Overview. Stanley J. Rogers, MD, FACS Associate Clinical Professor of Surgery University of California San Francisco

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1 GASTROINTESTINAL COMPLICATIONS AFTER BARIATRIC SURGERY Stanley J. Rogers, MD, FACS Associate Clinical Professor of Surgery University of California San Francisco UCSF DEPARTMENT OF SURGERY Original Article Long-Term Mortality after Gastric Bypass Surgery Ted D. Adams, Ph.D., M.P.H., et al University of Utah School of Medicine Salt Lake City, UT N Engl J Med Volume 57(8): August, 7 Original Article Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects Lars Sjöström, M.D., Ph.D., et al. Swedish Obese Subjects (SOS) Study Sahlgrenska University Hospital, Gothenburg, Sweden, N Engl J Med Volume 57(8): August, 7 Overview The prospective, controlled Swedish Obese Subjects study enrolled 447 subjects who either underwent bariatric surgery or received conventional treatment The results of follow-up for up to 15 years suggest that bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality Sjostrom L et al. N Engl J Med 7;57:741-75

2 Unadjusted Cumulative Mortality Sjostrom L et al. N Engl J Med 7;57: (95% CI,.59 to.99; P =.4) % Resolution Comorbidity Resolution of Comorbidities,94 patients Bariatric Surgery A Systematic Review and Meta-analysis Buchwald H. et al. JAMA. 4; 9(14):174-7 Diabetes Hyperlipidemia HTN Sleep apnea Band GBP Laparoscopic vs. Open Gastric Bypass Complications Review of 464 cases Malabsorptive Procedures % Complications Splenectomy Leak Early SBO OPEN GBP GI Bleed PE LAP GBP 6.6 Wound Inf Pneumonia Death.1 Late SBO Inc Hernia.5.7 Stenosis Podnos YD et al. Arch Surg ;18: Duodenal Switch/ Biliopancreatic Diversion Highest rate of longterm complications related to malnutrition / diarrhea Death rate highest of any bariatric procedure at 1.1 percent

3 Current Most-Used Bariatric Procedures Roux-en-Y GB Gastric Banding % Complications Splenectomy.4 Laparoscopic vs. Open Gastric Bypass Complications Review of 464 cases 1.7 Leak Early SBO OPEN GBP No difference GI Bleed PE LAP GBP 6.6 Wound Inf Pneumonia Death.1 Late SBO Inc Hernia.5.7 Stenosis Podnos YD et al. Arch Surg ;18: Laparoscopic vs. Open Gastric Bypass Complications Review of 464 cases OPEN GBP LAP GBP Laparoscopic vs. Open Gastric Bypass Complications Review of 464 cases OPEN GBP LAP GBP % Complications No difference Lap > Open % Complications No difference Lap > Open Open > Lap Splenectomy Leak Early SBO GI Bleed PE Wound Inf Pneumonia Death Late SBO Inc Hernia Stenosis Splenectomy Leak Early SBO GI Bleed PE Wound Inf Pneumonia Death Late SBO Inc Hernia Stenosis Podnos YD et al. Arch Surg ;18: Podnos YD et al. Arch Surg ;18:

4 UCSF Bariatric Program ( patients) Gastric Band & Gastric Bypass Lap GBP Open GBP LAGB Lap Sleeve Lap Revision Lap Band Advantages -ease/safety MIS -adjustability -less nutritional cons. Disadvantages -higher failure rate -device complications -esoph dil./ erosion 6 4 July4-June5 July5-June6 July6-June7 July7-June8 N=14 N=178 N=164 N=196 Lap GBP -better weight loss -enhanced satiety -longer term studies -greater peri-op risk -longer learning curve -nutritional deficiencies Complications after Bariatric Surgery GASTRIC BYPASS GASTRIC BAND 1. G-J Stricture 4%. Bleeding %. Fistula 1% 4. SBO % 5. Slippage 6. Erosion 7. Esophageal Dilation 8. Tubing/Port Infections

5 Complication of Lap Gastric Bypass (n = 44) % Complications 1 Grade I - events carrying minor risks ; requiring only bedside interventions Grade IIa - events requiring use of drug therapy or blood transfusions Grade IIb - events requiring therapeutic intervention and without lasting disability Grade III - complications resulting in organ resection or lasting disability Grade IV - death All Grades Grade I Grade IIa Grade IIb Grade III Grade IV Campos GM, Ciovica R, Rogers SJ, Posselt AM, Vittinghoff E, Takata M, Cello JP. Archives of Surgery 7; 14(1): Campos GM, Ciovica R, Rogers SJ, Posselt AM, Vittinghoff E, Takata M, Cello JP. Archives of Surgery 7; 14(1): Complications of Lap Gastric Bypass (n = 44) v. Open (n=74) Complications after Bariatric Surgery % Complications * * * LAP GBP Open GBP All Grades Grade I Grade IIa Grade IIb Grade III Grade IV GASTRIC BYPASS GASTRIC BAND 1. G-J Stricture. Bleeding. Fistula 4. SBO 5. Gastric Erosion 6. Gastric Slippage 7. Esophageal Dilation 8. Tubing/Port Infections Campos GM, Ciovica R, Rogers SJ, Posselt AM, Vittinghoff E, Takata M, Cello JP. Archives of Surgery 7; 14(1):

6 Blackstone R, et al. J Gastrointestinal Surgery, 7, Blackstone R, et al. J Gastrointestinal Surgery, 7,

7 Takata, et al. Obesity Surgery, 7; 17: Predictors of G-J Stricture after Gastric Bypass Predictors of G-J Stricture after Gastric Bypass At the multivariate level, only the use of a 1-mm circular stapler was identified as an independent predictor of a GJ stricture: (odds ratio 11.; 95% CI.-57., P=.4). Takata, et al. Obesity Surgery, 7; 17: Takata, et al. Obesity Surgery, 7; 17:

8 Predictors of G-J Stricture after Gastric Bypass Complications after Bariatric Surgery GASTRIC BYPASS GASTRIC BAND 1. G-J Stricture. Bleeding. Fistula 4. SBO 5. Gastric Erosion 6. Gastric Slippage 7. Esophageal Dilation 8. Tubing/Port Infections Takata, et al. Obesity Surgery, 7; 17: Bleeding after GBP In our series, the rate of bleeding complications was similar for laparoscopic and open cases (.1% vs.4%,respectively, P=.69) The main potential sources of bleeding are: NS Bleeding after GBP Proposed Algorithm Suspected Bleed -Melena/UGI Bleed -Drain output -Drop HCT -Tachycardia/Low BP Resuscitat., Serial HCT, Stop Heparin Check coags, Type & Cross Intra-luminal EGD/Enteroscopy Intra-peritoneal Laparoscopy 1. Intraluminal: G-J, J-J, and gastric remnant staple lines. Intraperitoneal: Mesenteric staple line and dissection planes. Stop Bleed GJ / JJ Bleed Rem. Bleed IP Bleed. Abdominal Wall: Trocar insertion sites Transfuse Epi / Heater Probe 8% successful Remnant Gastrectomy Campos GM, Ciovica R, Rogers SJ, Posselt AM, Vittinghoff E, Takata M, Cello JP. Archives of Surgery 7; 14(1): Stop Bleed Intubate and Return to O.R Laparoscopy Mehran A, et al. Obesity Surgery ; 1:84-47 Jamil LH, et al. Am J Gastro 7;1:1 6

9 Bleeding after GBP How to treat? Bleeding after GBP While bleeding from the GJ may manifest as hematemesis and permit endoscopic intervention, bleeding from the other sources may pose a diagnostic and treatment challenge. The decision to transfuse, use therapeutic endoscopy or re-operation is based on a combination of clinical factors and local experience. Post-operative protocols should actively pursue this diagnosis Campos GM, Ciovica R, Rogers SJ, Posselt AM, Vittinghoff E, Takata M, Cello JP. Archives of Surgery 7; 14(1):

10 Gastrointestinal Fistula / Leak after GBP: Literature * Anatomotic leaks -.8 to 7% * Suggested to be the most common preventable cause of death after pulmonary embolism * Leak-associated mortality ranging from 6% to 17%. GI Fistula after GBP Routine UGI Series?? GI Fistula after GBP Routine UGI Series?? 7/64 = 1.1% Carter J, Tafreshian S, Campos GM, Tiwari U, Herbella F, Cello JP, Patti MG, Rogers SJ, Posselt AM. Surgical Endoscopy 7; 1: Carter J, Tafreshian S, Campos GM, Tiwari U, Herbella F, Cello JP, Patti MG, Rogers SJ, Posselt AM. Surgical Endoscopy 7; 1:17-77.

11 SBO after GBP Incidence % Sudden onset abdominal pain CAT Scan Internal Hernia Refer to bariatric surgeon Carter J, Tafreshian S, Campos GM, Tiwari U, Herbella F, Cello JP, Patti MG, Rogers SJ, Posselt AM. Surgical Endoscopy 7; 1: Campos GM, Ciovica R, Rogers SJ, Posselt AM, Vittinghoff E, Takata M, Cello JP. Archives of Surgery 7; 14(1): Complications after Bariatric Surgery Complication Band / Port Erosion GASTRIC BYPASS GASTRIC BAND 1. G-J Stricture. Bleeding. Fistula 4. SBO 5. Gastric Erosion 6. Gastric Slippage 7. Esophageal Dilation 8. Tubing/Port Infections

12 Early Complications Within Days After Operation Late Complications Within Days After Operation Weber M, Kuller M, Bucher T, et al. Ann Surg, 5 Weber M, Kuller M, Bucher T, et al. Ann Surg, 5 Late Complications Within Days After Operation Results Band Versus Gastric Bypass BAND GASTRIC BYPASS N 1 1 Female 71% 71% Age (median, range) 47 (15-7) 46 (19-65) BMI (median, range) 45 (6-66) 45 (6-67) Type Diabetes 4% 4% Race, n 71% Caucasian 71% Caucasian Operative technique Laparoscopic, 1% Laparoscopic, 99% Conversion open, 1% LOS, median, range (1-5) (-8) Weber M, Kuller M, Bucher T, et al. Ann Surg, 5 Rabl C, Palazzo F, Rogers S, Posselt A, Cello J, Campos GM Laparoscopic Gastric Bypass is as Safe as Laparoscopic Gastric Banding and Provides Superior Weight Loss Outcomes. Obesity Surgery. 18 (4): 459, 8.

13 Results Complications BAND GASTRIC BYPASS Complications 8% 11% Early Complications % 6% Wound infection Trocar site bleeding Urinary Retention Late Complications 5% Port Malfunction Port Erosion Severe dysphagia Band Erosion Conversion to Bypass Wound infection (n=) G-J Bleed LUQ abscess Pneumonia 5% G-J Ulcer G-J Strictures (n=) G-J Bleed Small Bowel Obstruction P =.6 P =.49 Laparoscopic Conversion Band to Bypass 1 Re-operation 7 1 No Mortality P =.6 Rabl C, Palazzo F, Rogers S, Posselt A, Cello J, Campos GM Laparoscopic Gastric Bypass is as Safe as Laparoscopic Gastric Banding and Provides Superior Weight Loss Outcomes. Obesity Surgery. 18 (4): 459, 8. 4 Conclusions Conclusions Lap Gastric Bypass has similar rates of early and late complications compared to Lap Band There was a strong trend to more re- operations in the Lap Band group With the benefit of superior weight loss, greater resolution of type DM, and similar rate of complications (and possibly lower rate of reoperations), Lap Gastric Bypass may have a similar or lower risk-benefit ratio compared to Lap Band. This information should be available when informing patients about surgical options available to treat morbid obesity. Rabl C, Palazzo F, Rogers S, Posselt A, Cello J, Campos GM Laparoscopic Gastric Bypass is as Safe as Laparoscopic Gastric Banding and Provides Superior Weight Loss Outcomes. Obesity Surgery. 18 (4): 459, 8. Rabl C, Palazzo F, Rogers S, Posselt A, Cello J, Campos GM Laparoscopic Gastric Bypass is as Safe as Laparoscopic Gastric Banding and Provides Superior Weight Loss Outcomes. Obesity Surgery. 18 (4): 459, 8.

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