Surgical Management Of Obesity & Its Complications

SURGICAL MANAGEMENT
OF OBESITY
Dr Santosh M Narayankar

 Bariatric surgery is the best known
& most effective treatment for
obesity.
 Meta analysis have shown that it is
more effective than diet & exercise
or pharmacotherapy

Eligibility-Patient Selection
 BMI ≥ 40
 BMI ≥35 and at least one or more obesity-
related co-morbidities( such as T2DM, HTN, OSA,
NAFLD, OA, Dyslipidaemia, GERD or CAD).
 Inability to achieve a healthy weight loss
sustained for a period of time with prior
weight loss efforts

Contra indications
 Psychiatric Illness
 Severe Cardiac disease
 Severe Coagulopathy
 Inability to comply with post op follow up
 RYGB in >65 & <18 yrs

Current Options
 Gastric Bypass –Roux en Y
 Sleeve Gastrectomy
 Adjustable Gastric Banding
 Biliopancreatic Diversion

Surgical Options
7
Laparoscopic Sleeve
Gastrectomy (LSG)
Roux-en-Y Gastric
Bypass (RYGB)
Biliopancreatic Diversion
with Duodenal Switch
Laparoscopic
Adjustable
Gastric Band (LABG)
Mechanick JI, et al. Endocr Pract. 2013;19:337-372.

Mechanism Of Action
 Bile Flow Alteration
 Reduction of gastric size
 Anatomic gut rearrangement & altered
flow of nutrients
 Vagal manipulation
 Enteric gut hormone modulation

Effects of Bariatric Surgery on
Appetite Control Mechanisms
11
GIP = glucose-dependent insulinotropic polypeptide; GLP = glucagon-like peptide; PYY = protein YY.
Ionut V, Bergman RN. J Diabetes Sci Technol. 2011;5:1263-1282.
Hormone Potential post-surgical effect
 GLP-1  Increased satiety and decreased food intake
 Peptide YY
 Increased satiety and decreased food intake
 Possible alterations to energy expenditure
 Oxyntomodulin  Increased satiety and decreased food intake
 GLP-2
 Increased mucosal cell mass in response to injury, leading to
 Long-term increases in GLP-1 and PYY
 Gut proliferation, reducing malabsorption
 GIP  Reduced fat accumulation and long-term weight loss/maintenance
 Ghrelin(?)  Reduced appetite, possibly mediated by vagal denervation
Vagus denervation
 Reduced hunger signals?
 Alterations in GI hormone release?
Altered gut flora
 Shift in Bacteroidetes and Firmicutes bacterial populations to
proportions more like those found in lean individuals

Expected weight
loss / mechanism
EWL:
14% - 60%
after
7-10 y
Use adjustable band to create upper gastric pouch of 15-
45 mL and restrict inlet to stomach
• Produce early satiety and limit food intake
Safety
1-Year mortality: 0.08%; 30-day reoperation/intervention rate: 0.92%; overall
complication rate: 3.2%; high reoperation rate due to complications or weight loss
failure
Common
complications
Band slippage and erosion
Band and port infections
Balloon failure
Port malposition
Esophageal dilatation
Postoperative
metabolic
management
Greater adherence to lifestyle change required to maintain weight loss
Daily multivitamin plus calcium with vitamin D; additional nutrient
supplementation as needed
Reversible? Yes
Cost $$*
Laparoscopic Adjustable Gastric Band
13
*Increased risk of procedure failure may increase overall costs.
EWL = excess weight loss (ie, weight loss as percentage of excess body weight).
Mechanick JI, et al. Endocr Pract. 2008;14(suppl 1):1-83. Mechanick JI, et al. Endocr Pract. 2013;19:337-372.
Jackson TD, Hutter MM. Adv Surg. 2012;46:25-268.

 Initially a popular procedure.
 Long term, band-related complications
requiring band removal in almost 50% of
patients.
 Who have not had the band removed, reports
of EWL range up to 50%, with follow-up
between 5 and 15 years.
 Compared with LSG & RYGB, GB has shown
inferior weight loss results and a higher
complication rate.
Gastric Banding

Expected weight
loss / mechanism
EWL:
50% - 69%
after 5-9 y
Excision of lateral aspect of stomach to create
smaller gastric tube
• Limits food intake
• Increases GLP-1 and PYY; decreases ghrelin
Safety
1-Year mortality: 0.21%; 30-day reoperation/intervention rate: 2.97%; major
complication rate: 12.1%
Long-term safety/effectiveness data lacking (>5-10 years)
Common
complications
Staple line leak
Staple line bleeding
Sleeve stenosis
Sleeve kinking
Sleeve dilation
Postoperative
metabolic
management
Daily multivitamin-mineral preparation plus iron, vitamin B12, and calcium with
vitamin D; iron may be required in some patients
Reversible? No
Cost $$$
Laparoscopic Sleeve Gastrectomy
(LSG)
16

 A systematic review involving 123 studies
 59% EWL 1 year after surgery
 64.5% 2 years after surgery
 66% 3 years after surgery
 60.9% 4 years after surgery
Sleeve Gastrectomy

Expected weight
loss / mechanism
EWL:
60%-70%
after
7-10 y
Stomach transected to create proximal gastric
pouch of 10-30 mL, which is anastomosed to a
Roux-en-Y proximal jejunal segment, bypassing
remainder of stomach and duodenum
• Limits food intake
• Induces micronutrient malabsorption
• Decreases ghrelin and increases PYY and
GLP-1
Safety
1-Year mortality: 0.34%; 30-day reoperation/intervention rate: 5.02%;
overall complication rate: 16%
Common
complications
Anastomotic leak
Pouch dilation
Internal hernia
Staple line disruption/failure
Stomal ulceration
Gastrogastric fistula
Postoperative
metabolic
management
Daily multivitamin-mineral preparation plus iron, vitamin B12, and calcium with
vitamin D; additional nutrient supplementation as needed
Reversible? Yes
Cost $$$
Roux-en-Y Gastric Bypass (RYGB)
19

Expected weight
loss / mechanism
EWL:
60% - 80%
after
7-10 y
Sleeve gastrectomy with intestinal bypass of all
but ~100-150 cm of distal ileum
• Limits digestion and absorption to 50-100
cm of small intestine
• Induces extensive nutrient and caloric
malabsorption
Safety 1-Year mortality : 1.1%; overall complication rate: 16%
Common
complications
Anastomotic leak
Pouch dilation
Incisional hernia
Staple line disruption/failure
Stomal ulceration
Gastrogastric fistula
Malabsorption with nutritional deficiencies
Postoperative
metabolic
management
Daily multivitamin-mineral preparation plus iron, vitamin B12, calcium with
vitamin D, and fat-soluble vitamins
Reversible? Partially
Cost $$$
Biliopancreatic Diversion with
Duodenal Switch (BPD-DS)
21

Survival/Mortality
 In-hospital mortality of bariatric surgery
is low, the range of mortality as 0.1%to
2.0%.
 A meta-analysis that included nearly
200,000 patients showed that patients
who underwent bariatric surgery
 Had greater than a 50% reduction in
mortality
 Gained an extra 6.5 years of life
expectancy

Surgical Complications
 Average 30 day mortality
 Gastric bypass-0.2%
 Sleeve gastrectomy-0.14%
 Gastric banding-0.02%

Surgical complications
 Intra operative
 Early <30 days
 Late >30 days

Early Complications
 Leaks- anastomotic, gastric pouch & duodenal
leakage (depends on surgeons experience)
 MC from gastrojejunostomy leak-independent
risk factor for mortality
 Pulmonary embolism – 50% deaths
 DVT- IVC filter
 Cardiovascular complications - MI

Late complications
 Anastomotic Stricture-2 to 14%
 Gall stone formation-38%
 Nutritional defeciencies-16.9%
 Bowel obstruction-0.2 to 7%
 Intususception
 Marginal ulcers-1 to 16%
 Dumping syndromes-20%
 Hypoglycemia
 GI Bleed-2%
Complications may not affect long term weight loss, which is
the outcome which best predicts long term mortality risk.

Effects of Different Types of Bariatric
Surgery on Weight
 A meta-analysis by Buchwald that included
22,094 patients found the mean percentage of
excess weight loss (EWL) for all patients to be
61.2%. EWL was for RYGB (61.6%), and for
LAGB (47.5%).
 A meta-analysis by Maggard found similar
weight loss trends at 3 or more years
postoperatively, with the greatest weight loss
achieved after the mal absorptive procedures of
BPD (53 kg) and RYGB (42 kg), and less weight
loss after the restrictive LAGB (35 kg) and
gastroplasty (32kg).
28

Gastrointestinal Related
 Gall Bladder Disease
 Prophylactic cholecystectomy
 35-38% develop cholelithiasis-40% become
symptomatic.
 ASMBS - Normal and asymptomatic
gallbladders not be removed at the time of
surgery unless clinically indicated.
 Prophylaxis-UDCA 600mg/day for 6 months

 NAFLD
 70 % incidence
 Improves both steatosis & fibrosis

Bariatric Surgery Improves Clinical
Parameters
 Prospective study following bariatric surgery in pts who
are severely obese (N = 381) with ≥ 1 comorbidity, no
excessive drinking < 2 yrs, no chronic liver diseases
 Liver biopsies assessed by 2 blinded reviewers for fibrosis
(F0-4), NAFLD scoring to determine NASH (≥ 3, probable or
definite; ≥ 5, definite)
Mathurin P, et al. Gastroenterology. 2009;137:532-540.
Parameter Before Surgery After 5 Yrs P Value
Diabetes mellitus, n (%) 94 (24.8) 24 (10.8) .00001
Arterial hypertension, n (%) 185 (48.8) 85 (37.0) .0005
Serum triglycerides, mean (g/L) 1.67 1.06 .00001
Fasting glucose, mean (g/L) 1.18 0.94 .00001
Insulin resistance index, mean 3.2 2.83 .00001
ALT, mean (IU/L) 30.1 22.8 .00003
GGT, mean (IU/L) 39.9 29.2 .00001

Bariatric Surgery Improves Fibrosis in Pts
With NASH
 Prospective study of bariatric surgery in pts who are morbidly
obese with biopsy-validated NASH, ≥ 1 comorbidity factor for
> 5 yrs, no chronic liver disease (N = 109)
Lassailly G, et al. Gastroenterology. 2015;149:379-388.
Distribution of Fibrosis METAVIR Scores
Baseline After 1 Yr
Pts(%)
Wilcoxon signed-
rank paired t test
P < .003
F4
F3
F2
F1
F0
100
80
60
40
20
0
3.75
7.5
2.5
7.5
21.25
40
27.5
13.75
32.5
43.75
Fibrosis METAVIR Score

 GERD
 37-72% prevalence
 Roux en Y bypass is superior to other
procedures
 If medical therapy fails, then re visional surgery
is considered.
 GB & SG conversion to gastric bypass has
successfully reduced GERD symptoms.
 RYGB revisions include lengthening the Roux
limb or downsizing the pouch that was created
during the initial surgery.

 Metabolic Syndrome -Remission
 OSA - 75 % had improvement in symptoms
 BPD - 99% showed an improvement in their
symptoms, and 82% had a resolution of sleep
apnea.
 86% of sleeve gastrectomy
 79% of RYGB patients showed resolution
 LAGB improving sleep apnea, -77% .
Non-Gastrointestinal Related

Nutritional deficiencies
 16.9%
 RYGB & Prolonged Vomiting
 Protein
 Iron
 Vit B12
 Folate
 Calcium
 Fat soluble vitamins-ADEK
 Thiamine

Pregnancy & Bariatric Surgery
 Recommended avoiding pregnancy for 12
to 24 months following bariatric surgery.
 Infants born - more likely to be premature
and small for their gestational age.
 Internal hernias and the early
involvement of a bariatric surgeon in such
cases is recommended

Cancers
 14% decrease in cancer
 Esophageal adenocarcinomas (2%
reduction),
 Colorectal (30% reduction)
 Postmenopausal breast (4%)
 Uterine corpus (78%)
 Non-Hodgkin lymphoma (27%)
 Multiple myeloma (54%)

Quality Of Life
 Improves quality of life.
 SF36 survey shows that quality of life
improves greatly after RYGB surgery.

ENDOSCOPIC MANAGEMENT
OF
BARIATRIC SURGICAL
COMPLICATIONS

Ulceration
 Common late complication of RYGB -20%
 GJ Anastomotic Ulcer
 Often 1st 3months
 Presents – Pain, nausea, vomiting ,food
intolerance & GI bleed.
 Etiology - Acid, ischaemia , bile reflux, Hp,
NSAIDs, Smoking, Foreign bodies, tension on
roux limb & rarely gastrogastric fistula.

Ulceration-Management
 Evaluation - 1st 2 weeks water soluble contrast
(avoids stomal disruption)
 Endoscopic Visualisation - Gsatric pouch, GJA &
proximal roux limb.
 Hp -Detection- serology, confirm by stool antigen.
 Treatment –
 PPI
 Sucralfate
 Cholestyramine
 Smoking cessation, stop NSAIDs
 DM contral

GI Bleeding
 Incidence- 1.9%
 RYGB>SG,LAGB,VBG
 Sites -Pouch, Anastomotic site, staple lines ,
contiguous small bowel, excluded stomach.
 Early<24hrs- significant extra luminal
 Late – Anastomotic ulcers
 Endoscopy--Early-perforation risk
 Dual endotherapy-Endoclips+Adrenaline
 Hemostatic powder-more data required.

 Angiographic intervention can be considered.
 Risk of ischemia in new anastomosis.
 Electro cautery should be avoided at fresh
staple sites.
GI Bleeding

Stenosis
 Sites - Common-GJA,Less common-JJA
 Others-At intestinal adhesions,passage through
mesocolon.
 Rates- 5-12% of lap RYGB after 4-10 weeks
 Definition – Standard 9.5mm scope cannot be
passed through anastomosis.
 Treatment -TTS, Savary dilators,
Elictrosurgical incision.

 Balloon dilatation
 15mm –safe, 20mm- successful
 Gradual approach –
Can reduce perforation risk( 3% to 5%)
Decrease the possibility of over dilation with
resultant weight regain.
Suture material at the GJA may have to be
removed to achieve successful dilation.
Stenosis-Management

Foreign Body Complications
 Foreign material (e.g., sutures, staples, bands)
are often placed during bariatric surgery.
 Inflammatory response - may result in pain,
ulceration and obstruction.
 Implanted foreign bodies (e.g., bands,
mesh)can also erode or migrate.

 Associated with pain even when there is no
adjacent visible inflammation.
 Traction on sutures or staples often reproduces
pain.
 Ryou and colleagues demonstrated immediate
symptomatic improvement in 71% of patients
after foreign body removal.
Foreign Body Complications

Leaks & Fistulas
 Incidence of leak 1.7% to 2.6% after open
RYGB , to 2.1% to 5.2% after laparoscopic
RYGB, and is as high as 5.1% after SG.
 MC sites are the GJ(68%) or JJ (5%) or at
gastric pouch staple lines (10%); an additional
14% involve multiple sites.
 Risk of chronic GG fistula is highest when the
pouch and excluded stomach are contiguous,
as with the open surgical approach.

 Leaks - mortality rate of 3.3% to 14%.
 Leaks result in a 6-fold increase in hospital
stay.
 Leaks often present without fever,
leukocytosis, or pain.
 MC reported sign of leak is tachycardia,
present in 72% to 92% of patients.
 Other symptoms - Nausea and vomiting
(81%), fever (62%) and leukocytosis (48%).
 Objective - Increased drain output, as well as
elevated CRP 2 days after surgery .
Leaks & Fistulas

 Endoscopic management-
 Dilatation of distal stenosis
 Stents- SEMS/SEPS
 Clips,suturing devices.
 Stents –
 A meta-analysis by Puli and coworkers found a
pooled proportion for successful leak
closure(radilogical evidence) of 87.8% both SEMS
and SEPS were used in 7 of the included studies.
 Most leaks closed with 1 treatment, 9% of patients
had failure to respond and required re visional
surgery
Leaks & Fistulas--Management

 Other methods
 Clips
 OTSC -The Over the Scope Clip (Ovesco
Endoscopy AG Tübingen, Germany), is a
nitinol clip placed on a cap at the endoscope
tip. 72-91 % success .
 Fibrin glues/fistula plugs.
Leaks & Fistulas--Management

Pancreaticobiliary Disease
 Prior to ERCP - preparation should include
characterization of anatomy and pathology via
cross-sectional imaging.
 Patients with LAGB, SG, and VBG are usually
able to have successful ERCP with a side-
viewing endoscope.
 Patients with history of RYGB and BPD+DS
often require special tools and procedures.
 Laparoscpic assisted ERCP

Weight Regain and Dilated Gastrojejunal
Anastomosis
 Neuroendocrine-metabolic regulation,
resulting in a starvation response that induces
increased appetite and energy conservation.
 Larger pouch size and GJA diameter are
associated with postoperative weight regain.
 Revisionsal surgery- high complication rate
 Endoluminal surgery- Promising.

 Transoral outlet reduction (TORe) has been
studied on multiple platforms.
 A RCT-
 TORe using the Bard EndoCinch with sham
procedure in 77 patients with GJA diameter
greater than 20 mm.
 GJA diameter was reduced to less than 10 mm in
89.6%, with no perforations and an adverse event
rate that was similar to that of the sham group
 96% of revised patients had weight loss or
stabilization in the following 6 months.
Weight Regain and Dilated Gastrojejunal
Anastomosis

Surgical Management Of Obesity & Its Complications

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