly abdominal pain and nausea during the first week BMI was 48.9 and 47.4 kg/m2 for the device and control patients at onset  Mean excess weight loss after 3 months  19.0% for device patients versus 6.9% for control patients (P < 0.002).  Absolute change in BMI at 3 months was 5.5 and 1.9 kg/m2, respectively.  Type 2 diabetes mellitus was present at baseline in 8 patients of the device group and  improved in 7 patients during the study period  lower glucose levels, HbA1c, and medication requirements

Duodenal–jejunal bypass sleevePooled study results following12 months with EndoBarrier: mean absolute weight loss of 20%, or 49.5 pounds mean excess weight loss (EWL) of 46.3% cholesterol levels dropped from 196.5 mg/dL at baseline to 161.0 mg/dL diastolic blood pressure dropped from 84.8 mmHg at baseline to 71.2 mmHg) improved type 2 diabetes (reduction in HbA1c levels).

I want one!?!$5000 anticipated costNot for use > 1 year

Transoral endoscopically guided staplers (TOGA)

Transoral endoscopically guided staplers(TOGA)—revision of procedure?  Retraction wire and sail to keep stomach in proper position as suction is applied and before stapling  Restrictor to pleat/narrow the lower end of the sleeve

Transoral endoscopically guided staplers (TOGA) Mean Average Absolute  11 patients excess BMI weight weight loss  mean BMI 41.6 loss  No SAE1 month 19.2% 9.9 kg  100% successful3 month 33.7% 17.5 kg endoscopic stapling6 month 46% 33.1 24.0 kg

Transoral endoscopically guidedstaplers (TOGA) Pilot Clinical Study – Belgium and Italy As of July 2010 > 180 patients, continuing to recruit, follow up one year Not commercially available No cost analysis available

Intragastric balloon treatment BioEnterics Intragastric Balloon (BIB)  Inamed Health; Santa Barbara, CA, USA  limited to maximum 6 months  Follow up immediately if urine turns blue  Methylene blue plus 500- 700 cc saline  nausea, vomiting and belching within the first 3- 5 days after the BIB introduction, usually disappear within few days

Intragastric balloon treatment 32 patients,  mean BMI 43.7+/-1.5 kg/m2, mean %EW: 43.1 +/- 13.1  BIB followed by sham procedure after 3 months (Group A)  Sham procedure followed by BIB after 3 months (Group B).  BIB filled with saline (500 ml) and methylene blue (10 ml)  Discharged with omeprazole therapy and diet (1000 kcal) No AE from endoscopy, balloon placement and removal. Mean time of BIB positioning was 15 +/- 2 min, range 10-20 min.

Intragastric balloon treatment After the first 3 months Group A patients the mean BMI lowered from 43.5 to 38.0 kg/m2, Group B weight loss not significant.  The mean %EWL was significantly higher in Group A than in Group B (34.0 vs 2.1; P < 0.001).  After crossover, at the end of the following 3 months, the BMI lowered from 38.0 to 37.1 kg/m2 and from 43.1 2 to 38.8 kg/m2 in Groups A and B, respectively.

Want a blue balloon? Available in Germany, Poland, Czech Republic, Estonia, Slovakia, UK Prices range from $1800 - $6500  Concerns  Trials short term and stomach adapts  American grazing behavior verses European large meals

Botulinum toxin  injecting botulinum toxin-A in the stomach wall can be used to manipulate appetite and reduce food intake  This slows down the process of stomach contraction so that food takes longer empty stomach and patients feel full 50% sooner.

Botulinum toxin 30 obese patients  Botulinum Toxin A (120 U into the antrum and 80 U into the fundus or saline by intraparietal endoscopic injection  Body weight and body mass index, solid gastric emptying and maximal gastric capacity for solids (kcal) were determined before injection and 2 months later. Both treatments induced a significant reduction of body weight and body mass index but Botulinum Toxin A exerted a significantly greater effect  body weight -11.8 vs. -5.5kg, p<0.0002; body mass index -4.1vs. - 2.2, p<0.001.  maximal gastric capacity for solids was also reduced by both Botulinum Toxin A and placebo, the former being significantly more effective (679kcal vs. 237kcal, p<0.008)  Botulinum Toxin A also significantly increased T(1/2) from 83.4to 101.6min, p<0.03). Placebo had no effect on gastric emptying.

Give me the needle!  $10-15 per unit for botox  200 units used = $2000 to $3000 + cost of endoscopy  Should we offer saline injections routinely to obese patients undergoing EGD for proper indications?  Sclero needles $35  Sterile saline $6 Just a thought!

Endoscopy fits into the skinny scene.  pre op assessment  Evaluate and treat H Pylori  Assess for Barrett’s (selection of surgery)  Consider bariatric surgery rather than Nissan for Barrett’s in obese  endoscopic management of complications  Dilate modestly and gently  Check marginal ulcers for H pylori  primary endoscopic bariatric in the future  Slip and slide  TOGA party  Blue balloons  Wrinkle free

Why do Fat chance andSlim chance mean the same thing?

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The Skinny on he Role of Endoscopy in Bariatric Surgery

by Patricia Raymond on Jan 20, 2012

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