George S. Ferzli, MD Joel Ricci, MD
<ul><li>Dramatic increase during last 2 decades </li></ul><ul><li>2/3 US individuals are overweight </li></ul><ul><li>50% ...
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 Ar...
<ul><li>BMI ≥ 35 kg/m²: </li></ul><ul><ul><li>Risk of death ≈ 2.5 times greater than if BMI of 20-25 kg/m² </li></ul></ul>...
<ul><li>Calle et al. N Eng J Med, 1999; (15)341:1097-105.  </li></ul><ul><li>Ali H, Mokdad AH, et al. JAMA 2004;291:1238-1...
<ul><li>Relatively ineffective: </li></ul><ul><ul><li>Diet with and without support organizations </li></ul></ul><ul><ul><...
<ul><li>First line of treatment </li></ul><ul><ul><li>Calorie restriction </li></ul></ul><ul><ul><li>Exercise regimen </li...
<ul><li>Consensus Guidelines 2003 </li></ul><ul><li>Surgical therapy should be considered for individuals who: </li></ul><...
<ul><li>Bariatric Surgery </li></ul>Diet Exercise Behavior Modification “ Postoperative care, nutritional counseling, and ...
<ul><li>Obesity related to a metabolic or endocrine disorder </li></ul><ul><li>History of substance abuse or major psychia...
<ul><li>National Hospital Discharge Survey Public-use data file and documentation. Multi-year data CD-ROM. National Center...
<ul><li>Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review ...
<ul><li>Jejuno-ileal bypass </li></ul><ul><ul><li>70% excess wght loss </li></ul></ul><ul><ul><li>Reduced caloric intake <...
<ul><li>Loop gastric bypass </li></ul><ul><ul><li>Reduced capacitance </li></ul></ul><ul><ul><li>Aversive eating </li></ul...
<ul><li>Horizontal gastroplasty </li></ul><ul><ul><li>“ Gastric stapling” </li></ul></ul><ul><ul><li>1970’s </li></ul></ul...
 
<ul><li>“ Gold Standard” </li></ul><ul><li>80% of bariatric proc. </li></ul><ul><li>Lap vs Open </li></ul><ul><li>Restrict...
<ul><li>Pouch formation: </li></ul><ul><ul><li>Small gastric pouch </li></ul></ul><ul><ul><li>15-30 mL </li></ul></ul><ul>...
<ul><li>Roux limb orientation: </li></ul><ul><ul><li>Antecolic vs Retrocolic </li></ul></ul><ul><ul><li>Antegastric vs Ret...
<ul><li>Gastrojejunostomy </li></ul><ul><ul><li>Circular stapler </li></ul></ul><ul><ul><ul><li>↑  risk of wound infection...
<ul><li>Brolin RE. Long limb Roux en Y gastric bypass revisited. Surg Clin North Am 2005;85:807-17, vii. </li></ul><ul><li...
<ul><li>Popular in 80’s and 90’s </li></ul><ul><li>Less common than RYGB </li></ul><ul><li>Purely restrictive </li></ul><u...
<ul><li>Randomized trials: </li></ul><ul><ul><li>VBG vs RYGB </li></ul></ul><ul><ul><li>Better weight loss w/ RYGB </li></...
<ul><li>Dr. Cadiere 1992 </li></ul><ul><li>Technically simple </li></ul><ul><li>Purely restrictive </li></ul><ul><ul><li>D...
<ul><li>Pouch creation </li></ul><ul><ul><li>“ Pars flaccida” technique </li></ul></ul><ul><ul><ul><li>Proximal stomach di...
<ul><li>Scopinaro (Italy) </li></ul><ul><li>Significant weight loss </li></ul><ul><ul><li>75% excess weight loss </li></ul...
<ul><li>Partial gastrectomy </li></ul><ul><ul><li>200 – 500 ml gastric pouch </li></ul></ul><ul><li>Ileal transection </li...
<ul><li>1988 </li></ul><ul><ul><li>Hess et al. </li></ul></ul><ul><ul><li>Marceau et al. </li></ul></ul><ul><li>Longer com...
<ul><li>Sleeve gastrectomy </li></ul><ul><ul><li>150 – 200 ml reservoir </li></ul></ul><ul><ul><li>Over 35 – 60 Fr bougie ...
<ul><li>Supersuper obese (BMI > 55 kg/m²) </li></ul><ul><li>75% excess body weight loss </li></ul><ul><li>2 stage procedur...
<ul><li>Induced weight loss: </li></ul><ul><ul><li>Improves comorbidities before 2 nd  operation </li></ul></ul><ul><li>Si...
<ul><li>OPEN   </li></ul><ul><li>↑  post op pain </li></ul><ul><li>Longer hospitalizations </li></ul><ul><li>↑  wound comp...
<ul><li>RYGB: </li></ul><ul><ul><li>Avg. % excess weight loss = 70% at 1 year post op </li></ul></ul><ul><ul><li>Inversely...
<ul><li>VBG vs LAGB </li></ul><ul><ul><li>Similar % excess weight loss: </li></ul></ul><ul><ul><ul><li>38% at 12 months </...
<ul><li>RYGB vs LAGB </li></ul><ul><ul><li>Recent Italian randomized study </li></ul></ul><ul><ul><li>5 year follow-up </l...
<ul><li>Surgical patients vs Control subjects </li></ul><ul><li>Recent studies: </li></ul><ul><ul><li>Mortality decreased ...
Schauer, et al. Ann Surg 2000 Oct;232(4):515-29 N=104 1 year post op Number  Pre-op % Worse % No change % Improved % Resol...
<ul><li>Rapid decrease in serum blood sugar </li></ul><ul><li>Decrease in medication requirements </li></ul><ul><li>66% to...
<ul><li>50% complete resolution </li></ul><ul><li>25% reduced medications </li></ul><ul><li>Swedish Obese Subject Trial: 2...
<ul><li>70% prevalence in gastric bypass pts </li></ul><ul><li>80% improvement </li></ul><ul><li>No more CPAP </li></ul><u...
<ul><li>Non-alcoholic fatty liver: </li></ul><ul><ul><li>Resolution of steatosis </li></ul></ul><ul><ul><li>Improved liver...
<ul><li>Surgical </li></ul><ul><ul><li>Technical errors </li></ul></ul><ul><ul><li>Errors in judgment </li></ul></ul><ul><...
 
<ul><li>0.5% to 4% rate </li></ul><ul><li>DVT prophylaxis </li></ul><ul><ul><li>HSQ </li></ul></ul><ul><ul><li>LMWH </li><...
<ul><li>0.5% to 1% rate </li></ul><ul><li>Obesity </li></ul><ul><li>Cardiac comorbidities </li></ul><ul><li>Pre-op stress ...
<ul><li>2% to 4% incidence </li></ul><ul><li>Gastrojejunostomy </li></ul><ul><li>Gastric stapled line </li></ul><ul><li>Sy...
<ul><li>Prevention </li></ul><ul><ul><li>Intraoperative   </li></ul></ul><ul><ul><ul><li>Visual inspection </li></ul></ul>...
<ul><li>Gonzalez R, et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J ...
<ul><li>4% incidence </li></ul><ul><li>Acute </li></ul><ul><li>Chronic </li></ul><ul><li>↑  Risk if anticoagulation </li><...
<ul><li>5% to 20% incidence </li></ul><ul><li>Less in laparoscopic vs open </li></ul><ul><ul><li>Laparoscopic wounds heal ...
<ul><li>Early and Late </li></ul><ul><li>Small bowel anastomosis </li></ul><ul><li>2% to 8% incidence </li></ul><ul><li>↑ ...
<ul><li>Prevention </li></ul><ul><ul><li>Closure of defects </li></ul></ul><ul><ul><li>Substantial anastomosis </li></ul><...
<ul><li>Complete vs Partial </li></ul><ul><li>Type: </li></ul><ul><ul><li>I: proximal roux limb </li></ul></ul><ul><ul><li...
 
<ul><li>After gastric banding </li></ul><ul><li>Early post op </li></ul><ul><li>Band volume adjustment </li></ul><ul><li>O...
<ul><li>RYGB and BPD </li></ul><ul><ul><li>Bypass pyloric sphincter </li></ul></ul><ul><li>After meals (sweets) </li></ul>...
<ul><li>Partial obstruction </li></ul><ul><ul><li>Gastrogastrostomy </li></ul></ul><ul><ul><li>Gastrojejunostomy </li></ul...
<ul><li>LAGB </li></ul><ul><li>Recent studies: </li></ul><ul><ul><li>25% incidence </li></ul></ul><ul><ul><li>< 1% need to...
<ul><li>LAGB </li></ul><ul><li>2% to 4% incidence </li></ul><ul><li>Obstructive symptoms </li></ul><ul><li>Band orientatio...
<ul><li>Months to years after LAGB </li></ul><ul><li>1% to 2% incidence </li></ul><ul><li>Epigastric pain </li></ul><ul><l...
<ul><li>15% incidence in RYGB </li></ul><ul><li>Less common after Duodenal Switch </li></ul><ul><ul><li>Gastro duodenal co...
<ul><li>Rapid weight loss -> Gallstone formation </li></ul><ul><li>50% incidence </li></ul><ul><ul><li>10% symptomatic </l...
<ul><li>RYGB </li></ul><ul><ul><li>Transected/Occluded Lumen </li></ul></ul><ul><li>Recanalization -> Fistula </li></ul><u...
<ul><li>GI contrast study </li></ul><ul><li>EGD </li></ul><ul><li>Indications for Rx: </li></ul><ul><ul><li>Symptomatic ul...
<ul><li>Laparoscopic Remnant Gastrectomy </li></ul><ul><ul><li>Cho et al. </li></ul></ul><ul><ul><li>1400 pts w/ RYGB </li...
Carbohydrate Lipid Proteins Ca²+ Fe ²+ B 12 A, D, E, K
<ul><li>Restrictive: </li></ul><ul><ul><li>Intolerance </li></ul></ul><ul><ul><li>Inadequate weight loss </li></ul></ul><u...
<ul><li>Band deflation </li></ul><ul><li>Replacement size </li></ul><ul><li>Conversion to RYGB </li></ul><ul><li>Conversio...
<ul><li>Decrease pouch size </li></ul><ul><li>Lengthen biliary limb </li></ul><ul><li>Distal jejuno-ileal anastomosis </li...
<ul><li>Metabolic Surgery </li></ul><ul><li>Surgical resolution for Diabetes? </li></ul><ul><ul><li>Too fast to be account...
<ul><li>Duodenum divided just below pylorus </li></ul><ul><li>Both limbs: 75cm </li></ul><ul><li>Gastrojejunostomy: </li><...
<ul><li>Promising glucose control at 6 to 12 months </li></ul><ul><li>Non drug alternate maintenance for non obese diabete...
<ul><li>Endoscopic plication of the pylorus with laparoscopic gastrojejeunostomy </li></ul><ul><li>N.O.T.E.S </li></ul><ul...
 
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Bariatric Surgery: Options, Trends, and Latest Innovations

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Bariatric Surgery: Options, Trends, and Latest Innovations

  1. 1. George S. Ferzli, MD Joel Ricci, MD
  2. 2. <ul><li>Dramatic increase during last 2 decades </li></ul><ul><li>2/3 US individuals are overweight </li></ul><ul><li>50% of these are obese </li></ul><ul><li>5% morbidly obese </li></ul><ul><li>Rapid growth in BMI subgroups ≥ 35 and ≥ 40 </li></ul><ul><li>Increase in comorbidities </li></ul><ul><li>2.5 million deaths per year worldwide from comorbidities </li></ul>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
  3. 3. Derived from Center for Disease Control and Prevention website www.cdc.gov
  4. 4. Derived from Center for Disease Control and Prevention website www.cdc.gov
  5. 5. 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
  6. 6. <ul><li>BMI ≥ 35 kg/m²: </li></ul><ul><ul><li>Risk of death ≈ 2.5 times greater than if BMI of 20-25 kg/m² </li></ul></ul><ul><li>BMI ≥ 40 kg/m²: </li></ul><ul><ul><li>Risk of death 10 times greater </li></ul></ul><ul><li>Obesity </li></ul><ul><li>2 nd leading cause of preventable premature death in US (smoking) </li></ul>
  7. 7. <ul><li>Calle et al. N Eng J Med, 1999; (15)341:1097-105. </li></ul><ul><li>Ali H, Mokdad AH, et al. JAMA 2004;291:1238-1245. </li></ul>
  8. 8. <ul><li>Relatively ineffective: </li></ul><ul><ul><li>Diet with and without support organizations </li></ul></ul><ul><ul><li>Pharmaceutical agents </li></ul></ul><ul><li>Only long-term options: </li></ul><ul><ul><li>Bariatric surgery </li></ul></ul><ul><ul><li>Metabolic surgery </li></ul></ul><ul><li>1991 National Institute of Health Guidelines </li></ul><ul><ul><li>BMI ≥ 40 or ≥ 35 with significant comorbidities </li></ul></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>National Institutes of Health Consensus Development Panel. Gastrointestinal surgery for severe obesity. Ann Intern Med . 1991; 115: 956-961 </li></ul>
  9. 9. <ul><li>First line of treatment </li></ul><ul><ul><li>Calorie restriction </li></ul></ul><ul><ul><li>Exercise regimen </li></ul></ul><ul><ul><li>Behavior modification </li></ul></ul><ul><ul><li>Pharmacotherapy </li></ul></ul><ul><li>Avg. weight loss ≈ 5% to 10% initial body weight at 3 to 6 months </li></ul><ul><li>Regain weight after 1 to 2 years </li></ul>1. Yanovski SZ, Yanovski JA. Obesity. N Engl J Med 2002;346: 591-602
  10. 10. <ul><li>Consensus Guidelines 2003 </li></ul><ul><li>Surgical therapy should be considered for individuals who: </li></ul><ul><ul><li>Have a BMI of greater than 40 kg/m² </li></ul></ul><ul><ul><li>OR </li></ul></ul><ul><ul><li>Have a BMI greater than 35 kg/m² with significant comorbidities </li></ul></ul><ul><ul><li>AND </li></ul></ul><ul><ul><li>Can show that dietary attempts at weight control have been ineffective </li></ul></ul>Derived from American Society of Bariatric Surgery website: www.asbs.org
  11. 11. <ul><li>Bariatric Surgery </li></ul>Diet Exercise Behavior Modification “ Postoperative care, nutritional counseling, and surveillance should continue for an indefinitely long period.”
  12. 12. <ul><li>Obesity related to a metabolic or endocrine disorder </li></ul><ul><li>History of substance abuse or major psychiatric problem </li></ul><ul><li>Surgery contraindicated or high risk </li></ul><ul><li>Women who want to become pregnant within the next 18 months </li></ul>
  13. 13. <ul><li>National Hospital Discharge Survey Public-use data file and documentation. Multi-year data CD-ROM. National Center for Health Statistics, 1979-1996. </li></ul><ul><li>Nguyen et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg 2005; 140: 1198-202. </li></ul><ul><li>Griffen et al. The decline and fall of the jejunoileal bypass. Surg Gynecol Obstet 1983; 157: 301-8. </li></ul><ul><li>Shirmer et al. Bariatric Surgery Training: Getting Your Ticket Punched. J Gastrointest Surg 2007;11: 807-12. </li></ul>Period or Decade Incidence of surgery Reason for change Late 1970’s Early 1980’s 25,000 procedures per year <ul><li>Innovative procedures </li></ul><ul><li>gastroplasty </li></ul><ul><li>loop GBP </li></ul><ul><li>jejuno-ileal bypass </li></ul>Late 1980’s 1990’s 5,000 procedures per year <ul><li>Multifactorial: </li></ul><ul><li>High M&M </li></ul><ul><li>Ineffective long-term </li></ul><ul><li>Perceived failure </li></ul><ul><li>Surgeon experience </li></ul>2000’s 80,000 to 110,000 procedures per year <ul><li>Multifactorial: </li></ul><ul><li>Laparoscopy </li></ul><ul><li>Long-term data </li></ul><ul><li>Centers of Excellence </li></ul>
  14. 14. <ul><li>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. </li></ul><ul><li>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. </li></ul>Study Type and size Effect on weight Effect on comorbidities Buchwald et al. Meta-analysis n = 22,094 pts Mean excess weight loss: 61% <ul><li>Resolution of: </li></ul><ul><li>Diabetes: 70% </li></ul><ul><li>HTN: 62% </li></ul><ul><li>Sleep apnea: 86% </li></ul>Swedish Obese Subject trial (SOS) Prospective matched cohort n = 4,047 pts <ul><li>At 10 years: </li></ul><ul><li>Med: 1.6% gain </li></ul><ul><li>Surg: 16% loss </li></ul><ul><li>Improved by surg: </li></ul><ul><li>Diabetes </li></ul><ul><li>Lipid profile </li></ul><ul><li>HTN </li></ul><ul><li>Hyperuricemia </li></ul>
  15. 15. <ul><li>Jejuno-ileal bypass </li></ul><ul><ul><li>70% excess wght loss </li></ul></ul><ul><ul><li>Reduced caloric intake </li></ul></ul><ul><ul><li>Malabsorption </li></ul></ul><ul><ul><li>Dehydration </li></ul></ul><ul><ul><li>Acidosis </li></ul></ul><ul><ul><li>Electrolyte abnormalities </li></ul></ul><ul><ul><li>Liver failure </li></ul></ul><ul><ul><li>Bacterial overgrowth </li></ul></ul><ul><li>Griffen WO Jr, Bivins BA, Bell RM. The decline and fall of the jejunoileal bypass. Surg Gynecol Obstet 1983; 157: 301-8 . </li></ul>
  16. 16. <ul><li>Loop gastric bypass </li></ul><ul><ul><li>Reduced capacitance </li></ul></ul><ul><ul><li>Aversive eating </li></ul></ul><ul><ul><li>Dumping syndrome </li></ul></ul><ul><ul><li>Alkaline reflux gastritis </li></ul></ul><ul><ul><li>Esophagitis </li></ul></ul>
  17. 17. <ul><li>Horizontal gastroplasty </li></ul><ul><ul><li>“ Gastric stapling” </li></ul></ul><ul><ul><li>1970’s </li></ul></ul><ul><ul><li>Regained weight </li></ul></ul><ul><ul><li>Many pts left </li></ul></ul><ul><ul><ul><li>GERD </li></ul></ul></ul><ul><ul><ul><li>Obesity </li></ul></ul></ul><ul><ul><ul><li>May seek re-operation for correction anatomy </li></ul></ul></ul><ul><li>Salmon PA. Salvage of failed horizontal gastroplasty by the addition of a distal gastric bypass. Obes Surg 1993;3:45-51. </li></ul>
  18. 19. <ul><li>“ Gold Standard” </li></ul><ul><li>80% of bariatric proc. </li></ul><ul><li>Lap vs Open </li></ul><ul><li>Restrictive and Malabsorptive: </li></ul><ul><ul><li>Reduced calorie intake </li></ul></ul><ul><ul><li>Macronutrient malabsorption </li></ul></ul>
  19. 20. <ul><li>Pouch formation: </li></ul><ul><ul><li>Small gastric pouch </li></ul></ul><ul><ul><li>15-30 mL </li></ul></ul><ul><ul><li>Transect vs Stapling </li></ul></ul><ul><ul><li>Re-inforcement of staple line </li></ul></ul><ul><li>Roux limb creation: </li></ul><ul><ul><li>15 to 100 cm distal to Ligament of Treitz </li></ul></ul><ul><ul><li>Jejuno-jejunostomy 75 to 150 cm down Roux limb </li></ul></ul><ul><ul><li>Long limb bypass: ↑ weight loss from malabsorption </li></ul></ul><ul><li>Brolin RE. Long limb Roux en Y gastric bypass revisited. Surg Clin North Am 2005;85:807-17, vii. </li></ul>
  20. 21. <ul><li>Roux limb orientation: </li></ul><ul><ul><li>Antecolic vs Retrocolic </li></ul></ul><ul><ul><li>Antegastric vs Retrogastric </li></ul></ul><ul><ul><li>Surgeon’s preference </li></ul></ul><ul><ul><li>Antecolic: </li></ul></ul><ul><ul><ul><li>May lead to high tension gastro-jejunostomy </li></ul></ul></ul><ul><ul><ul><ul><li>Ischemic strictures and ↑ bile leak rate </li></ul></ul></ul></ul><ul><ul><ul><ul><li>No literature supporting this hypothesis </li></ul></ul></ul></ul><ul><ul><ul><li>No evidence of protection against internal hernias </li></ul></ul></ul><ul><ul><li>Retrocolic: </li></ul></ul><ul><ul><ul><li>Shorter </li></ul></ul></ul><ul><ul><ul><li>Creation of transverse mesocolic defect </li></ul></ul></ul><ul><li>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. </li></ul><ul><li>Bertucci W, et al. Antecolic laparoscopic Roux-en-Y gastric bypass is not associated with higher complication rates. Am Surg 2005;71:735-7. </li></ul><ul><li>Carmody B, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 205;1:543-8 . </li></ul>
  21. 22. <ul><li>Gastrojejunostomy </li></ul><ul><ul><li>Circular stapler </li></ul></ul><ul><ul><ul><li>↑ risk of wound infection (10%) </li></ul></ul></ul><ul><ul><ul><li>May be lower if protected stapler </li></ul></ul></ul><ul><ul><li>Linear stapler </li></ul></ul><ul><ul><li>Hand-sewn </li></ul></ul><ul><li>Drainage placement </li></ul><ul><ul><li>Monitors for leak or post-op bleeding </li></ul></ul><ul><ul><li>Surgeon’s preference </li></ul></ul><ul><li>Post op water-soluble contrast study </li></ul><ul><ul><li>Evaluates for leaks before resuming po intake </li></ul></ul><ul><li>Podnos YD, et al. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg 2003;138:957-61. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
  22. 23. <ul><li>Brolin RE. Long limb Roux en Y gastric bypass revisited. Surg Clin North Am 2005;85:807-17, vii. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>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 <ul><li>Mean exc. wght loss: </li></ul><ul><li>50% for short limb </li></ul><ul><li>64% for long limb </li></ul><ul><li>No difference in complications </li></ul><ul><li>Internal hernia </li></ul><ul><li>Lap vs Open </li></ul><ul><li>Roux limb position </li></ul><ul><li>Mesocolic closure </li></ul>Higa et al. Retrospective (n = 2000) <ul><li>Hernia site: </li></ul><ul><li>mesocolic: 67% </li></ul><ul><li>Jejunal: 21% </li></ul><ul><li>Petersen: 7.5% </li></ul><ul><li>Leaks or bleeding: </li></ul><ul><li>Drain placement </li></ul><ul><li>UGI series </li></ul>Dallal et al. Prospective (n = 352) No drains or UGI Small complication rate recognized from tachycardia
  23. 24. <ul><li>Popular in 80’s and 90’s </li></ul><ul><li>Less common than RYGB </li></ul><ul><li>Purely restrictive </li></ul><ul><ul><li>Rapid sense of satiety </li></ul></ul><ul><ul><li>Reduced calorie intake </li></ul></ul><ul><li>Pouch creation </li></ul><ul><ul><li>Hole through anterior and posterior wall </li></ul></ul><ul><ul><li>Staple line to angle of His </li></ul></ul><ul><ul><li>Nondistensible band around distal neo-pouch </li></ul></ul>
  24. 25. <ul><li>Randomized trials: </li></ul><ul><ul><li>VBG vs RYGB </li></ul></ul><ul><ul><li>Better weight loss w/ RYGB </li></ul></ul><ul><ul><li>Similar operative risks </li></ul></ul><ul><li>Replaced by Adjustable gastric band </li></ul><ul><ul><li>Similar outcomes </li></ul></ul><ul><ul><li>Technically easier </li></ul></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
  25. 26. <ul><li>Dr. Cadiere 1992 </li></ul><ul><li>Technically simple </li></ul><ul><li>Purely restrictive </li></ul><ul><ul><li>Decrease hunger </li></ul></ul><ul><ul><li>Early satiety </li></ul></ul><ul><ul><li>Food aversion </li></ul></ul><ul><li>Adjustment to stoma diameter </li></ul>
  26. 27. <ul><li>Pouch creation </li></ul><ul><ul><li>“ Pars flaccida” technique </li></ul></ul><ul><ul><ul><li>Proximal stomach dissection </li></ul></ul></ul><ul><ul><li>Band placement and fixation </li></ul></ul><ul><ul><li>SQ port placement </li></ul></ul><ul><li>Long-term follow up less studied </li></ul><ul><li>Proper adjustement of band is paramount </li></ul>
  27. 28. <ul><li>Scopinaro (Italy) </li></ul><ul><li>Significant weight loss </li></ul><ul><ul><li>75% excess weight loss </li></ul></ul><ul><ul><li>Maintained > 20 yrs </li></ul></ul><ul><li>Super-morbid obesity </li></ul><ul><ul><li>BMI ≥ 60 kg/m² </li></ul></ul><ul><li>Restrictive </li></ul><ul><li>Malabsorptive </li></ul><ul><li>Decreased hunger </li></ul><ul><ul><li>Hormonal changes: distal delivery of nutrients </li></ul></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
  28. 29. <ul><li>Partial gastrectomy </li></ul><ul><ul><li>200 – 500 ml gastric pouch </li></ul></ul><ul><li>Ileal transection </li></ul><ul><ul><li>250 cm above ileocecal valve </li></ul></ul><ul><li>Gastro-ileal anastomosis </li></ul><ul><li>End-to-side ileoileostomy </li></ul><ul><ul><li>50 cm proximal to ICV </li></ul></ul><ul><li>Alimentary channel = 200 cm </li></ul><ul><li>Common channel = 50 cm </li></ul>
  29. 30. <ul><li>1988 </li></ul><ul><ul><li>Hess et al. </li></ul></ul><ul><ul><li>Marceau et al. </li></ul></ul><ul><li>Longer common channel </li></ul><ul><li>Pylorus preservation </li></ul><ul><li>Restriction </li></ul><ul><li>Malabsorption </li></ul><ul><li>Decreases </li></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><li>Dumping syndrome </li></ul></ul><ul><ul><li>Ulcerogenesis </li></ul></ul>
  30. 31. <ul><li>Sleeve gastrectomy </li></ul><ul><ul><li>150 – 200 ml reservoir </li></ul></ul><ul><ul><li>Over 35 – 60 Fr bougie </li></ul></ul><ul><li>Roux limb </li></ul><ul><ul><li>150 cm </li></ul></ul><ul><li>Distal common channel </li></ul><ul><ul><li>100 cm </li></ul></ul><ul><ul><li>“ Duodeno-ileal switch” </li></ul></ul><ul><li>Higher degree of difficulty </li></ul><ul><ul><li>Multiple enteric anastomoses </li></ul></ul>
  31. 32. <ul><li>Supersuper obese (BMI > 55 kg/m²) </li></ul><ul><li>75% excess body weight loss </li></ul><ul><li>2 stage procedure: </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
  32. 33. <ul><li>Induced weight loss: </li></ul><ul><ul><li>Improves comorbidities before 2 nd operation </li></ul></ul><ul><li>Silechia et al: </li></ul><ul><ul><li>41 superobese pts </li></ul></ul><ul><ul><li>2 nd stage operation </li></ul></ul><ul><ul><li>60% resolved comorbidities </li></ul></ul><ul><ul><li>24% resoved prior to 2 nd procedure </li></ul></ul><ul><li>Avoids complications: </li></ul><ul><ul><li>Anastomotic leak </li></ul></ul><ul><ul><li>Stricture </li></ul></ul><ul><ul><li>Internal hernia </li></ul></ul><ul><li>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. </li></ul><ul><li>Frezza EE, et al. Laparoscopic vertical sleeve gastrectomy for morbid obestiy. The future procedure of choice? Surg Today 2007;37:275-81. </li></ul>
  33. 34. <ul><li>OPEN </li></ul><ul><li>↑ post op pain </li></ul><ul><li>Longer hospitalizations </li></ul><ul><li>↑ wound complications </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Hernias </li></ul></ul><ul><ul><li>Seromas </li></ul></ul><ul><li>Return to work in 4-8 weeks </li></ul><ul><li>LAPAROSCOPIC </li></ul><ul><li>↓ post op pain </li></ul><ul><li>Early mobility </li></ul><ul><li>↓ Wound complications </li></ul><ul><li>2-3 day hospital stay </li></ul><ul><li>Return to work in 1-3 weeks </li></ul><ul><li>Nguyen NT, et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg 2005;140:1198-202. </li></ul>
  34. 35. <ul><li>RYGB: </li></ul><ul><ul><li>Avg. % excess weight loss = 70% at 1 year post op </li></ul></ul><ul><ul><li>Inversely related to preoperative BMI </li></ul></ul><ul><ul><li>50% maintenance weight loss up to 15 years post op </li></ul></ul><ul><li>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. </li></ul>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 )
  35. 36. <ul><li>VBG vs LAGB </li></ul><ul><ul><li>Similar % excess weight loss: </li></ul></ul><ul><ul><ul><li>38% at 12 months </li></ul></ul></ul><ul><ul><ul><li>45% at 24 months </li></ul></ul></ul><ul><ul><ul><li>54% at 36 months </li></ul></ul></ul><ul><ul><li>European trials: LAGB up to 70% </li></ul></ul><ul><li>Ren CJ, Horgan S, Ponce J. US experience with the LAP-BAND system. Am J Surg 2002;184(6B):46S-50S. </li></ul><ul><li>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. </li></ul>
  36. 37. <ul><li>RYGB vs LAGB </li></ul><ul><ul><li>Recent Italian randomized study </li></ul></ul><ul><ul><li>5 year follow-up </li></ul></ul><ul><ul><li>RYGB: significantly lower weight and BMI </li></ul></ul><ul><li>BPD or Duodenal switch </li></ul><ul><ul><li>Greater weight loss in super-obese </li></ul></ul><ul><ul><li>70% excess weight loss up to 25 yrs post op </li></ul></ul><ul><ul><li>Minimal rebound at 10 yrs post op </li></ul></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
  37. 38. <ul><li>Surgical patients vs Control subjects </li></ul><ul><li>Recent studies: </li></ul><ul><ul><li>Mortality decreased by 40% in surgical group </li></ul></ul><ul><ul><li>Long-term death lower in surgical group </li></ul></ul><ul><li>Multiple studies: </li></ul><ul><ul><li>Weight loss and improved comorbidities </li></ul></ul><ul><ul><li>30% to 85% Reduced Mortality </li></ul></ul><ul><ul><li>compared to nonsurgical care </li></ul></ul>
  38. 39. 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
  39. 40. <ul><li>Rapid decrease in serum blood sugar </li></ul><ul><li>Decrease in medication requirements </li></ul><ul><li>66% to 75% complete resolution </li></ul><ul><li>Increased insulin sensitivity </li></ul><ul><li>Inhibits progression of disease </li></ul><ul><li>Swedish Obese Subject Trial: </li></ul><ul><ul><li>Reduced relative risk by factor of 30 compared to medically treated population </li></ul></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
  40. 41. <ul><li>50% complete resolution </li></ul><ul><li>25% reduced medications </li></ul><ul><li>Swedish Obese Subject Trial: 2 years post op </li></ul><ul><ul><li>Decreased relative risk of new onset HTN = 10 </li></ul></ul><ul><li>Time interval for resolution not cleared </li></ul><ul><li>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. </li></ul>
  41. 42. <ul><li>70% prevalence in gastric bypass pts </li></ul><ul><li>80% improvement </li></ul><ul><li>No more CPAP </li></ul><ul><li>Decreased pCO2 </li></ul><ul><li>Increased pO2 </li></ul><ul><li>Dixon JB, et al. Predicting sleep apnea and excessive day sleepiness in the severity obese: indicators for polysomnography. Chest 2003;123:1134-41. </li></ul><ul><li>Sugerman HJ, et al. Gastric surgery for respiratory insufficiency of obestiy. Chest 1986;90:81-6. </li></ul>
  42. 43. <ul><li>Non-alcoholic fatty liver: </li></ul><ul><ul><li>Resolution of steatosis </li></ul></ul><ul><ul><li>Improved liver contour </li></ul></ul><ul><li>Osteoarthritis: </li></ul><ul><ul><li>50% reduced medication intake </li></ul></ul><ul><ul><li>Decreased joint stress from weight loss </li></ul></ul><ul><ul><li>Delayed operative joint intervention </li></ul></ul><ul><li>Depression: </li></ul><ul><ul><li>High prevalence in obese </li></ul></ul><ul><ul><li>Decreased medication use </li></ul></ul><ul><li>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 </li></ul><ul><li>Abu-Abeid S, et al. The influence of sugically-induced weight loss on the knee joint. Obes Surg 2005;15:1437-42. </li></ul><ul><li>Sarwer DB, et al. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg 2004;14:1148-56. </li></ul>
  43. 44. <ul><li>Surgical </li></ul><ul><ul><li>Technical errors </li></ul></ul><ul><ul><li>Errors in judgment </li></ul></ul><ul><ul><li>Type of procedure </li></ul></ul><ul><li>Metabolical </li></ul><ul><ul><li>Malabsorption </li></ul></ul><ul><ul><ul><li>Nutrients </li></ul></ul></ul><ul><ul><ul><li>Vitamins </li></ul></ul></ul><ul><li>Mason EE, et al. Causes of 30-day bariatric surgery mortality: with emphasis on bypass obstruction. Obes Surg 2005;71:9-14 . </li></ul>
  44. 46. <ul><li>0.5% to 4% rate </li></ul><ul><li>DVT prophylaxis </li></ul><ul><ul><li>HSQ </li></ul></ul><ul><ul><li>LMWH </li></ul></ul><ul><li>High pre-op risk: </li></ul><ul><ul><li>Heparin </li></ul></ul><ul><ul><li>Coumadin </li></ul></ul><ul><ul><li>IVC filters </li></ul></ul><ul><li>Sapala JA, et al. Fatal pulmonary embolism after bariatric operations for morbid obesity: a 24-year retrospective analysis. Obes Surg 2003;13:819-25. </li></ul><ul><li>Prystowsky JB, et al. Prospective analysis of the incidence of deep venous thrombosis in bariatric surgery patients. Surgery 2005;138:759-63. </li></ul>
  45. 47. <ul><li>0.5% to 1% rate </li></ul><ul><li>Obesity </li></ul><ul><li>Cardiac comorbidities </li></ul><ul><li>Pre-op stress testing </li></ul><ul><li>Long term benefit out-weights slightly increased risk </li></ul><ul><li>McCullough PA, et al. Cardiorespiratory fitness and short-term complications after bariatric surgery. Chest 2006;130:517-25 . </li></ul>
  46. 48. <ul><li>2% to 4% incidence </li></ul><ul><li>Gastrojejunostomy </li></ul><ul><li>Gastric stapled line </li></ul><ul><li>Systemic symptoms </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Tachypnea </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Hypoxia </li></ul></ul><ul><ul><li>Extreme anxiety </li></ul></ul><ul><li>Hamilton EC, et al. Clinical predictors of leak after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc 2003;17:679-84. </li></ul>
  47. 49. <ul><li>Prevention </li></ul><ul><ul><li>Intraoperative </li></ul></ul><ul><ul><ul><li>Visual inspection </li></ul></ul></ul><ul><ul><ul><li>Water-tight seal </li></ul></ul></ul><ul><ul><ul><li>Re-inforce staple line </li></ul></ul></ul><ul><li>Recognition </li></ul><ul><ul><li>Imaging </li></ul></ul><ul><ul><ul><li>CAT scan </li></ul></ul></ul><ul><ul><ul><li>Contrast study </li></ul></ul></ul><ul><ul><li>Exploration </li></ul></ul><ul><li>Gonzalez R, et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg 2007;204:47-55. </li></ul>
  48. 50. <ul><li>Gonzalez R, et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg 2007;204:47-55. </li></ul>
  49. 51. <ul><li>4% incidence </li></ul><ul><li>Acute </li></ul><ul><li>Chronic </li></ul><ul><li>↑ Risk if anticoagulation </li></ul><ul><li>Prevention </li></ul><ul><ul><li>Hemostasis </li></ul></ul><ul><ul><li>Reinforce anastomosis </li></ul></ul><ul><li>Recognition </li></ul><ul><ul><li>Physical Exam </li></ul></ul><ul><ul><li>Drains </li></ul></ul><ul><ul><li>Hgb/Hct </li></ul></ul><ul><ul><li>EGD </li></ul></ul><ul><ul><li>CAT Scan </li></ul></ul>
  50. 52. <ul><li>5% to 20% incidence </li></ul><ul><li>Less in laparoscopic vs open </li></ul><ul><ul><li>Laparoscopic wounds heal faster </li></ul></ul><ul><li>Risk factors in obese: </li></ul><ul><ul><li>Thick layer of SQ fat -> liquefaction fat necrosis </li></ul></ul><ul><ul><li>Lower SQ tissue Oxygen tension </li></ul></ul><ul><li>5 to 20 days post op </li></ul><ul><li>Wound opening & packing </li></ul><ul><li>Revision of port site in LAGB </li></ul><ul><ul><li>Rule out band erosion into gastric lumen </li></ul></ul><ul><ul><li>EGD </li></ul></ul><ul><li>Podnos YD, et al. Complications after laparoscopic gastric bypass: a review of 3464 case. Arch Surg 2003;138:957-61. </li></ul><ul><li>Anaya DA, et al. The obese surgical patient: a susceptible host for infection. Surg Infect (Larchmt) 2006;7:473-80. </li></ul><ul><li>Kabon B, et al. Obesity decreases perioperative tissue oxygenation. Anesthesiology 2004;100:274-80. </li></ul>
  51. 53. <ul><li>Early and Late </li></ul><ul><li>Small bowel anastomosis </li></ul><ul><li>2% to 8% incidence </li></ul><ul><li>↑ with Laparoscopic approach </li></ul><ul><li>Adhesions: months to years post op </li></ul><ul><li>Internal hernias through defects: </li></ul><ul><ul><li>Small bowel mesentery </li></ul></ul><ul><ul><li>Transverse mesocolon </li></ul></ul><ul><li>Obstruction </li></ul><ul><ul><li>Perforation of gastric remnant </li></ul></ul><ul><ul><li>Blow-out duodenal stump </li></ul></ul>
  52. 54. <ul><li>Prevention </li></ul><ul><ul><li>Closure of defects </li></ul></ul><ul><ul><li>Substantial anastomosis </li></ul></ul><ul><ul><li>Loop orientation </li></ul></ul><ul><li>Recognition </li></ul><ul><ul><li>Distention </li></ul></ul><ul><ul><li>Nausea & Vomiting </li></ul></ul><ul><ul><li>Contrast studies </li></ul></ul><ul><ul><li>CAT scan </li></ul></ul><ul><li>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. </li></ul>
  53. 55. <ul><li>Complete vs Partial </li></ul><ul><li>Type: </li></ul><ul><ul><li>I: proximal roux limb </li></ul></ul><ul><ul><li>II: proximal bile limb </li></ul></ul><ul><ul><li>III: common limb </li></ul></ul><ul><li>Cho et al. </li></ul><ul><ul><li>1400 pts </li></ul></ul><ul><ul><li>Antecolic-antegastric </li></ul></ul><ul><ul><li>1.5% incidence of internal hernias </li></ul></ul><ul><li>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. </li></ul><ul><li>. </li></ul>
  54. 57. <ul><li>After gastric banding </li></ul><ul><li>Early post op </li></ul><ul><li>Band volume adjustment </li></ul><ul><li>Outlet obstruction </li></ul><ul><ul><li>Small band size </li></ul></ul><ul><ul><li>Edema and inflammation </li></ul></ul><ul><li>Non-operative management </li></ul><ul><li>If persistent: re-operation </li></ul><ul><ul><li>Excision of perigastric fat under band </li></ul></ul><ul><ul><li>Replacement with larger size </li></ul></ul><ul><li>Shen R, et al. Removal of perigastric fat prevents acute obstruction after Lap-Band surgery. Obes Surg 2004;14:224-9. </li></ul><ul><li>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. </li></ul>
  55. 58. <ul><li>RYGB and BPD </li></ul><ul><ul><li>Bypass pyloric sphincter </li></ul></ul><ul><li>After meals (sweets) </li></ul><ul><li>Early: Osmotic gradient </li></ul><ul><li>Late: Reactive hypoglycemia </li></ul><ul><li>Lightheadedness </li></ul><ul><li>Dizziness </li></ul><ul><li>Sweating </li></ul><ul><li>Bloating </li></ul><ul><li>Diarrhea </li></ul>
  56. 59. <ul><li>Partial obstruction </li></ul><ul><ul><li>Gastrogastrostomy </li></ul></ul><ul><ul><li>Gastrojejunostomy </li></ul></ul><ul><li>5% to 15% incidence after RYGB </li></ul><ul><li>4 to 8 weeks after procedure </li></ul><ul><li>Postprandial nausea & vomiting </li></ul><ul><li>EGD </li></ul><ul><li>Pneumatic balloon dilation </li></ul><ul><ul><li>< 15mm -> recurrent stenosis </li></ul></ul><ul><ul><li>70% to 80% cure rate </li></ul></ul><ul><ul><li>Rule out ulcer </li></ul></ul><ul><li>Persistent -> Operative revision </li></ul><ul><li>Schwartz ML, et al. Stenosis of the gastroenterostomy after laparoscopic gastric bypass. Obes Surg 2004;14:484-9. </li></ul><ul><li>Peifer KJ, et al. Successful endoscopic management of gastrojejunal anastomotic strictures after Roux-en-Y gastric bypass. Gastrointest Endosc 2007;66:248-52. </li></ul>
  57. 60. <ul><li>LAGB </li></ul><ul><li>Recent studies: </li></ul><ul><ul><li>25% incidence </li></ul></ul><ul><ul><li>< 1% need to remove band </li></ul></ul><ul><ul><li>Improved by deflation of band </li></ul></ul><ul><ul><li>Achalasia-type symptoms </li></ul></ul><ul><li>If suspected: </li></ul><ul><ul><li>Barium swallow </li></ul></ul><ul><ul><li>Band deflation </li></ul></ul><ul><li>Early resolution of Sx </li></ul><ul><li>Dargent J. Esophageal dilatation after laparoscopic adjustable gastric banding: definition and strategy. Obes Surg 2005;15:843-8. </li></ul><ul><li>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. </li></ul>
  58. 61. <ul><li>LAGB </li></ul><ul><li>2% to 4% incidence </li></ul><ul><li>Obstructive symptoms </li></ul><ul><li>Band orientation change </li></ul><ul><ul><li>Plain film </li></ul></ul><ul><li>Posterior: perigastric technique </li></ul><ul><li>Anterior: “pars flaccida” </li></ul><ul><ul><li>Less common </li></ul></ul><ul><li>Deflation of band </li></ul><ul><li>Laparoscopic revision </li></ul><ul><li>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. </li></ul><ul><li>Keidar A, et al. Band slippage after laparoscopic adjustable gastric banding: etiology and treatment. Surg Endosc 2005;19:262-7. </li></ul>
  59. 62. <ul><li>Months to years after LAGB </li></ul><ul><li>1% to 2% incidence </li></ul><ul><li>Epigastric pain </li></ul><ul><li>Persistent port site infection </li></ul><ul><li>EGD: </li></ul><ul><ul><li>Black foreign body in cardia region </li></ul></ul><ul><li>Avoid plication sutures over buckle of band </li></ul>
  60. 63. <ul><li>15% incidence in RYGB </li></ul><ul><li>Less common after Duodenal Switch </li></ul><ul><ul><li>Gastro duodenal continuity </li></ul></ul><ul><li>Epigastric pain </li></ul><ul><ul><li>Heartburn </li></ul></ul><ul><ul><li>Upper GI bleeding </li></ul></ul><ul><li>Risk factors: </li></ul><ul><ul><li>NSAID’s </li></ul></ul><ul><ul><li>Large pouch </li></ul></ul><ul><ul><li>Non-absorbable sutures </li></ul></ul><ul><li>EGD </li></ul><ul><li>Contrast study </li></ul><ul><ul><li>Rule out gastro-gastric fistula </li></ul></ul><ul><li>Rasmussen JJ, Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Surg Endosc 2007;21:1090-4. </li></ul><ul><li>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. </li></ul><ul><li>Capella JF, et al. Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes Surg 1999;9:22-7. </li></ul>
  61. 64. <ul><li>Rapid weight loss -> Gallstone formation </li></ul><ul><li>50% incidence </li></ul><ul><ul><li>10% symptomatic </li></ul></ul><ul><li>Adjunt cholecystectomy </li></ul><ul><ul><li>Cholelithiasis or cholecystitis at time or operation </li></ul></ul><ul><li>Ursodeoxycholic acid: </li></ul><ul><ul><li>↓ incidence of gallstones post op by 30% </li></ul></ul><ul><li>Post op anatomy: </li></ul><ul><ul><li>Difficult management of pancreatitis, CBD stones </li></ul></ul><ul><li>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. </li></ul><ul><li>Taylor J, et al. Is routine cholecystectomy necessary at the time of Roux-en-Y gastric bypass? Obes Surg 2006;16:759-61. </li></ul><ul><li>Ceppa FA, et al. Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2007;3:21-4. </li></ul>
  62. 65. <ul><li>RYGB </li></ul><ul><ul><li>Transected/Occluded Lumen </li></ul></ul><ul><li>Recanalization -> Fistula </li></ul><ul><li>2% to 25% incidence </li></ul><ul><li>Risk factors: </li></ul><ul><ul><li>Anastomotic leak </li></ul></ul><ul><ul><li>LUQ abscess </li></ul></ul><ul><li>Long-term consequence: </li></ul><ul><ul><li>Marginal ulcer </li></ul></ul><ul><ul><li>Suboptimal weight loss </li></ul></ul><ul><ul><li>Sudden weight gain </li></ul></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
  63. 66. <ul><li>GI contrast study </li></ul><ul><li>EGD </li></ul><ul><li>Indications for Rx: </li></ul><ul><ul><li>Symptomatic ulcers </li></ul></ul><ul><ul><li>Suboptimal weight loss </li></ul></ul><ul><li>PPI’s </li></ul><ul><li>Sucralfate </li></ul><ul><li>Surgical revision </li></ul>
  64. 67. <ul><li>Laparoscopic Remnant Gastrectomy </li></ul><ul><ul><li>Cho et al. </li></ul></ul><ul><ul><li>1400 pts w/ RYGB </li></ul></ul><ul><ul><li>21 pts w/ GGF (1.5%) </li></ul></ul><ul><ul><li>15 underwent LRG </li></ul></ul><ul><ul><li>No recurrence of GGF </li></ul></ul><ul><ul><li>No mortality </li></ul></ul>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.
  65. 68. Carbohydrate Lipid Proteins Ca²+ Fe ²+ B 12 A, D, E, K
  66. 69. <ul><li>Restrictive: </li></ul><ul><ul><li>Intolerance </li></ul></ul><ul><ul><li>Inadequate weight loss </li></ul></ul><ul><ul><li>Complications </li></ul></ul><ul><li>Combined: </li></ul><ul><ul><li>Enlarged pouch </li></ul></ul><ul><ul><li>Regained weight </li></ul></ul><ul><ul><li>Gastro-gastric fistula </li></ul></ul>
  67. 70. <ul><li>Band deflation </li></ul><ul><li>Replacement size </li></ul><ul><li>Conversion to RYGB </li></ul><ul><li>Conversion to Duodenal Switch </li></ul><ul><li>Multiple Short Studies </li></ul><ul><ul><li>Short follow up </li></ul></ul><ul><li>Conversion is safe with significant weight loss and lower BMI </li></ul>
  68. 71. <ul><li>Decrease pouch size </li></ul><ul><li>Lengthen biliary limb </li></ul><ul><li>Distal jejuno-ileal anastomosis </li></ul><ul><ul><li>Increases malabsorption </li></ul></ul><ul><ul><li>May increase weight loss </li></ul></ul><ul><li>Mason EE, et al. Optimizing results of gastric bypass. Ann Surg 1975;182(4):405-14. </li></ul><ul><li>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. </li></ul>
  69. 72. <ul><li>Metabolic Surgery </li></ul><ul><li>Surgical resolution for Diabetes? </li></ul><ul><ul><li>Too fast to be accounted to weight loss alone </li></ul></ul><ul><li>Duodenojejunal Bypass (DJB) </li></ul><ul><ul><li>Non-obese Rat models </li></ul></ul><ul><ul><li>Complete resolution of diabetes </li></ul></ul><ul><li>Intestinal bypass </li></ul><ul><ul><li>Hormonal regulation </li></ul></ul><ul><ul><li>Foregut vs Hindgut hypothesis </li></ul></ul><ul><li>Rubino F. Bariatric Surgery: Effects on Glucose Homeostasis. Curr Opin Clin Nutr Metab Care 9:497-507 </li></ul>
  70. 73. <ul><li>Duodenum divided just below pylorus </li></ul><ul><li>Both limbs: 75cm </li></ul><ul><li>Gastrojejunostomy: </li></ul><ul><ul><li>50% hand-sewn </li></ul></ul><ul><ul><li>50% stapled </li></ul></ul><ul><li>Duodenojejunostomy: </li></ul><ul><ul><li>100% hand-sewn </li></ul></ul>
  71. 74. <ul><li>Promising glucose control at 6 to 12 months </li></ul><ul><li>Non drug alternate maintenance for non obese diabetes </li></ul><ul><li>Resolution of: </li></ul><ul><ul><li>Metabolic Syndrome </li></ul></ul>
  72. 75. <ul><li>Endoscopic plication of the pylorus with laparoscopic gastrojejeunostomy </li></ul><ul><li>N.O.T.E.S </li></ul><ul><ul><li>Endoscopic plication of the pylorus </li></ul></ul><ul><ul><li>Endoscopic transgastric gastric jejeunostomy </li></ul></ul><ul><li>Human multicenter trials underway </li></ul><ul><li>Kantsevoy SV, et al. Technical feasibility of endoscopic gatric reduction: a pilot study in a porcine model. Gastrointes Endosc 2007;65:510-3. </li></ul><ul><li>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. </li></ul>

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