2. Introduction
Morbid Obesity, pandemic
Bariatric Surgery offers the only long term weight
loss in Morbid Obesity
Improves life expectancy & quality
Not only weight, but also amelioration of co-
morbidities
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18. Nutritional :
Ca++, Trace element, Iron,
Vit: B2,B6,D,B12, Thiamin
Albumin, protein malnutrition
Liver
Kidney
Gall bladder stones
Nesidiplastosis
Weight Regain
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19. Gastric Bypass
27%
Used to be the commonest
RYGP,MGB
Intraoperative:
Bleeding
Perforation
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22. Leakage
Staple line Dehiscence, incidence
Timing: from intraoperative up to 40 days
postoperative
Site, O-G junction, staple line crossing, above
obstruction
24. How to Avoid?
Technical intraoperative
Staples:
Height
Overcrowding of tissues
Butteress material
Tristapler
Insisuura,angulation,
Stricture, obstruction
Ischemia, O-G junction,
folded layers
Bouge size
Methylene blue test
Redo
25. Clinical Less likely or late
Tachypnoea, Dyspnea,
orthopnea
Tachycardia>110
Pain on swallowing
Left shoulder pain
Drain, amount, colour
Tenderness & gaurding
Fever
Hypovolaemia & oliguria
Early Diagnosis
26. Radiology
Water soluble dye
Under screen
Swallow & meal
Routine+-
Highly sensitive but
C.T. oral dye
Lab not conclusive
Investigations
27. Management
Timing, General Condition, Degree of Peritonitis
Early
Good General condition
Well drained, minor localized
peritonitis
Late
Sepsis
Peritonitis
28. Early
Good general condition, no sepsis, controlled
minor leak, well drained, contained localized
collection:
Stent, metal silicon covered temporary for 6-8
weeks
radiologically applied or endoscopically
29. Late
Poor General condition, sepsis, peritonitis:
Resolution: laparotomy, lavage& drainage +
stent 6-8 weeks+|- feeding jejunostomy
30. Endoscopic Management
Minor leak, delayed presentation,
No sepsis, no peritonitis
Endoscopic intervention:
Clips
Glue
Success
32. Introduction
Bariatric Surgery demand is growing
Gastric bypass is commonly performed
Low complications
Long term
Comorbidities resolution
Weight loss
Marginal Ulcer (MU), anastomotic ulcer, ischemic ulcer,
unclear etiology:
remain a cause of significant morbidity in medium
and long-term reports
Prevention, complication and management
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33. Marginal Ulcer
Definition:
A peptic ulcer produced at the jejunal mucosa
just distal to the gastrojejunal anastomosis
MU is subdivided
Early < 12 months
Late > 12 months
Underlying aetiology may differ
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34. Incidence
83% to 95% of MU within 12 months
Early 6%, late 0.6%
Incidence varies, 0.6%-16%
6% asymptomatic mean time to symptoms
development is 4.3 months
Endoscopic assessment, MU
Prophylaxis to the high risk period at least 1
year post-operatively
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36. Perforation
Overall perforation rate 1.4%
Mean time 12 months
10% mortality
Laparoscopic patch repair
Avoid surgical revision of gastro-jejunal
anastomosis (in chronic ulcer and stenosis not
in perforation)
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37. Prevention
H. pylori, ulcer, risk of cancer
Eradication prior to bypass, gastric remnant
inaccessible to endoscopy
Role in pathogenesis of MU is inconclusive
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38. Prevention
Smoking
Smokers should be treated as high risk for
MU
Persistent smoking is a recognized cause of
refractory ulceration and should be tested
prior to revisional surgery
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40. Treatment
Modification of patient-related risk factors successful
in majority of MUs
Inhibition of gastric and secretion
Success in treating 70-100% of MU’s
Relapse rates of 8%
Longterm PPI poor Ca absorption, iron and B12
deficiency
Adding sucralfate
Revisional surgery to correct anatomical
abnormalities and refractory ulcers
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41. Conclusion
MU remains a source of serious morbidity
High quality level 1 evidence is lacking
Management algorithm
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43. Conclusion
Diagnosis of MU,
high index of suspicion
Low threshold for endoscopy
Risk factors modification is integral
Prevention and treatment
Long term PPI for high risk patients
Low-risk patients, 6-12 months empirical PPI
therapy, the period of highest incidence
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