Obesity epidemic; so where does endoscopy fit in with current bariatric surgery in preoperative assessment and management of complications, and what's under development for primary endoscopic bariatric techniques-- get the skinny here!
Dr Pravin John and Dr John Thanakumar, Anurag Hospital, Coimbatore present the differences between metabolic and obesity surgery - dept of advanced laparoscopy and obesity
Peroral Endoscopic Myotomy (POEM) | Treatment For Achalasia of Esophagus and ...YashodaHospitals
POEM is a minimally invasive procedure that uses a high definition endoscope (a flexible tube with a mounted camera at end) to help treat certain swallowing disorders and stands for Peroral Endoscopic Myotomy.
Who cannot undergo this procedure?
Although POEM is a safe and effective procedure, it may not be a suitable option in certain cases. People with any of the following conditions are generally not recommended to undergo POEM for achalasia:
1. Disorders of coagulation
2. History of any kind of therapy that is likely to compromise the integrity of the mucosa of the esophagus or lead to fibrosis of the submucosa for e.g. radiation for cancer treatment, endoscopic mucosal resection, or radiofrequency ablation
3. Liver cirrhosis with portal hypertension
4. Severe erosive esophagitis
When should it be done?
POEM is generally indicated for treating the following disease:
1. Achalasia: It is a medical condition that affects the muscles of the esophagus. The lower esophageal sphincter (LES), a muscular valve present between the esophagus and the stomach fails to relax during swallowing in this condition.
2. Diffuse esophageal spasm: Esophageal disorders of muscle spasm that are unresponsive to medical therapies
3. Nutcracker esophagus also known as hypertensive peristalsis is a muscle spasm disorder which needs surgical correction.
Dr Pravin John and Dr John Thanakumar, Anurag Hospital, Coimbatore present the differences between metabolic and obesity surgery - dept of advanced laparoscopy and obesity
Peroral Endoscopic Myotomy (POEM) | Treatment For Achalasia of Esophagus and ...YashodaHospitals
POEM is a minimally invasive procedure that uses a high definition endoscope (a flexible tube with a mounted camera at end) to help treat certain swallowing disorders and stands for Peroral Endoscopic Myotomy.
Who cannot undergo this procedure?
Although POEM is a safe and effective procedure, it may not be a suitable option in certain cases. People with any of the following conditions are generally not recommended to undergo POEM for achalasia:
1. Disorders of coagulation
2. History of any kind of therapy that is likely to compromise the integrity of the mucosa of the esophagus or lead to fibrosis of the submucosa for e.g. radiation for cancer treatment, endoscopic mucosal resection, or radiofrequency ablation
3. Liver cirrhosis with portal hypertension
4. Severe erosive esophagitis
When should it be done?
POEM is generally indicated for treating the following disease:
1. Achalasia: It is a medical condition that affects the muscles of the esophagus. The lower esophageal sphincter (LES), a muscular valve present between the esophagus and the stomach fails to relax during swallowing in this condition.
2. Diffuse esophageal spasm: Esophageal disorders of muscle spasm that are unresponsive to medical therapies
3. Nutcracker esophagus also known as hypertensive peristalsis is a muscle spasm disorder which needs surgical correction.
Comparison of Revision in Roux-en-Y vs Mini-Gastric BypassDr. Robert Rutledge
Comparison of Revision in
Roux-en-Y vs
Mini-Gastric Bypass
Dr K S Kular
Kular Medical Education & Research Society
Kular Group of Institutes
drkskular@gmail.com
www.kularhospital.com
SMALL BOWEL OBSTRUCTION- GENERALISED ABDOMINAL PAIN
#surgicaleducator #epigastricabdominalpain #pepticulcerdisease #usmle #babysurgeon #surgicaltutor
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Small Bowel Obstruction- a didactic lecture.
• It is one of the common surgical problems you see in surgical wards.
• I have discussed the various causes for Generalised Abdominal Pain, epidemiology, etiology,pathology, clinical features, investigations, and treatment of Small Bowel Obstruction.
• I have also included a mind map, diagnostic algorithm and a treatment algorithm for Small Bowel Obstruction.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the video.
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
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.
Pancreatic cystic lesions are encountered quite commonly nowadays. How to appraoch them is important as some are bnign and some having malignant potential. EUS helps in characterising them complementing with the CT or MRI
Obstructed defecation syndrome (ODS) is a functional disorder leading to the sensing of outlet obstruction in the absence of any pathological findings. In this article, we also provide the etiology of acquired constipation. Constipation is a very common presentation by the patients of a practicing surgeon. Any constipation that defies the existing understanding merits consideration for its evaluation for ODS. Constipation can be of primary or secondary variety. After clinically excluding the usual causes of constipation and ruling out colonic motility disorders, specialised investigations like dynamic defecography help in further management of ODS.
POEM (Per Oral Endoscopic Myotomy) is a rising well known treatment for Achalasia ....... in this ppt we discuss the feasibility of POEM versus dilation and Heller's myotomy
Comparison of Revision in Roux-en-Y vs Mini-Gastric BypassDr. Robert Rutledge
Comparison of Revision in
Roux-en-Y vs
Mini-Gastric Bypass
Dr K S Kular
Kular Medical Education & Research Society
Kular Group of Institutes
drkskular@gmail.com
www.kularhospital.com
SMALL BOWEL OBSTRUCTION- GENERALISED ABDOMINAL PAIN
#surgicaleducator #epigastricabdominalpain #pepticulcerdisease #usmle #babysurgeon #surgicaltutor
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Small Bowel Obstruction- a didactic lecture.
• It is one of the common surgical problems you see in surgical wards.
• I have discussed the various causes for Generalised Abdominal Pain, epidemiology, etiology,pathology, clinical features, investigations, and treatment of Small Bowel Obstruction.
• I have also included a mind map, diagnostic algorithm and a treatment algorithm for Small Bowel Obstruction.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the video.
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
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.
Pancreatic cystic lesions are encountered quite commonly nowadays. How to appraoch them is important as some are bnign and some having malignant potential. EUS helps in characterising them complementing with the CT or MRI
Obstructed defecation syndrome (ODS) is a functional disorder leading to the sensing of outlet obstruction in the absence of any pathological findings. In this article, we also provide the etiology of acquired constipation. Constipation is a very common presentation by the patients of a practicing surgeon. Any constipation that defies the existing understanding merits consideration for its evaluation for ODS. Constipation can be of primary or secondary variety. After clinically excluding the usual causes of constipation and ruling out colonic motility disorders, specialised investigations like dynamic defecography help in further management of ODS.
POEM (Per Oral Endoscopic Myotomy) is a rising well known treatment for Achalasia ....... in this ppt we discuss the feasibility of POEM versus dilation and Heller's myotomy
Recent Update on Management of Ulcerative ColitisDr Amit Dangi
Recent update on the surgical and medical management of ulcerative colitis, including various controversies regarding IPAA and recent medical management incorporating the role of biologicals
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
---------- Forwarded message ----------
From: UCD Graduate '09 None <ucdgrad09@gmail.com>
Date: 2009/2/12
Subject: Bambury tutorial Upper GI Surgery
To: ucdgrad09@gmail.com
She does not know that we have this so please don't print it and bring it to
the lecture
Information about Obstructed Recto Sigmoid Malignancy by Dr Dhaval Mangukiya.
Details of introduction of obstructed recto sigmoid malignancy, Epidemiology, Pathophysiology, Complications, Early Presentation, Stools, History, Late Presentation, Diagnosis, Imaging, Contrast enema, Screenig, Treatment, Management, Surgical management, Surgical options etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
esophageal cancer surgery types and complicationsved sah
Background-Anatomy & Staging
Surgical Candicate
Contraindication of sx
Assessment of patients for surgery
Approaches of esophagectomies
Esophageal reconstruction
Complications of esophagectomy
Hash It Out: The Role of Medical Marijuana in GIPatricia Raymond
Marijuana's side effect of Cannabinoid Hyperemesis Syndrome is well known to us, as is use of Marinol to enhance appetite in the chronically ill, but are there other high points in the use of medical marijuana? What about the possible use of CBD oil for chronic pancreatitis or intractable abdominal pain?
Studies have shown cannabis' effect on GI motility, inflammation and immunity, intestinal and gastric acid secretion, nociception and emesis pathways, and appetite. Let's weed through the available data on the medical use and side effects of medicinal cannabis in gastroenterology.
Celiac Disease: Beyond Bowes, Bone, & Blood Rev 2019Patricia Raymond
Celiac disease can cause iron deficiency anemia, osteoporosis, and malabsorption…but is that all? Nope. There are a huge number of other disease associations with celiac disease beyond just bowels, bone, and blood. Join us for this classic presentation of celiac comorbidities that may alert you to the presence of this woefully under-diagnosed condition.
Diverticulitis: Popular Misconceptions & New Management rev 2019Patricia Raymond
As presented at RMSGNA 2019: Of course, it's not about just avoiding nuts and seeds. However, do you know how many attacks you can endure before suggesting a resection? How to manage young or immunosuppressed patients with diverticulitis? How Eastern (asian)diverticulitis differs? The role of mesalamine in treatment? It's time to re-explore a disease that you thought you knew!
Evolving diets in GI Disease 2019 Raymond/GallagherPatricia Raymond
As presented 09/2019 at RMSGNA: In the 50's , doctors recommended smoking for your health. More recently gastroenterologists told patients with ulcers to drink milk and eat bread to heal.
Are you using new science based dietary information for your patients? It's time to update your timeworn dietary strategies and handouts. Join us and review the science on recent advances in dietary management for gastrointestinal disorders: Fatty liver, IBS, IBD, Gastroparesis, Post gastric bypass, Diverticulosis, Cirrhosis, and more!
Examine historical misinformation in dietary management of gastrointestinal disorders
Describe the emerging evidence supporting the primary role of dietary therapies in digestive disease including Irritable Bowel Syndrome, Inflammatory Bowel Disease, Small Intestinal Bacterial Overgrowth, Non-Alcoholic Fatty Liver Disease, Gastroparesis, Pancreatitis, Post-Gastric Bypass, and Diverticulitis.
Identify the role of the Registered Dietitian and the importance of a multi-disciplinary approach to the management of digestives diseases
Know GI Inside & Out? Recognizing Skin Lesions of GI DisordersPatricia Raymond
Skin lesions seen with disorders of the digestive tract are not rare; would you recognize and correctly correlate erythema nodosum, dermatitis herpetiformis, pyoderma gangrenosum? Those were easy-- how about pyoderma vegetans, pyostomatitis vegetans, sweet’s syndrome, xanthomas, tripe palms, palmoplantar keratoderma, or trichilemmomas? Stumped?
Join us and learn the art of GI diagnosis without resorting to our endoscopes.
Fun Functional Gallbladder Disorders: Update on Hypo and Hyperkinetic Gallbla...Patricia Raymond
Functional gallbladder disorder is biliary pain from motility disturbance in the absence of gallstones, sludge, or microcrystal disease. In patients with biliary-type pain and a normal US, the prevalence is 8% men and 21% women. We will review the clinical manifestations, diagnosis, and management of patients with suspected functional gallbladder disorder, and also address current evaluation and management of sphincter of Oddi dysfunction.
Cyst Assist: Pancreatic Cyst Evaluation & ManagementPatricia Raymond
Explore the clinical approach to cystic pancreatic lesions, and review recent guidelines directing observation, endoscopic evaluation, and surgical referral for patients with pancreatic cystic neoplasms. Much of our focus will be to understand the natural history and management of the four subtypes of pancreatic cystic neoplasms (PCNs): Serous cystic tumors (SCTs), Mucinous cystic neoplasms (MCNs), Intraductal papillary mucinous neoplasms (IPMNs), and Solid pseudopapillary neoplasms (SPNs). Pseudocyst management will be included in this review of these increasingly frequent and often incidental and asymptomatic CT and MRI findings.
Kudos To You: Learning your Kudo Pit Patterns and Paris Polyp ClassificationsPatricia Raymond
We've told patients that we won't know about their polyps until after the pathology report is back; turns out that's not precisely true. Today's excellence in optics provides an accurate instantaneous assessment of the histology of colon polyps which may help in decision making during colonoscopy.
Did you know that if a polyp has a type 5 Kudo pit pattern, 50% were invasive cancers to the submucosal layer? What is it about that scary polyp that raises your hackles? Join us in this highly interactive session where we'll learn Kudo pit patterns as well as Paris polyp classifications to elevate your GI procedure reporting and your patient care.
Describe the emerging evidence supporting the primary role of Kudo Pit Patterns in visual inspection of in situ polyps, and demonstrate your ability to identify the patterns
Authentication of Kudo Pits
Pits and their risks
Images of Kudo pits
Quiz of Kudo Pits
Discuss the potential and shortcomings of the Paris Polyp Classification, and demonstrate an ability to classify the polyp shape
Polyp shapes and and their risks (pedunculated, elevated, depressed)
Images of polyps for Paris classification
Polyps and their risks
Quiz of polyp shapes
Concerns regarding interobserver variability
Familial Adenomatous Polyposis affects 1 in 10,000 to 30,000 Americans who experience 100% risk of colon cancer, and FAP doesn't end with a total colectomy for removal of their hundreds of polyps.
Follow this journey of two real FAP patients through pancreatitis from symptomatic ampulla polyps, surgical resection of giant small bowel polyps, bowel obstruction from abdominal desmoid tumors, and Wilm's tumor of the kidney. How do we diagnose, monitor and support our FAP patients? Can pharmacotherapy reduce risk of polyp growth in FAP? What are the extracolonic manifestations of the APC gene mutation? Our responsibility doesn't end when the colon does.
Bored with Barretts: Diagnosing Gastric Intestinal Metaplasia, Meckels, & Pa...Patricia Raymond
We all know what to do with the border disorder that is Barretts, but what about other mucosal heterotopia: intestinal mucosa in the stomach, stomach mucosa in the intestine, pancreas mucosa in the stomach...what's going on with all this meandering mucosa? Join us for a discussion about how to diagnose and manage various misplaced gastrointestinal mucosa.
Discuss the natural history of Gastric Intestinal Metaplasia and construct proper endoscopic surveillance and mapping guidelines
Epidemiology and risk factors
Complete and incomplete, types I-III based on mucin expression
Risk of progression to cancer
Proper surveillance and endoscopic mapping
Management
35 min
Meckels
Describe the presumed anatomical development of Meckel's Diverticulum, summarize the 'Rule Of Twos', formulate management of a Meckel's associated cryptic bleed
Who was Meckel
Epidemiology and risk factors
Rule of twos
Risk of bleed
Management
10 min
Pancreatic Rests
Discuss the natural history of Gastric Intestinal Metaplasia and construct proper endoscopic surveillance and mapping guidelines
Review the endoscopic appearance of the Pancreatic Rest, discuss rare symptoms attributable to the finding and current endoscopic evaluation and management
Endoscopic appearance
Anatomic development
Risks for pancreatitis, cancer, obstruction
Endoscopic and surgical management
10 min
Do You Believe in Reflux: Idiopathic Pulmonary FibrosisPatricia Raymond
Recent studies suggest that if you have IPF (idiopathic pulmonary fibrosis), that you may not perceive the GERD (reflux) that you have, and that this acid reflux may cause the fibrosis to progress. Ask for proper testing and treatment to see if you are one of the almost 80% of IPF patients who have reflux, often silent reflux.
Hospitals have become unfriendly places for patients to be in…rushed, harried staff simply doesn’t have the time to provide the personal touch anymore…or can we? Delighted patients refer their friends and return for repeat procedures.
The ‘Spa Hospital’ addresses our patients’ needs with low or no cost techniques adapted from those used at spas. Attention will also be given to reception and departure from unit, patient privacy concerns, and their lasting impression with reviews of medical literature supporting these techniques.
Diverticulitis: Popular Misconceptions and New ManagementPatricia Raymond
Of course, it's not about just avoiding nuts and seeds. However, do you know how many attacks you can endure before suggesting a resection? How to manage young or immunosuppressed patients with diverticulitis? How Eastern (asian)diverticulitis differs? The role of mesalamine in treatment? It's time to re-explore a disease that you thought you knew!
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
3. Where does endoscopy fit in?
pre op assessment
endoscopic management
of complications
primary endoscopic
bariatric in the future
Not addressing:
selection criteria for
bariatric surgery
efficacy of bariatric surgery
non endoscopic
complications of bariatric
surgery
4. Pre op bariatric surgery-
controversial
prevalence of upper gastrointestinal (GI) symptoms in patients with
morbid obesity is higher than that of the general population
H pylori prevalence higher?
cannot get to excluded stomach post op for ulcers, MALT, or cancer
American Society of Gastroenterology (ASGE) 2008 guidelines
recommend screening EGD in bariatric patients who have symptoms of
GERD or dyspepsia
Others recommend for all, even those without symptoms
Retrospective study
448 bariatric patients undergoing screening EGD
141 (31%) had abnormal findings
18% resulted in change of medical management and 0.4% change
surgical plans
5. Which endoscopies?
EGD with biopsy for H pylori
urease breath or stool antigen tests, accuracy of 96 and
91%
serology assays sensitivity and specificity of greater than
95 percent in patients without atrophic gastritis or
intestinal metaplasia
some payers require routine H. pylori screening before
bariatric surgery
Colonoscopy for all over 60 (Cornell University)
6. Barrett’s esophagitis
Barrett’s esophagitis (BE) incidence in morbid obesity as high as
5.8%
regression of Barrett’s esophagus following gastric bypass has
been described (better than Nissan in obese patient with BE)
557 RYGBs
BE was identified in 12 (2.1%) of the subjects on routine
preoperative endoscopy
Postop endoscopy showed regression of metaplasia in 42%
Need to continue BE surveillance post op
NOTE: RYGB stomach remains for use for esophagectomy, VSG
leaves no remnant stomach
VSG may be contraindicated in patients with
Barrett’s
7. Bariatric Surgeries as of 2011
Roux-en-Y gastric bypass
Vertical banded gastroplasty
Laparoscopic adjustable gastric banding
Sleeve gastrectomy
Sleeve gastrectomy with duodenal switch
8. Roux-en-Y gastric bypass
small stomach pouch only
able to hold an ounce of
food; over time, the pouch
stretches to hold one cup
body absorbs fewer calories
since food bypasses the
duodenum
intestinal arrangement
(Roux-en-Y) seems to
change the release of GI
hormones (improved
metabolism, decreased Image from: Huang CS. Endoscopy in patients who have undergone bariatric surgery. In:
UpToDate, Saltzman JR, Jones D (Ed), UpToDate, Waltham, MA, 2011. Used with permission.
appetite)
9. Roux-en-Y gastric bypass
Image from: Huang CS. Endoscopy in patients who have undergone bariatric surgery. In:
UpToDate, Saltzman JR, Jones D (Ed), UpToDate, Waltham, MA, 2011. Used with permission.
10. Vertical banded gastroplasty
purely restrictive
procedure
upper part of the stomach
is partitioned by a vertical
staple line with a tight
outlet wrapped by a
prosthetic mesh or band
small upper stomach
pouch gets filled quickly by
solid food and prevents
consumption of a large
meal
Image from: Huang CS. Endoscopy in patients who have undergone bariatric surgery. In:
UpToDate, Saltzman JR, Jones D (Ed), UpToDate, Waltham, MA, 2011. Used with permission.
11. Vertical banded gastroplasty
From Huang CS, Farraye FA, Endoscopy in the Bariatric
Surgical Patient. Gastroenterol Clin N Am 34 (2005)
151–166
12. “Lap band”
purely restrictive
procedure
tight, adjustable
prosthetic band around
the entrance to the
stomach
soft, locking silicone ring
connected to an infusion
port placed in the
subcutaneous tissue.
Image from: Huang CS. Endoscopy in patients who have undergone bariatric surgery. In:
UpToDate, Saltzman JR, Jones D (Ed), UpToDate, Waltham, MA, 2011. Used with permission.
13. “Lap band”
Image from: Huang CS. Endoscopy in patients who have undergone bariatric surgery. In:
UpToDate, Saltzman JR, Jones D (Ed), UpToDate, Waltham, MA, 2011. Used with permission.
14. Sleeve gastrectomy
Majority of the greater curvature
of the stomach is removed
small capacity tubular
stomach
resistant to stretching due to
the absence of the fundus
few ghrelin producing cells
(a gut hormone involved in
regulating food intake).
Image from: Huang CS. Endoscopy in patients who have undergone bariatric surgery. In:
UpToDate, Saltzman JR, Jones D (Ed), UpToDate, Waltham, MA, 2011. Used with permission.
15. Duodenal switch
partial sleeve
gastrectomy with
preservation of the
pylorus
Roux limb with a short
common channel
significant risks of long-
term malabsorption and
is used only for patients
with very severe obesity
(BMI >50 kg/m2).
Image from: Huang CS. Endoscopy in patients who have undergone bariatric surgery. In:
UpToDate, Saltzman JR, Jones D (Ed), UpToDate, Waltham, MA, 2011. Used with permission.
16.
17. It would be far easier to lose weight
permanently if replacement parts
weren't so handy in the refrigerator.
Hugh Allen
18. Pulmonary embolism
most common cause of
mortality in the
perioperative period
after weight-loss surgery
and can
over 50 % of deaths
19. Post op bleeding 0.6 to 4.0 %
higher rate laparoscopic versus open GBP
surgical anastomotic and/or staple lines, and may be
intra- or extraluminal, most commonly intraluminal.
usually resolves without surgery, but may require
transfusion and reversal of anticoagulation
careful endoscopic examination and therapy for
continued bleeding with high transfusion needs
surgery for hemodynamic instability, intraluminal
bleeding not amenable to endoscopic therapy (eg,
staple line of the excluded stomach) or continued
bleeding despite of normal coagulation
20. Endoscopy & late complications
stomal stenosis
marginal ulcers
appliance erosion
staple line disruption
suture material
21. Stomal stenosis
6 to 20 % with RYGB , higher with LRYGB
20 to 33 percent with VBG
several weeks post op with nausea, vomiting, dysphagia,
gastroesophageal reflux, and eventually an inability to tolerate
oral intake
diagnosis by endoscopy or upper gastrointestinal series.
endoscopic balloon dilation is usually successful, repeat dilation
sessions may be required
complication rate for dilation 3 %
surgical revision (< 0.05 %) for persistent stenosis despite
repeated dilations
dilation for VBG may be unsuccessful (32%) due to the rigid
nature of the prosthetic band
22. Stomal stenosis
Dilate to 10-12 mm, no
greater than 15 mm
weight regain
Perforation
Recurrent stenosis
options
glucocorticoid injection
stent
needle-knife
electrocautery N Am 34 (2005)
From Huang CS, Farraye FA, Endoscopy in the Bariatric
Surgical Patient. Gastroenterol Clin
151–166
23. Marginal ulcer
0.6 to 16%
Causes of marginal ulcers include:
foreign material, such as staples or nonabsorbable suture
NSAIDs
Helicobacter pylori infection
Smoking
present with nausea, pain, bleeding and/or perforation
diagnosis of a marginal ulcer by upper endoscopy
treatment gastric acid suppression +/-
sucralfate, treatment of H pylori if present
24. Marginal ulcer
From Huang CS, Farraye FA, Endoscopy in the Bariatric
Surgical Patient. Gastroenterol Clin N Am 34 (2005)
151–166
25. H. Pylori & marginal ulcers
preoperative testing
and treatment of H.
pylori significantly
reduced the
incidence of
postoperative
marginal ulcers
(2.4% versus 6.8% in
unscreened
patients) http://www.bio.davidson.edu/people/sosarafova/Assets/Bio307/vinardone/page01.html
26. Band or mesh erosion
band erosion 7 % of LAGB patients, occurs at a mean
of 22 months after surgery
1 to 7 % of VBG, occurs one to three years after the
surgery
symptoms nausea and vomiting, epigastric pain.
hematemesis from erosion of the lap band into the left
gastric artery
diagnosis endoscopic, treatment is surgical
Reports of endoscopic removal of eroded lap bands
28. Staple line disruption
results in a fistula to the fundus in VBG
occur in 27 to 31 of VBG, may be as high as 48% if
assessed on routine postoperative endoscopy
weight regain due to increased food
consumption, since patients can eat around their
restriction without feeling full
surgical treatment is conversion to a RYGB or a
BPD/Duodenal switch
29. Staple line disruption
From Huang CS, Farraye FA, Endoscopy in the Bariatric
Surgical Patient. Gastroenterol Clin N Am 34 (2005)
151–166
30. OMG Staple line disruption
From Huang CS, Farraye FA, Endoscopy in the Bariatric
Surgical Patient. Gastroenterol Clin N Am 34 (2005)
151–166
31. Trial endoscopic methods for
fistulae or staple line disruption
Expandable stent
Full thickness staple
Fibrin glue
None are successful
enough for general
application at this time
32. Symptomatic suture material
pain, marginal ulcers, and
obstructive symptoms
(secondary to food
entrapment/bezoar
formation)
removal of foreign body
only required if
symptomatic
cut the suture material
with endoscopic scissors
and extract with biopsy or
rat-toothed forceps
symptom resolution or
improvement in over 80%
33. Look what we’re NOT looking at:
Weeks 1 to 6 (Phase 1) Various/Continous
- Bleeding Eating disorders
- Anastomotic leaks Nutritional deficiencies
- Obstruction Micronutrient deficiencies
Weeks 7 to 12 (Phase 2) Psychosocial
- Prolonged vomiting - Depression and sadness
- Dumping syndrome - Effects of body changes
Months 4 to 12 (Phase 3) Cosmetic issues
- Cholelithiasis
- Small bowel obstruction
- Band erosion
- Band slippage
34. Complications specific to
procedures
Roux-en-Y gastric bypass Lap band
- Gastric remnant distension - Stomal obstruction
- Ventral incisional hernia - Port infection
- Internal hernias - Band slippage and gastric
- Short bowel syndrome prolapse
- Dumping syndrome - Port malfunction
Jejunoileal bypass - Esophageal dilatation
- Electrolyte imbalances
- Renal failure
- Cirrhosis
35. Today's beauty ideal, strictly enforced
by the media, is a person with the
same level of body fat as a paper clip.
Dave Barry
37. Duodenal electrical stimulation (DES)
12 healthy non-obese volunteers
feeding tube placed in the duodenum under endoscopy.
three ring electrodes at the end tip of the tube and the two
distal electrodes were used for recording and electrical
stimulation.
On two separate days, water intake test and GES with actual
DES or sham randomly assigned No dyspeptic symptoms
DES may have a potential application for the treatment
of obesity.
38. Duodenal electrical stimulation (DES)
Delayed gastric emptying
Reduced maximum water
ingestion by subjects
drink water at a 37°C
temperature over a 5-min
period until reaching the
point of complete fullness
39. Various DES devices (under development)
System and method for
providing electrical pulses
to the vagus nerve(s) to
provide therapy for obesity,
eating disorders,
neurological and
neuropsychiatric disorders
with a stimulator,
comprising bi-directional
Sensor based gastrointestinal electrical stimulation for the communication and
treatment of obesity or motility disorders network capabilities United
United States Patent Application 2005022263, 2005 States Patent Application
20050049655 2005
Gastrointestinal stimulation device
United States Patent 7054690, 2006
40. Duodenal–jejunal bypass sleeve
duodenal–jejunal bypass
sleeve
Endobarrier ™ (GI
Dynamics™, Watertown,
MA)
commercially available in
Chile, Germany, the United
Kingdom, Netherlands; soon
available in Australia.
not approved for sale in the
US and is considered
investigational.
Trial underway at Carolinas
Medical Center, Charlotte
NC
41. Duodenal–jejunal bypass sleeve
41 study patients
30 underwent sleeve implantation, 11 diet control group.
All on same low-calorie diet during the study
26 devices were successfully implanted
Unable to implant in 4 .
4 removed before end of study
migration (1), dislocation of the anchor(1), sleeve obstruction (1), and continuous epigastric
pain (1).
Mean procedure time was 35 minutes (range: 12–102
minutes) for a successful implantation
17 minutes (range:5–99 minutes) for explantation.
42. Duodenal–jejunal bypass sleeve
Adverse events universal
26 sleeve patients (100%) had at least one adverse event
mainly abdominal pain and nausea during the first week
BMI was 48.9 and 47.4 kg/m2 for the device
and control patients at onset
Mean excess weight loss after 3 months
19.0% for device patients versus 6.9% for control patients (P <
0.002).
Absolute change in BMI at 3 months was 5.5 and 1.9
kg/m2, respectively.
Type 2 diabetes mellitus was present at baseline in 8 patients of the
device group and
improved in 7 patients during the study period
lower glucose levels, HbA1c, and medication requirements
43. Duodenal–jejunal bypass sleeve
Pooled study results following
12 months with EndoBarrier:
mean absolute weight loss of
20%, or 49.5 pounds
mean excess weight loss
(EWL) of 46.3%
cholesterol levels dropped
from 196.5 mg/dL at baseline
to 161.0 mg/dL
diastolic blood pressure
dropped from 84.8 mmHg at
baseline to 71.2 mmHg)
improved type 2 diabetes
(reduction in HbA1c levels).
46. Transoral endoscopically guided staplers
(TOGA)—revision of procedure?
Retraction wire and sail
to keep stomach in
proper position as
suction is applied and
before stapling
Restrictor to
pleat/narrow the lower
end of the sleeve
47. Transoral endoscopically guided staplers (TOGA)
Mean Average Absolute 11 patients
excess BMI weight
weight loss mean BMI 41.6
loss
No SAE
1 month 19.2% 9.9 kg
100% successful
3 month 33.7% 17.5 kg endoscopic
stapling
6 month 46% 33.1 24.0 kg
48. Transoral endoscopically guided
staplers (TOGA)
Pilot Clinical Study – Belgium and Italy
As of July 2010 > 180 patients, continuing to recruit,
follow up one year
Not commercially available
No cost analysis available
49. Intragastric balloon treatment
BioEnterics Intragastric
Balloon (BIB)
Inamed Health; Santa
Barbara, CA, USA
limited to maximum 6
months
Follow up immediately if
urine turns blue
Methylene blue plus 500-
700 cc saline
nausea, vomiting and
belching within the first 3-
5 days after the BIB
introduction, usually
disappear within few days
50. Intragastric balloon treatment
32 patients,
mean BMI 43.7+/-1.5 kg/m2, mean %EW: 43.1 +/- 13.1
BIB followed by sham procedure after 3 months (Group A)
Sham procedure followed by BIB after 3 months (Group B).
BIB filled with saline (500 ml) and methylene blue (10 ml)
Discharged with omeprazole therapy and diet (1000 kcal)
No AE from endoscopy, balloon placement and removal.
Mean time of BIB positioning was 15 +/- 2 min, range 10-20
min.
51. Intragastric balloon treatment
After the first 3 months
Group A patients the mean BMI lowered from 43.5 to
38.0 kg/m2, Group B weight loss not significant.
The mean %EWL was significantly higher in Group A
than in Group B (34.0 vs 2.1; P < 0.001).
After crossover, at the end of the following 3 months, the
BMI lowered from 38.0 to 37.1 kg/m2 and from 43.1 2 to
38.8 kg/m2 in Groups A and B, respectively.
52. Want a blue balloon?
Available in Germany,
Poland, Czech Republic,
Estonia, Slovakia, UK
Prices range from $1800 -
$6500
Concerns
Trials short term and
stomach adapts
American grazing
behavior verses European
large meals
53. Botulinum toxin
injecting botulinum
toxin-A in the stomach
wall can be used to
manipulate appetite and
reduce food intake
This slows down the
process of stomach
contraction so that food
takes longer empty
stomach and patients feel
full 50% sooner.
54. Botulinum toxin
30 obese patients
Botulinum Toxin A (120 U into the antrum and 80 U into the fundus or
saline by intraparietal endoscopic injection
Body weight and body mass index, solid gastric emptying and
maximal gastric capacity for solids (kcal) were determined before
injection and 2 months later.
Both treatments induced a significant reduction of body weight and
body mass index but Botulinum Toxin A exerted a significantly greater
effect
body weight -11.8 vs. -5.5kg, p<0.0002; body mass index -4.1vs. -
2.2, p<0.001.
maximal gastric capacity for solids was also reduced by both Botulinum
Toxin A and placebo, the former being significantly more effective
(679kcal vs. 237kcal, p<0.008)
Botulinum Toxin A also significantly increased T(1/2) from 83.4to
101.6min, p<0.03). Placebo had no effect on gastric emptying.
55. Give me the needle!
$10-15 per unit for botox
200 units used = $2000 to
$3000 + cost of endoscopy
Should we offer saline
injections routinely to
obese patients undergoing
EGD for proper
indications?
Sclero needles $35
Sterile saline $6
Just a thought!
56. Endoscopy fits into the skinny scene.
pre op assessment
Evaluate and treat H Pylori
Assess for Barrett’s (selection of
surgery)
Consider bariatric surgery rather
than Nissan for Barrett’s in obese
endoscopic management of
complications
Dilate modestly and gently
Check marginal ulcers for H pylori
primary endoscopic bariatric in the
future
Slip and slide
TOGA party
Blue balloons
Wrinkle free
57. Why do Fat chance and
Slim chance mean the same
thing?