Bariatric Surgical Complications and Recent Trends in Outcome Data

Transcription

1 Bariatric and Metabolic Conference Bariatric Surgical Complications and Recent Trends in Outcome Data Daniel A.P. Smith, MD Bariatric Surgery Director Essentia Health Park Rapids St. Joseph s Center for Weight Management Laparoscopic Adjustable Gastric Band Complications 2 Slippage Erosion Esophageal & gastric pouch dilation Port / tubing problems Long term: high rates of reoperations & failures Band Slippage 3 Normal location SOURCE: surgery.com/images gastric_band_comp05.jpg Stomach up under band SOURCE: Laparoscopic Bariatric Surgery, 2004; INABNET, MD; DEMARIA, MD; IKRAMUDDIN, MD

2 Band Slippage 4 Symptoms: Partial Gastric Obstruction Intolerance to solids Heartburn Dysphasia, vomiting Coughing, wheezing Gastric Necrosis Severe abdominal pain Peritonitis, sepsis } If present, consider case an emergency. Band Slippage Self emptying pouch. 5 SOURCE: lapbandfollowup.co.uk Slipped band, changed angle. SOURCE: lapbandfollowup.co.uk Band Slippage 6 SOURCE: lapbandfollowup.co.uk Slipped band with swallow. Note pouch and horizontal band. SOURCE: lapbandfollowup.co.uk

3 7 Band Slippage Treatment: 1) Deflate band 2) UGI X Ray 3) Surgery Repositioning stomach around band Removal and/or replacement Gastric Necrosis: Laparotomy with gastric resection & band removal 8 Band Erosion Symptoms: Usually insidious onset Weight gain/loss of satiety Band adjustments ineffective Port infection Workup suspected erosion UGI contrast around band EGD band visible Band Erosion 9 SOURCE: lapbandfollowup.co.uk Endoscopic view of band erosion into lumen of stomach. SOURCE: Laparoscopic Bariatric Surgery, 2004; INABNET, MD; DEMARIA, MD; IKRAMUDDIN, MD

4 Band Erosion Treatment: Removal of band system, usually laparoscopically Closure damaged gastric wall 10 Can sometimes be removed using UGI endoscopy Later band replacement or conversion to gastric bypass Esophageal & Gastric Pouch Dilation 11 Normal location. SOURCE: surgery.com/images/ gastric_band_comp05.jpg Esophageal dilation. SOURCE: Bariatric Times. 2010; 7(11):8 12 PONCE, MD & SMITH, DO, FACOS Esophageal & Gastric Pouch Dilation Symptoms: Dysphasia, vomiting, severe reflux Pneumonia/wheezing Workup: UGI X Ray 12

5 13 Esophageal & Gastric Pouch Dilation Treatment: 1) Deflate band if symptoms improve, slowly begin refilling after 2 3 months 2) If deflation fails: Remove band Convert to gastric bypass Port & Tubing Problems Malposition/flip of port Leakage Kinked tubing Infection 14 Bowel obstruction/erosion around tubing Europe: Emerging Theme from Late Follow-up Data 15 LAGB has high re operation and failure rates Swiss (2006) 317 patients, 7 year follow up Re operation rate, 42% Failure rate at 7 years, 57% Conclusion: With a nearly 40% 5 year failure rate, and a 43% 7 year success rate; LAGB should no longer be considered as the procedure of choice for obesity. OBESITY SURGERY 16:829 35

6 Europe: Emerging Theme from Late Follow-up Data Swiss (2010) 167 patients, bands placed Late complications, 40% Failure rate at 10 years, 32% Conclusion: the high complication, re operation, and long term failure rates lead to the conclusion that the LAGB should be performed in selected cases only... OBESITY SURGERY 20: Europe: Emerging Theme from Late Follow-up Data Paris (2010) 907 patients, mean follow up 8.4 years 17 Late complications, 32% Overall band removal, 30% Conclusion: LAGB should no longer be considered as the procedure of choice for obesity. SURG OBES RELAT DIS 6: Europe: Emerging Theme from Late Follow-up Data Austria (2010) patients, at least 9 years post op Re operation rate, 53% Only 54% had original band in place Conclusion: Long term, gastric banding has a high complication and band loss rate. OBESITY SURGERY 20:

7 Europe: Emerging Theme from Late Follow-up Data Netherlands (2010) 201 patients, mean follow up 10 years 1/3 of patients underwent removal of band due to complications or inadequate weight loss 19 Only 1/3 of patients had functioning band after a mean of 10 years Conclusions: an enormous heritage of re do bariatric surgery is in the making one should wonder whether the gastric band still has a future. SURG OBES RELAT DIS 6: Emerging U.S. Data Regarding Adjustable Gastric Banding Cleveland Clinic Florida (Obesity Surgery, 2010, 6: ) Conclusion: 20 LAGB appears to have a high incidence of complications requiring revisional surgery and/or band removal. Emerging U.S. Data Regarding Adjustable Gastric Banding 21 American Journal of Medicine (2008): Department of Internal Medicine review of data comparing LGBP and LAGB. * Conclusions: 1. In comparative trials, weight loss, resolution of obesity related co morbidities, and patient satisfaction all are greater for LGBP than LAGB. 2. Despite widespread marketing of gastric banding, no subgroup has been identified in whom LAGB performs better than LGBP. * Am. J. Med. (2008) 121:885

8 Complications of Gastric Bypass 22 Strictures gastrojejunostomy Marginal ulcer Small bowel obstruction Leaks Cholelithiasis Thromboembolic Nutritional deficiencies Strictures at Gastrojejunostomy 23 Symptoms Usually within 12 weeks post op Progressive food intolerance first solids, later liquids Usually not much pain, but usually dehydrated SOURCE: RadioGraphics Strictures at Gastrojejunostomy 24 Treatment: Vitamin replacement especially thiamine Early thiamine deficiency: a) Wernicke's Encephalitis b) Motor & sensory neuropathy Rehydration Endoscopic balloon dilation Surgery rarely needed

9 Marginal Ulcer 25 SOURCE: Bariatric Times. 2010; 7(1):23 25 RACU, MD, MPH & MEHRAN, MD, FACS, FASMBS Marginal Ulcer Incidence: 3 5% Most present with: Bleeding Epigastric pain, radiates to back Nausea / emesis 26 Diagnosis: EGD best Serum gastrin for refractory ulcer Marginal Ulcer 27 Medical management usually successful Acid suppression: High dose PPI or H 2 blocker Carafate Cytotec Stop smoking Stop NSAIDS Surgery Perforation Bleeding refractory to medical and endoscopic management Chronic, intractable to medical management Revise to very small pouch

10 Small Bowel Obstruction Potentially devastating complication: Must diagnose & treat early Incidence: 3 6 % Most occur in first year 28 Causes: Internal hernia most common Adhesions Incisional hernia Small Bowel Obstruction 29 Plain x ray will miss many obstructions: At biliopancreatic limb Proximal roux limb Volvulus through internal hernias If any suspicion of SBO after gastric bypass, get CT of abdomen! Small Bowel Volvulus 30 SOURCE: Laparoscopic Bariatric Surgery, 2004; INABNET, MD; DEMARIA, MD; IKRAMUDDIN, MD

11 Volvulus, CT scan 31? Volvulus, CT scan 32 Volvulus, CT scan 33

12 Volvulus, CT scan 34 Volvulus, CT scan 35 Small Bowel Obstruction 36 Treatment Replace thiamine banana bags plus extra thiamine Rehydration don t give dextrose until after thiamine is replaced NGT if distended Roux limb or if given PO contrast Early diagnostic laparoscopy Persistent or severe abdominal pain after gastric bypass needs diagnostic laparoscopy!

13 Leaks Site Usually gastrojejunostomy Can also be at jejunojejunostomy or bypassed stomach 37 Usually early post op 5 to 7 days Leaks 38 Presentation: Tachycardia, fever, tachypnea, decreased urinary output Increasing pain abdomen, left shoulder Dyspnea, hiccoughs, pleural effusion Change in character of drain output Sense/look of impending doom Workup: CT abdomen with oral contrast If sick, explore even if negative radiologic workup Leaks 39 Treatment: If well drained & no sepsis NPO, TPN, stents, fibrin sealant Surgery: Gastrojejunostomy leaks: +/ closure, provide wide drainage jejunojejunostomy: may be present with pelvic pain all require surgery Excluded stomach: close leak & drain

14 Cholilithiasis / Biliary Pain Increased incidence of gallstone formation during period of rapid weight loss 40 Presentation: Acute cholecystitis Chronic cholecystitis Biliary dyskinesia Gallstone pancreatitis Sphincter of Oddi dysfunction Cholilithiasis / Biliary Pain 41 Signs & Symptoms: Nausea Pain usually postprandial RUQ, often radiating to back Quite variable Workup: US, CCK stimulated HIDA scan Treatment: Cholecystectomy CBD stones/suspected SOD Transgastric ERCP Postoperative Thromboembolism 42 Low incidence/high mortality 0.85 % / 40 to 60 % Fatal PE occur sooner after surgery Median interval for fatal PE was 3 days Median interval for non fatal PE was 10 days Can occur up to months postoperatively Maintain high index of suspicion Workup Venous Duplex Scan, CT chest

15 Nutritional Deficiencies 43 Protein lean body mass, 60+ g/day Iron Ferrous form Microcytic anemia Vitamin B12 and Folate Megaloblastic anemia Neuropathy Increased homocysteine Thiamine Don t give dextrose to gastric bypass patients with prolonged nausea Motor and sensory neuropathy Wernicke s encephalopathy Nutritional Deficiencies 44 Calcium / Vitamin D Metabolic bone disease urine calcium and vitamin D, PTH and Alkaline Phospatase Zinc Alopecia, dermatitis, diarrhea, emotional disorders Pregnancy Need to Folate to prevent neural tube defects Recent Trends Bariatric Surgical Outcomes 45

16 Five-year Morbidity & Mortality Christou, Condition/Disease Bariatric Surgery (N = 1,035) Nonsurgical Controls (N = 5,746) % Change in Risk Surgery vs. Non surgical Treatment Cancer 2.03% 8.49% 76% Cardiovascular & Circulatory 4.73% 26.69% 82% Diabetes 9.47% 27.25% 65% Respiratory 2.71% 11.36% 76% Musculoskeletal 4.83% 11.9% 59% Infections Diseases 8.7% 37.33% 83% Mortality 0.68% 6.17% 90% Effect of Bariatric Surgery on Mortality in Swedish Obese Subjects 47 NEJM, August 23, Long-term Mortality after Gastric Bypass Surgery US Study Mean follow up 7.1 years; 7,925 patients per group Reoperation Failure = Removal or Death due to disease 48 % inadequate weight loss Death due to CV disease 48 % Swiss ( Death related to diabetes 88 % Death secondary to cancer 59 %

17 NEJM Conclusion Statement The Missing Link Lose Weight, Live Longer George A. Bray, MD 49 Conclusion statement: Thus, the question as to whether intentional weight loss (bariatric surgery) improves life span has been answered, and the answer appears to be a resounding yes. NEJM, August 23, 2007 Meta-analysis Bariatric Surgery Revisional Literature * 50 Procedure 30 day mortality (%) Overall series Banding 0.1 % Gastric Bypass 0.5 % Biliopancreatic Diversion /Duodenal Switch 1.1 % 11,720 Patients 30 day op Mortality = 0.55% *Buchwald et al, JAMA, 2004 ASMBS Center of Excellence 51 Hospital must perform at least 125 bariatric surgeries per year collectively, and the surgeon must have performed at least 125 himself and perform at least 50 per year. The Center must also have a dedicated, multi disciplinary bariatric team that includes surgeons, nurses, medical consultants, nutritionists, psychologists, and exercise physiologists. The Center must report long term patient outcomes and have an on site inspection to verify all data.

18 Primary Outcome Data From first 55,567 patients in ASMBS COE program Patients from St. Joseph s Center for Weight Management program 52 Aggregate Outcome Data of the first 176 applicants for full approval by SRC. Pories, June 2006 Variable N % Total patients 55, day mortality day mortality SJAHS Park Rapids Jan Jan N % 1, SJAHS Park Rapids Jan Jan N % 2, day Operative Mortality Rates Bariatric Surgery ASMBS COE Average 0.29 % SJAHS Park Rapids 0.15 % 53 Other common major surgeries US Hospital Averages* Elective aortic aneurysm 3.9 % CABG 3.5 % Esophageal resections 9.1% Hip replacements 0.3 % Pancreatic surgeries 8.3 % *Dimick et a., JAMA, 2004 More Recent Outcome Data 54 ASMBS Bariatric Outcomes Longitudinal Database, June 2007 May ,918 Bariatric Surgeries 30 day Mortality N 22 % 0.09 % 90 day Mortality N 45 % St. Joseph s Center for Weight Management Outcomes, 2007 Feb ,106 Bariatric Surgeries 30 day Mortality N 1 % 0.09 % 90 day Mortality N 1 % 0.09 Meta analysis Most recent data, day mortality 0.55 % 0.09 % An 86 % drop in operative mortality!

19 Thank you! 55 CATHOLIC HEALTH INITIATIVES St. Joseph s Area Health Services CENTER FOR WEIGHT MANAGEMENT