How can the surgeon help? M. Lannoo B. Navez
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1 How can the surgeon help? M. Lannoo B. Navez 1
2 Reimbursed indications > 18 year BMI > 40 BMI >35 in combination with: OSAS Hypertension with 3 anti-hypertensive drugs Diabetes type II Multidisciplinary intake internal medicine and psychology. At least 1 year of unsuccesful conservative weight loss therapy
3 Preoperative intake Multidisciplinaire evaluatie GP! Dietician Psychologist Endocrinologist Surgeon Preoperative tests Gastroscopy + HP screening Echo abdomen Lab ananlysis: preoperative deficiencies in 57% of patients. Healthcare professionals should be aware that the morbidly obese patient is by definition not a well-nourished patient. Liz Goldberg and Alfons Pomp. The ASMBS textbook of bariatric surgery. Volume 1. New York: Springer-Verlag; p. Gehrer S, Kern B, Peters T et al. Fewer nutrient deficiencies after LSG tah after LRYGB a prospective study. Obes Surg (2010) 20: ,
4 Surgical procedures
5 Sleeve gastrectomie (SG) First step in two step BilioPancreatic Diversion + Duodenal Switch. BPD-DS Sleeve gastrectomy
6 SG: mechanisms of action RYGB SG Orexigenic Anorexigenic
7 Why SG? Lowest morbidity/mortality? Technical easyness No small bowel involvement (internal herniatie, SBO ) Less dumping and hypoglycemia on long term Minder postoperatieve micronutriëntdeficiënties
8 SG nutritional deficencies 2 jaar follow-up
9 SG results Resultaten: Excess Weight Loss op 5 jaar: 52.3% - 63% DM type II: resolutie op 5 jaar: 66% aht: resolutie op 5 jaar: 50% Nguyen NT, Blackstone RP, Morton JM, Ponce J, Rosenthal RJ. The ASMBS textbook of bariatric surgery. Volume 1. New York: Springer-Verlag; p.
10 Roux-en-Y Gastric bypass (RYGB) 1994: First laparoscopic RYGB Pouch Bypass Alimentary limb: cm Biliary limb Common channel
11 RYGB: mechanisms of action RYGB Sleeve Orexigenic Anorexigenic
12 RYGB results Excess Weight Loss: % DM type II: 2 jaar FU: 80 % resolutie Himpens et al.: 27.9% new onset DM type II na 9 jaar FU. aht: 75 % resolutie Dyslipidemie: 94 % resolutie OSAS: 87% resolutie Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and metaanalysis. Am J Med. 2009;122: e245.
13 RYGB variations More WL? No DOUBT! Solution? MALABSORPTION! Vitamin D long BP All limb 57 (30.5 %) 39 (44.8 %) long A limb P value 18 (20.9 %) <0.001 PTH 1 (0.5 %) 15 (17.2 %) 3 (3.5 %) Iron 2 (6.4 %) 32 (36.8 %) (15.1 %) < Ferritin 11 (5.9 %) 58 (66.7 %) (52.3 %) Haemoglobin 2 (1.1 %) 53 (60.9 %) 37 (43.0 %) diarrhea (GSRS) 2, Trophic effect on L- cells Nergaard et al. Obes Surg. 2014; 24: Nergaard et al. SOARD 2015; 11:
14 Endoscopic plication BMI kg/m 2 RCT Sullivan et al. TWL 1y is only 4,9% vs 1,4% sham Secondary endpoint: > 50% pat > 5% TWL not reached 5% complication rate 14
15 Surgical Complications after Bariatric Surgery Pr B. Navez Service de Chirurgie et Transplantation Abdominale Cliniques Universitaires St Luc Bruxelles
16 Operative Mortality % Early Complications % Late Complications % Excess Weight Loss % BANDING > 30 % reintervention SLEEVE Fistula : 2.3 % GERD : 8-20 % Stenosis 65 BYPASS Fistule 1.9 % 15 Obstruction Stenosis/Ulcer Dumping 75
17 Gastric Banding complications Food impaction : food intolerance, Vô Pouch dilatation (14%) Esophageal dysmotility Intra-gastric migration (5-10%) Infected port a cath, catheter break Small bowel on-bstruction (rare)
18 The General Practitioner facing early complications of bariatric surgery - Return to home on p.o. day Possible symptoms : - Pain : intra-abdo >< abdo wall (trocars)? - Fever : intra-abdo sepsis >< lung, urine, wound infection? - Vomiting : abdo complic. >< no respect of dietary counseling? - Dyspnea : abdo complic. >< cardio-respiratory problem? - Ileus : mechanical obstruction >< paralytic ileus? - Anemia, hematemesis, rectorrhagia
19 NAUSEA - VOMITING What to think? Too much food ingestion Swallowing too fast Insufficient chewing Drinking during meals Too spicy/fatty dishes Stenosis of sleeve / G-J anastomosis
20 Postop intra-abdo septic complications arly clinical signs TACHYCARDIA (> 110/ ) DYSPNEA Others : Pain/abdominal discomfort ileus Fever Hiccup constant Guarding, peritonism : difficult to highlight
21 Postop intra-abdo septic complications Tachycardia : > 110/ Exclude : - Hémorrhage - Dehydration - Pulmonary Embolism Dyspnea Exclude : - Pulmonary Embolism - Pneumonia BLOOD TESTS + CT Scan (injection & ingestion) CRP WBC Abdo Collection Peritonitis SUSPECTED FISTULA
22 Fistula Management Good tolerance Extra-digestive Collection + Bad tolerance Extra-digestive Collection ++ to +++ Rx Drainage ENDO treatment - Pigtail - Endoprosthesis - Ovesco Antibiotherapy Enteral or parentéral nutrition No oral food Watch Laparoscopy +/- laparotomy - Péritoneal washing - Suture of fistula?? - Drainage - Jéjunostomy Surgery : Resection, Roux-en-Y loop.
23 Post-Sleeve Complications Operative Mortality : 0.2 % Early Complications : 6 % Hemorrhage/hematoma : 2 % Fistula from staple line : 2.3 % Stenosis : % Portal Thrombosis : 0.3 % General Complic : 1-2 % Late Complications : Gastro-esophageal Reflux (Barett = CI SL) : 8-20 %
24 Post SLEEVE Fistula 90 % of cases 10 % of cases
25 Gastro-pleural Fistula Extremely serious!!! Subphrenic abscess Peritonitis
26
27 POST-BYPASS COMPLICATIONS EARLY : 9 % Anastomotic leakage 1.9 % Hemorrhage 3 % Stenosis/anast. ulcer 3.4 % Wound infection 0.2 % DVT/Pulm embolism < 1 % LATE : 10 % Obstruction 1 10 % Reoperation 4.4 % Late Dumping (hypoglycemia) Nutritional deficiencies RATIVE MORTALITY : 0.4 %
28 BYPASS : leakages 6 % 9 % 70 % 15 %
29 G-J STENOSIS : Barium swallow, Gastroscopia Epigastric pain, vomiting Early : often linked to anastomotic oedema, could be reversible Late : ischemic, ulcer, fibrosis
30 ost-bp Internal hernia tly after weight loss +++ ointer-mesenteric (1) opetersen space (2)
31 Petersen Hernia Specific to Roux en Y Byp Symptoms : - Abdominal transfixing cram calmed by * Anteflexio * left lateroflexio
32 Intussusception (rare) Jejuno-jejunal anterograde (30%) or retrograde (70%) Symptoms: - Acute abdominal pain - Vomiting - Electrolytic disturbances Diagnosis: CT Scan
33 Marginal Ulcer after BP : 2 12 % Contributing factors : Tabagism, NSAID, ASA, cortic, HP Clinics : pain, dysphagia, dyspepsia, vomiting, bleeding Traitement : PPI (+ Ranitidine), stop causal factors, sometimes surger
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