Rivision surgery after laparoscopic sleeve gastrectomyIbrahim Abunohaiah
Revision Surgery After Laparoscopic Sleeve Gastrectomy
Introduction to bariatric surgery
When to Revise a Weight Loss Surgery?
Options for redo surgery.
Laparoscopic Roux-en-Y gastric Bypass.
Understant what is obesity and Bariatric Surgery, what are the risk factors and how to overcome on the it. For more information visit at http://gisurgery.info
Rivision surgery after laparoscopic sleeve gastrectomyIbrahim Abunohaiah
Revision Surgery After Laparoscopic Sleeve Gastrectomy
Introduction to bariatric surgery
When to Revise a Weight Loss Surgery?
Options for redo surgery.
Laparoscopic Roux-en-Y gastric Bypass.
Understant what is obesity and Bariatric Surgery, what are the risk factors and how to overcome on the it. For more information visit at http://gisurgery.info
Dr Pravin John and Dr John Thanakumar, Anurag Hospital, Coimbatore present the differences between metabolic and obesity surgery - dept of advanced laparoscopy and obesity
Golden steps to perform laparoscopic sleeve gastrectomyDeep Goel
Laparoscopic sleeve gastrectomy is one of the popular procedure performed in morbidly obese patients to achieve significant weight loss upto 80%. We are explaining golden tips to perform safer sleeve gastrectomy surgery from surgeons perspective.
Gastric GIST by Dr Harsh Shah(www.gastroclinix.com)Dr Harsh Shah
GISTs are the commonest tumours of stomach. Their treatment is different from the traditional adenocarcinomas. Imatinib has an important role as neoadjuvant & adjuvant agent.
This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.
Laparoscopic cholecystectomy is the current gold standard for surgical removal of the Gall bladder, particularly in benign pathologies. Hence, it is necessary to highlight some steps to accomplish this procedure successfully while avoiding pitfalls.
Bariatric surgery is gaining popularity worldwide. The number of surgeries has increased by almost 10 times in the last decade and almost 14000 bariatric surgery were performed last year in India.
Dr Pravin John and Dr John Thanakumar, Anurag Hospital, Coimbatore present the differences between metabolic and obesity surgery - dept of advanced laparoscopy and obesity
Golden steps to perform laparoscopic sleeve gastrectomyDeep Goel
Laparoscopic sleeve gastrectomy is one of the popular procedure performed in morbidly obese patients to achieve significant weight loss upto 80%. We are explaining golden tips to perform safer sleeve gastrectomy surgery from surgeons perspective.
Gastric GIST by Dr Harsh Shah(www.gastroclinix.com)Dr Harsh Shah
GISTs are the commonest tumours of stomach. Their treatment is different from the traditional adenocarcinomas. Imatinib has an important role as neoadjuvant & adjuvant agent.
This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.
Laparoscopic cholecystectomy is the current gold standard for surgical removal of the Gall bladder, particularly in benign pathologies. Hence, it is necessary to highlight some steps to accomplish this procedure successfully while avoiding pitfalls.
Bariatric surgery is gaining popularity worldwide. The number of surgeries has increased by almost 10 times in the last decade and almost 14000 bariatric surgery were performed last year in India.
Drs. Penzler, Ricker, and Ahmad’s CMC Abdominal Imaging Mastery Project: Febr...Sean M. Fox
Dr. Morgan Penzler is an Emergency Medicine Resident and Drs. Raza Ahmad and Ansley Ricker are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s cases include:
- Pneumatosis intestinalis
- Gallstone ileus
- Cecal perforation
Metro Curing Story-Hernia Treatment by Laparoscopic Surgery Vansh Pundit
High clinical suspicion with early intervention in RICHTER'S hernia can prevent gangrene of the intestine.
Diagnostic laparoscopy (to assess the bowel) with Laparoscopic Inguinal Hernia repair is a safe and feasible minimally invasive surgical approach with early recovery
The Mini-Gastric BypassDr Rutledge, DrR@CLOS.netFour Stories for Four Radical Ideas
20 minutes, 4 topics
5 minutes each
1. (Mis)Understanding the MGB Mechanism of action
2. MGB Paradox (Good MGB/Bad MGB)
3. MGB: BP Limb Length
4. MGB-OT to the new MGB2i
The Mystery of Bile or No Bile:“Elementary My Dear Watson!”
Why the two opposite studies of the MGB
1. Minimal Bile Reflux
2. Common Bile Reflux
Answer: 1. Skill and knowledge of the Surgeons & 2. Propper care and education of post op patients
Conclusion: Don't Do the MGB! If You Don't Know What You are Doing
Rx Lifestyle & Diet Plan
Simple Diet & Lifestyle Changes: Rx gut microbiome: Plain Yogurt / Curd / Fermented Dairy:1-2 tsps 3-6 x / Day.
Stop smoking, NSAIDs, Iron, “Supplements”, Vitamins & Medications
Before Meals, Stay upright after eating, Small meals, Limit fatty foods,
Avoid problem (junk) foods: soda, candy, fried foods, caffeinated and carbonated drinks, chocolate, citrus juices, vinegar dressings & mint, etc.
Limit or avoid alcohol, Eat slowly, small amounts, chew thoroughly and rest between bites,
Keep head up for 30-90 minutes post meals, relax for 30-90 minutes after meals.
Understanding Weight Loss After Bariatric SurgeryUnderstanding the Bilio-Pancreatic Limb Length
Statistics, Random Distribution and Too Little or Too Much of a Good Thing
The Billroth II is a good safe operation
Routinely used daily by General, Trauma and Cancer Surgeons Around the world
Studies show surgeons who are more fearful of Billroth II and cancer are the least knowledgeable about the scientific data on the Billroth II and Gastric Cancer
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
2. Failed Bariatric Surgery
•Total health-care costs were
higher for patients with normal
Blood sugar levels or those
with prediabetes
•Who were given Bariatric
Surgery!!!
3. Bariatric Surgery
Patients Do Worse!
•Lancet Diabetes Endocrinol.
2015 Nov;3(11):855-65.
•Health-care costs over 15
years after bariatric surgery for
patients with different baseline
glucose status: results from
the Swedish Obese Subjects
study.
4. Bariatric Surgery
Patients Do Worse!
•Swedish Obese Subjects (SOS) study is a prospective
study of adults who had bariatric surgery and
contemporaneously matched controls who were treated
conventionally
•Data for inpatient and outpatient visits from the Swedish
National Patient Register. We followed up the sample
linked to register data for up to 15 years
•we followed up 4,030 patients (2,836 who were
euglycaemic; 591 who had prediabetes; 603 who had
diabetes
•Swedish Obese Subjects study.
5. Bariatric Surgery
Patients Do Worse!
•Compared with the No Surgery group, we noted
•greater inpatient costs in the surgery
group for the
•euglycaemic ($50,000 vs $25,000 p<0·0001)
•prediabetes ($58,000 vs $32,000 p<0·0001),
•diabetes ($61,000 vs $47,000 p<0·0001)
•Surgery Patients Did Worse
•Total health-care costs were higher in the
surgery group (x for diabetics)
•Swedish Obese Subjects study.
6. Bariatric Surgery
Patients Do Worse!
•INTERPRETATION:
•“Total health-care costs were
higher for patients with
euglycaemia or prediabetes in the
surgery group than in the
conventional treatment group”
•Swedish Obese Subjects study. 2015
10. Reminders of the Basics of
General Surgery
Sleeve is NOT New
Performed in 1940
Has been Abandoned 1950
Surgical Rx Hiatal Hernia “Alone”
(Hill/Allison Repairs)
Has been Abandoned
11. The Sleeve is NOT New
•As early as 1940, O.H.
Wangensteen performed
longitudinal gastric resection to
excise acid-producing body of the
stomach
•Wangensteen OH.
Aseptic gastric resection.
SGO. 1940;70:59–70
12. History of Ulcer Surgery
•K. Schwarz’s discovery of the concept of
“no ulcers without acids” in 1910
•O.H. Wangensteen who Devised
longitudinal gastric resection (Sleeve)
•Parietal cells, (HCL) most dense lengthwise along
the greater curvature
•Wangensteen performed the first experiments of
longitudinal resection along the greater gastric
curvature to reduce acidity of gastric juice in 1940
13. History of Ulcer Surgery
•Wangensteen applied this technique in 90 patients
with duodenal ulcers and reported initially Positive
Results
•Evolution and evaluation of an acceptable operation
for peptic ulcer. WANGENSTEEN OH Am J
Gastroenterol. 1953 Sep; 20(9):611-26
• Abandoned, after performing further animal
experiments in 1957
•The acid response of the stomach after test meals
was many-fold higher in animals spitting up
14. The Sleeve is NOT New
He concluded that
his “tubular gastric
resection” should be
viewed with caution
and he stopped using
the technique
Abandoned
Segmental gastric resection: an acceptable operation for peptic ulcer;
tubular resection unacceptable. WANGENSTEEN OH Surgery. 1957
Apr; 41(4):686-90.
15. The Sleeve is Very Popular
(Now?)
Remember the Lap Band
Vertical Banded Gastroplasty
16. A Modest Proposal
•My Opinion:
•Sleeve = Failed VBG
•(Vertical Banded Gastroplasty)
•and the ** VBG has been
abandoned! **
17. Sleeve = VBG
Sleeve Gastrectomy =
1. Irreversible Stomach only operation,
2. Makes Eating Usual Foods Difficult
Because of a ...
3. Partial Blockage (Obstruction) in the
stomach
4. Patients Complain of Frequent Nausea and
Vomiting
with MANY "Normal Foods" (i.e. Broccoli,
Sandwich, Apple)
5. N&V with "Normal" Food Encourages
"Junk" foods like Potato Chips, Coke, Soda,
Sweets, Ice Cream, etc.
6. Initially moderate to good weight loss
7. followed by high rates of weight regain and
8. ~1/3 of patients with moderate to severe
GERD
often requiring surgery and
Long Term Risk of Esophageal Cancer.
Failed VBG Vertical Banded Gastroplasty =
1. Irreversible Stomach only operation,
2. Makes Eating Usual Foods Difficult
Because of a ...
3. Partial Blockage (Obstruction) in the
stomach
4. Patients Complain of Frequent Nausea
and Vomiting
with MANY "Normal Foods" (i.e. Broccoli,
Sandwich, Apple)
5. N&V with "Normal" Food Encourages
"Junk" foods like Potato Chips, Coke,
Soda, Sweets, Ice Cream, etc.
6. Initially moderate to good weight loss
7. followed by high rates of weight regain and
8. ~1/3 of patients with moderate to severe
GERD
often requiring surgery and
Long Term Risk of Esophageal Cancer.
18. Sleeve = VBG Abandoned
Sleeve Gastrectomy =
1. Irreversible Stomach only operation,
2. Makes Eating Usual Foods Difficult Because of a ...
3. Partial Blockage (Obstruction) in the stomach
4. Patients Complain of Frequent Nausea and Vomiting
with MANY "Normal Foods" (i.e. Broccoli, Sandwich, Apple)
5. N&V with "Normal" Food Encourages
"Junk" foods like Potato Chips, Coke, Soda, Sweets, Ice Cream,
etc.
6. Initially moderate to good weight loss
7. followed by high rates of weight regain often requiring revision
8. ~1/3 of patients with moderate to severe GERD
often requiring revision surgery and
Long Term Risk of Esophageal Cancer.
23. Sleeve Gastrectomy
Creates HIGH Pressure System
• Study HIGH intragastric pressure after
water swallows in patients after SG
(77 %) often w/o upper GI symptoms
• Gastric dysrhythmia cause of vomiting
induced by retrograde gastric electrical
ectopic locus
•Obes Surg. 2016 Oct;26, High-resolution Impedance Manometry
after Sleeve Gastrectomy: Increased Intragastric Pressure and
Reflux are Frequent Events, Mion F, Tolone S et.al.
24. Sleeve N&V + GERD
Obes Surg. 2016 Oct;26
• Manometry Showed:
• Reflux episodes frequent after Sleeve
(52%):
• Significantly associated with
gastroesophageal reflux (GER)
symptoms and
• Ineffective esophageal motility
i.e. N&V
25. Abnormal Gastric Pacemaking
After Sleeve Gastrectomy
Gastric myoelectrical
activity (GMA) vomiting
Gastric dysrhythmia
precedes vomiting
major pattern of
dysrhythmia immediately
before vomiting also
noticed immediately after
vomiting
26. Abnormal Gastric Pacemaking
After Sleeve Gastrectomy
Sleeve gastrectomy (LSG) includes
excision of the normal gastric pacemaker,
which induces electrical dysrhythmias
impacting on post-operative symptoms and
recovery
High-resolution (HR) electrical mapping
before and after Sleeve
Patterns of Abnormal Gastric Pacemaking After Sleeve Gastrectomy
Defined by Laparoscopic High-Resolution Electrical Mapping. Obes Surg.
2017 Aug;27(8):1929-1937
27. Abnormal Gastric Pacemaking
After Sleeve Gastrectomy
All Sleeves developed
abnormalities either a
Ectopic pacemaker with
retrograde propagation (50%) or
Bioelectrical quiescence (50%)
Resection of the gastric
pacemaker resulted in aberrant
distal ectopic pacemaking or
bioelectrical quiescence.
Ectopic pacemaking can persist
long after LSG, inducing chronic
dysmotility.
29. Post Sleeve Manometry
• Heartburn and regurgitation
• Deteriorated in 11% & 28% patients
• Patients developed
• Decreased LES length and
• Weakened LES pressure after LSG.
31. Sleeve Gastrectomy = Vomiting
•352 patients;
Dysphagia Endoscopy **23%**
•1 out of every 4 Sleeves! =>
Endoscoped for dysphagia
(N&V)
•Nath A, Yewale S, Tran T, Brebbia JS, Shope TR, Koch TR. Dysphagia after
vertical sleeve gastrectomy: Evaluation of risk factors and assessment of
endoscopic intervention. World Journal of Gastroenterology.
2016;22(47):10371-10379. doi:10.3748/wjg.v22.i47.10371.
32. The hidden endoscopic
burden of sleeve gastrectomy
•Another Study 211 patients sleeve
gastrectomy over a 34-month period.
•17% of all sleeve gastrectomy patients
required post-operative endoscopy
•2% of sleeve gastrectomy patients
encountered a post-operative staple
line leak
•Equivalent cost of €159,898, €373/case
33. Repeated Belching After
Sleeve Gastrectomy
•Belching occurred significantly more often
after LSG,
•Total number of gastric belches increased
from 30 ± 12 before to **60** ± 38/24 h
•Esophageal acid exposure increased
significantly, from 4 ± 2.9 % before to
13 ± 10.5 % after LSG (p = 0.01)
•Burgerhart JS, van de Meeberg PC, Mauritz FA, et al. Increased
Belching After Sleeve Gastrectomy. Obesity Surgery. 2016;26:132-137
34. Sleeve Gastrectomy You are likely to
need to go back into the Hospital in the
first year after your surgery!!!
•1 out of every 10 Sleeve patients will be back in the
hospital in the first year!!
•"just over one-third of patients visited the ED (33.9%)"
•There were 14,080 SG between 2011 and 2013
•One in every ten of these visits resulted in readmission
(9.5%), with
•12.5% of Sleeve patients admitted to the Hospital within
their first year after SG surgery!!
35. Sleeve Gastrectomy You are likely to
need to go back into the Hospital in the
first year after your surgery!!!
•ED visits for abdominal pain (n = 1029; 11.14%),
vomiting (n = 237; 2.57%), dehydration (n = 224; 2.43%),
and syncope (n = 206; 2.23%) were attributed to surgery.
•Overall 1-year readmission rates after SG are greater
than 1 in ten (12.5%)
•1 out of every 10 Sleeve patients will be back in the
hospital in the first year!!
•Sleeve Gastrectomy: the first 3 Years: evaluation of emergency department
visits, readmissions, and reoperations for 14,080 patients in New York
State.
•https://www.ncbi.nlm.nih.gov/pubmed/28840343
36. Sleeve => N&V
•In another Sleeve study
•30% of Readmissions Nausea & Vomiting
•"Given the progressive increase in the
proportion of bariatric patients undergoing SG,
hospital programs that aim to
•**decrease readmissions after bariatric surgery
need to focus on
•**prevention and control of postoperative
nausea and dehydration"
•https://www.ncbi.nlm.nih.gov/pubmed/27067353
37. Proximal Leakage After
Laparoscopic Sleeve Gastrectomy
•Obes Surg. 2017 Aug 24.
•Proximal Leakage After Laparoscopic Sleeve
Gastrectomy: an Analysis of Preoperative and Operative
Predictors on 1,738 Consecutive Procedures.
•And 3 chances out of 100 you will have a leak
•Proximal leakage was observed in 45 patients out of
1738 (2.6%).
•No correlation was found between leakage and the
preoperative variables analyzed.
38. Google Search of Pubmed
Database for Complications
of Sleeve
Scary!
39. Wernicke's & Sleeve Gastrectomy
•Wernicke's & Sleeve Gastrectomy
Search results PUBMED
•Items: 1 to 20 of **29**
•Wernicke’s encephalopathy after
sleeve gastrectomy: Literature review
•(Note: Zero (0) Cases of Wernicke's
with MGB
40. Mesenteric ischaemia
Sleeve Gastrectomy
•Search results PUBMED
•Items: 1 to 20 of **68**
•Portal Vein Thrombosis due to Prothrombin Gene Mutation following
Sleeve Gastrectomy Murad Baba, Jordan Fakhoury, Amer Syed Case
Rep Gastrointest Med. 2015; 2015: 816914
•Portomesenteric Vein Thrombosis, Bowel Gangrene, and Bilateral
Pulmonary Artery Embolism Two Weeks after Laparoscopic Sleeve
Gastrectomy Case Rep Surg. 2015; 2015:
•(Note: Zero (0) Cases of Mesenteric Ischemia with MGB
42. From Rats to Man
Sleeve Causes Reflux,
Esophagitis Barrett's and
Esophageal cancer
43. Rats
•Association between sleeve gastrectomy (SG)
and gastroesophageal reflux disease
•Rats who underwent SG had significantly
increased reflux severity, compared with sham
(21.1% versus 0%, P = .02), respectively
•CONCLUSIONS:
•SG is independently associated with
histopathologic changes consistent with severe
esophagitis in an animal model
44. Gastroesophageal reflux disease & Barrett's
esophagus after laparoscopic sleeve gastrectomy
• Surg Obes Relat Dis. 2017
Apr;13(4):568-574.
• Gastroesophageal reflux disease and
Barrett's esophagus after laparoscopic
sleeve gastrectomy: a possible,
underestimated long-term complication.
• Genco A
45. Gastroesophageal reflux disease & Barrett's
esophagus after laparoscopic sleeve gastrectomy
•At a mean 58 months,
• GERD symptoms
68% vs 34%: P<.0001,
• Visual Analog Scale mean
3 vs 1.8: P = .018,
• PPI intake significantly increased
compared with preoperative values
57% vs 19%: P<.0001
46. Gastroesophageal reflux disease & Barrett's
esophagus after laparoscopic sleeve gastrectomy
• At EGD, upward migration of the "Z" line
• esophageal reflux was found in 75% of
cases.
• A significant increase in the incidence and
in the severity of erosive esophagitis (EE)
• Barrett's esophagus (BE) newly diagnosed
in 17%
• Lifetime Endoscopic surveillance after SG
should be advocated irrespective of GERD sx
48. Sleeve Gastrectomy
Reflux & Barrett's Esophagus
• 24-h pH metries, manometries,
gastroscopies, and questionnaires
focusing on reflux (GIQLI, RSI) in SG
patients with a
• Follow-up of more than 10 years who
did not suffer from symptomatic reflux or
hiatal hernia preoperatively.
49. Sleeve Gastrectomy
Reflux & Barrett's Esophagus
• 14% were converted to
RYGB due to intractable reflux
• Gastroscopies revealed
• De novo hiatal hernias in 45%
• Barrett's metaplasia in 15%.
50. Gastroesophageal reflux before
and after sleeve gastrectomy
•Surg Obes Relat Dis. 2014 Jul-Aug;
• Evaluation of gastroesophageal reflux
before and after sleeve gastrectomy using
symptom scoring, scintigraphy, and
endoscopy.
• Sharma A1, Aggarwal S2, Ahuja V3, Bal C4.
51. Gastroesophageal reflux before
and after sleeve gastrectomy
• Radionuclide scintigraphy
revealed a significant rise of
GERD from 6% to 78% in the
postoperative period (p<0.001).
• UGIE showed a rise in incidence of
esophagitis from 19% to 25%
52. Gastroesophageal reflux disease
symptoms and erosive esophagitis
•Surg Endosc. 2013 Apr;27(4)
•Increase in gastroesophageal reflux disease
symptoms and erosive esophagitis 1 year
after laparoscopic sleeve gastrectomy
among obese adults.
•Tai CM1, Huang CK, Lee YC, Chang CY, Lee
CT, Lin JT.
53. Gastroesophageal reflux disease
symptoms and erosive esophagitis
•Significant increase in the prevalence
of GERD symptoms (12 vs. 47%)
•
•Erosive Esophagitis (17 vs. 67%) after
LSG (P < 0.001).
• Hiatal hernias increased significantly
(6 vs. 27%; P < 0.001)
54. MGB and GERD
• Tolone Study
•After MGB surgery, none of the
patients reported de novo heartburn or
regurgitation.
•At endoscopic follow-up 1 year after
surgery,
•esophagitis was absent in all patients
and no biliary gastritis or presence of
bile was recorded
55. MGB and GERD
• Tolone Study
•MGB Manometric features and patterns
did not change significantly after
surgery
•Intragastric pressures (IGP)
diminished statistically (from a median
of 15 to 9.5, p<0.01)
•MGB is a Low Pressure System
56. MGB = Low Pressure
Sleeve = HIGH Pressure => GERD
• Tolone Study
•Intragastric pressures (IGP)
diminished statistically (from a median
of 15 to 9.5, p<0.01)
•MGB is a Low Pressure System
•In contrast, SG induced significant
elevation IGP (from 15 to 19, P < 0.01)
•Sleeve is a HIGH Pressure System
57. Reflux Events MGB vs Sleeve
Tolone Study
• MGB => A dramatic decrease in the
number of reflux events (from a median
of 41 to 7; P < 0.01) MGB
MGB Low Pressure = Less Reflux
•SG +> significant increase in
esophageal acid exposure & number of
reflux episodes (from 33 to 53; P <0.01)
•Sleeve is HIGH Pressure = More Reflux
58. Esophageal adenocarcinoma
after Sleeve
• Int J Surg Case Rep. 2017; 32:
47–50.
• Esophageal adenocarcinoma five
years after laparoscopic
sleeve gastrectomy. A case report
• Fernando Gabriel Wright
59. Esophageal adenocarcinoma
after Sleeve
• Int J Surg Case Rep. 2017; 32:
47–50.
• Esophageal adenocarcinoma five
years after laparoscopic
sleeve gastrectomy. A case report
• Fernando Gabriel Wright
60. Esophageal Cancer
After Sleeve
• Shortcoming of LSG in the long-term
follow-up and this is the
Frequent onset of de novo GERD
• Significant increase of GERD and
hiatal hernia post sleeve,
• Also an increase in revisional
surgeries associated with refractory
reflux post Sleeve
61. Esophageal Cancer
After Sleeve
•48-Year-old man that underwent a laparoscopic
sleeve gastrectomy
•Routine preoperative evaluation included an upper
gastrointestinal series and EGD, which showed no
reflux or hiatal hernia, no esophagitis or Barrett́ s
esophagus.
•Helicobacter pylori was negative.
•15 months after the operation, he complained of new
onset of typical GERD symptoms. He was put on
proton pump inhibitors (PPI)
•4 years later (fifth postoperative year) dysphagia to
solids and a 10 kg weight loss. Endoscopy
adenocarcinoma of the esophagus
62. Esophageal Cancer
After Sleeve
•In a prospective randomized trial that compared LSG
with gastric banding, Himpens et al. found
development of de novo reflux symptoms in 21.5% of
the LSG cohort at one-year follow-up
•Braghetto et al. analized 231 patients without reflux
symptoms, esophagitis or Barrett, who underwent a
LSG. In the follow-up, GERD symptoms were found
in 23.2%, erosive esophagitis in 15.5%, and Barrett’s
esophagus (intestinal metaplasia) in 1.2%
63. Esophageal Cancer
After Sleeve
•two other cases of esophageal adenocarcinoma
after LSG have been published.
•Scheepers et al. described the case of a 57-year-old
woman who was submitted for a LSG and was
diagnosed with esophageal adenocarcinoma four
months after bariatric surgery [15].
•In another case reported by Sohn et al., a 44-year-old
woman who underwent LSG developed an
adenocarcinoma of the gastroesophageal junction
2.5 years after surgery [16]
64. GERD & Bariatric Surgery
GERD, Barrett's, Esophageal Cancer
Hx of General Surgery, Forgotten
Allison, Hill Repairs (Failure Abandoned)
Rx with Nissen, Results of Nissen
GERD in Bariatric Surgery
Band & Sleeve CAUSE GERD
Sleeve Surgeons Failed Rx??
RNY Rx GERD
MGB Excellent Rx GERD
Understanding Why?
65. Systematic review: Laparoscopic Nissen
fundoplication for gastroesophageal reflux disease
Laparoscopic Nissen fundoplication (LF) for
gastroesophageal reflux disease (GERD).
10 years after LF, 36% reported heartburn &
29% reported regurgitation.
The proportion using PPIs increased, from
9% in year 1 to 18% at 10 years.
66. A randomized controlled trial of
laparoscopic Nissen fundoplication
versus proton pump inhibitors for the
treatment of patients with chronic
gastroesophageal reflux disease
(GERD): 3-year outcomes.
•Surg Endosc. 2011
Aug;25(8):2547-54.
67. RCT; Nissen vs PPIs
•A randomized controlled trial (RCT)
gastroesophageal reflux disease (GERD)
•1. who were stable and symptomatically
controlled with long-term medical therapy
to
•compare
•ongoing medical therapy with
•laparoscopic Nissen fundoplication (LNF).
68. Nissen vs PPIs: No difference
•GERD Sx or
Acid exposure on 24-h pH
monitoring
•There were six treatment failures
(12%) in the surgical group and
eight treatment failures (16%) in
the medical group by 3 years.
69. RCT: CONCLUSIONS:
For patients whose GERD
symptoms are stable and
controlled with PPI,
Medical therapy
Nissen
are equally effective
70. Use of proton pump
inhibitors after anti-reflux
surgery: a nationwide
register-based follow-up
study
•Jan 28, 2014 -
•Lødrup A(1), Pottegård
A(2), Hallas J(2),
71. Denmark Nationwide health
care registry study
•PPI use after Anti-reflux surgery
(ARS) in the general Danish
population using nationwide health
care registries.
•A nationwide retrospective follow-
up study of all patients aged ≥18
and undergoing first-time ARS in
Denmark during 1996–2010
72. Denmark Nationwide health
care registry study
• Female gender, high age,
recent ARS, previous use of
PPI & use of NSAIDs drugs or
antiplatelet therapy
significantly increased the risk
of PPI use (Nissen failure).
73. Long term failure of Nissen
•3465 patients ARS
•5, 10 & 15-year risks of
New PPI Rx =
57%, 72% & *83%*, respectively
•5, 10 & 15-year risks
Long-term PPI use =
30%, 41% and *57%*
74. Nissen Failure
• Conclusions Risk of PPI use after
Nissen high!
• More than 50% of patients became
long-term PPI users
• Patients should be made aware
that long-term PPI therapy is often
necessary after Nissen.
75. Majority of Gastro-Esophageal
Reflux Disease Patients
Continue to Use Proton Pump
Inhibitors After Anti-reflux
Surgery (Nissen)
A Madan et al. Aliment Pharmacol Ther
2006 Mar 01
76. Nissen Failure 80% Rx PPIs
•Nissen fundoplication at our
institution over a period of over 3
years were asked to complete a
questionnaire
•80% patients were still taking
anti-reflux medications including
proton pump inhibitors
79. Survey 3,000 MGB Patients
• 64% of MGB patients taking
antacid medications for GERD
preop (PPIs, H2Blockers or
Antacids)
• Post MGB resolution of GERD
Sx with discontinuation of
medications 81%
81. MGB Rx GERD
Mechanism of Action
1. Reduction of Acid
Production
2. Weight loss
3. Downward traction on the
stomach
4. *Creation of LOW Pressure
System*
82. MGB Rx GERD
Mechanism of Action
1. Reduction of Acid
Production
2. Weight loss
3. Downward traction on the
stomach
4. *Creation of LOW Pressure
System*
83. Conclusions
• GERD common serious problem
in Bariatric patients
• Nissen “gold standard” poor
results + = simply taking PPI's
• Dr Rutledge MGB Series:
80% success Rx GERD
• Understand WHY!
• MGB Good to Excellent Rx GERD
84. Post-op malnutrition
Vitamin and mineral deficiencies after Sleeve
Gastrectomy: A huge challenge
Thought that deficiencies mostly occurred in procedures with
a malabsorptive component, like the RNY, MGB or the BPD
The risk for deficiencies after sleeve gastrectomy was
considered low. 3
Studies show that sleeve deficiencies occur almost as
much.3,4
Research by Capoccia et al. showed that following
laparoscopic sleeve gastrectomy a significant proportion of
patients developed vitamin B12 and folate deficiency.4
85. Deficiencies in Sleeve
•Dr. Aarts iron deficiency 43% Sleeve patients
•In 26% of patients had significantly low B12, folate, iron
and vitamin D levels in sleeve gastrectomy patients.3
•“There is no doubt that the levels of nutritional
deficiencies after sleeve are higher than those reported
in the literature.”
•“In our series, 28% of patients were anemic, but the
literature states only a few percent of anemia cases per
year.
•This is incorrect, nutritional deficiency rates after sleeve
gastrectomy are grossly under reported.
86. Malnutrition MGB
•You Can Get Malnourished After MGB
•But
•Usually it is not a Poor Diet
•It usually means that the Bypass is Too Long
and Needs revision
•In skilled hands this occurs in 0.1 to 1% of
patients
•For 99%-99.9% of MGB Patients the
Recommended Diet for MGB is...
•Practically every system in the human body
benefits from the "Mediterranean diet"
87. MGB vs Sleeve, Meta-analysis
Mini-Gastric Bypass/One-Anastomosis Gastric
Bypass Versus Sleeve Gastrectomy
for Morbid Obesity: a Systematic Review and
Meta-analysis
Seventeen studies met the inclusion criteria
incorporating 6,761 patients.
In this study
MGB study patients were older, and heavier
than comparable Sleeve patients
88. MGB vs Sleeve, Meta-analysis
In spite of MGB patients being older and
heavier…This study reveals MGB
=> MGB better weight loss vs Sleeve
=> MGB better remission of comorbidities vs
Sleeve (i.e. Diabetes Mellitus),
=> MGB Shorter hospital stay vs Sleeve
=> MGB Significantly lower death rate in the MGB
than Sleeve!
Mini-Gastric Bypass/One-anastomosis gastric
bypass (MGB) is a safe, feasible and effective
bariatric procedure
89. Sleeve is a Poor Treatment
of Diabetes
MGB is an Excellent
Treatment of Diabetes
90. Sleeve Diabetes Remission Rates
at 7yrs (28%)
• Ann Surg. 2017 Jul 24. Individualized Metabolic Surgery
Score: Procedure Selection Based on Diabetes Severity.
•At median postoperative follow-up of 7 years
(range 5-12)
•Diabetes remission
(HbA1C <6.5% off medications)
•49% after RYGB and
•28% after SG (P < 0.001)
91. Sleeve Rx Diabetes
•Ann Surg. 2016 Oct;264(4):674-81.Can Sleeve
Gastrectomy "Cure" Diabetes? Long-term
Metabolic Effects of Sleeve Gastrectomy in
Patients With Type 2 Diabetes.
• long-term metabolic effects of laparoscopic
sleeve gastrectomy
•Complete remission (HbA1c <6% off
medications) in 11%
•"cure" (continuous complete remission for
≥5 years) was achieved in 3%
92. RCT Sleeve vs MGB 5 yrs
• At 60 months,
•18 MGB pts (60%)
•9 Sleeve pts (30%)
•Achieved the primary end
points
•HbA1c ≤6.5% without glycemic
therapy.
93. Considering the MGB
“In Every Study,
By Every Measure the
MGB is Equal to or
Better than
any other Surgery”