Surgical Management of Obesity. David A. Edelman, MD, MSHPEd, FACS Associate Professor of Surgery

Surgical Management of Obesity David A. Edelman, MD, MSHPEd, FACS Associate Professor of Surgery

Objectives Describe indications for surgical management of obesity Describe three types of bariatric surgery Describe complications of bariatric surgery

Score Question #1 A 38-year old woman who is 5'2" and weighs 200lbs (BMI 36.6) presents to the clinic for evaluation for possible bariatric surgery. How do you determine if she is a suitable candidate? Key Discussion Points Can recognize that BMI 36.6 places patient in obese category (not morbidly obese). Ask about obesity-related comorbidities and understands that with a BMI <40, co-existing comorbidities must be present. Ask about (untreated) psychological illness and substance abuse that would be contraindications to bariatric surgery.

Definition of Morbid Obesity Being 100 pounds above ideal body weight Twice ideal body weight, Body mass index (BMI; measured as weight in kilograms divided by height in meters squared) of 40 kg/m 2.

BMI Categories

Prevalence The percentage of obesity (BMI >30) in the United States increased 16 percentage points from 1980 to 2000. The prevalence of morbidly obese adults (BMI >40) has increased to 6.3% of the adult U.S. population in 2010. If the current trend of linear increases in obesity prevalence continue unabated, 51% of the U.S. population will be obese in 2030.

Morbid Obesity Impact Second leading cause of preventable death in the United States. Second only to smoking on the list of preventable factors responsible for increased health care costs. 25-year-old morbidly obese man has a 22% reduction in life expectancy, or 12 years of life lost, compared with a normal-sized man.

Pathophysiology The pathophysiology of severe obesity is poorly understood. Clear familial predisposition rare for a single family member to have severe obesity

Pathophysiology Increasing evidence that genes play a primary role in the development of obesity in certain individuals. Leptin deficiency leads to severe childhood obesity in afflicted individuals but can be successfully treated with leptin. FTO gene (fat mass and obesity related) plays a role in controlling feeding behavior and energy expenditure; MC4R deficiency gene (melanocortin 4 receptor), which is associated with obesity, increased fat mass, and insulin resistance

Medical Conditions Associated with Morbid Obesity

Medical Versus Surgical Therapy Medical therapy for severe obesity has limited short-term success and almost nonexistent long-term success. Once severely obese, the likelihood that a person will lose enough weight by dietary means alone and remain at a BMI below 35 kg/m 2 is estimated at 3% or less. The NIH consensus conference recognized that for this population of patients, medical therapy has been largely unsuccessful in treating the problem. Review of the clinical trials of lifestyle interventions for prevention of obesity demonstrated that the majority of trials were completely ineffective.

Score Question 2 A 28-year woman weighing 260lbs and 5'7" (BMI 40.7) has failed to lose weight following a diet and exercise program, and has been approved for bariatric surgery. She comes to the bariatric surgery clinic to explore her options. What options and potential complications should you discuss with her? Key Discussion Points Know the common bariatric surgical procedures performed in the US. Understand the potential perioperative complications. Explain the expected outcomes and necessary follow-up for each procedure.

Laparoscopic Adjustable Gastric Band (LAGB)

Laparoscopic Sleeve Gastrectomy

Lap Roux-en-Y Gastric Bypass

Framework Procedure Timing Complication Lap Roux-en-Y Gastric Bypass Early Late Leak Marginal Ulcer Stricture Lap Sleeve Gastrectomy Lap Band Early Late Early Late Internal Hernia Leak Stricture Obstruction Slip Erosion

Framework Lap Roux-en-Y Gastric Bypass Early Late Leak Marginal Ulcer Stricture Lap Sleeve Gastrectomy Lap Band Early Late Early Late Internal Hernia Leak Stricture Obstruction Slip Erosion

Leak Following Roux-en Y Gastric Bypass, what are the locations of an intestinal leak? Gastrojejunostomy Jejunojejunostomy Excluded stomach Inadvertent enterotomies

Leak Following Roux-en Y Gastric Bypass, what is the incidence of leak? Review of 22 studies 19,389 patients 398 Leaks (2.05%) Upper Gastrointestinal Series after Roux-en-Y Gastric Bypass for Morbid Obesity: Effectiveness in Leakage Detection. a Systematic Review of the Literature Obesity Surgery July 2014, Volume 24, Issue 7, pp 1096-1101

Leak Literature quotes leak rate between 0.4% and 5.2% Mortality of leak = 50% Management of anastomotic leaks after laparoscopic Roux-en-Y gastric bypass.ballesta C, Berindoague R, Cabrera M, Palau M, Gonzales M Obes Surg. 2008 Jun; 18(6):623-30. Laparoscopic management of complications following laparoscopic Rouxen-Y gastric bypass for morbid obesity. Papasavas PK, Caushaj PF, McCormick JT, Quinlin RF, Hayetian FD, Maurer J, Kelly JJ, Gagné DJ Surg Endosc. 2003 Apr; 17(4):610-4.

Leak What clinical findings could suggest leak? Tachycardia Tachypnea Fever Anxiety Leukocytosis It is not uncommon for a leak to manifest as unexplained persistent tachycardia in an asymptomatic patient.

Leak What is the best diagnostic study to confirm leak? emergent upper GI series using water-soluble contrast. If the study is negative but suspicion is high, the patient's abdomen should be re-explored

Normal

Leak

Gastric-Gastric Fistula

Treatment of Leak

Framework Lap Roux-en-Y Gastric Bypass Early Late Leak Marginal Ulcer Stricture Lap Sleeve Gastrectomy Lap Band Early Late Early Late Internal Hernia Leak Stricture Obstruction Slip Erosion

Marginal Ulcer

Marginal Ulcer Definition: Ulceration of the jejunal aspect of the gastrojejnual anastomosis

Marginal Ulcer Incidence: 0.6%-16% Coblijn UK et al. Development of ulcer disease after Roux-en-Y gastric bypass, incidence, risk factors, and patient presentation: a systematic review. Obes Surg. 2014;24(2):299 309. Risk Factors: NSAID use Tobacco use H. Pylori Location of Roux Limb

Marginal Ulcer Comparison of Marginal Ulcer Rates Between Antecolic and Retrocolic Laparoscopic Roux-en-Y Gastric Bypass Obesity Surgery February 2015, Volume 25, Issue 2, pp 215-221

Marginal Ulcer Medical Management Elimination of risk factors PPI therapy Carafate therapy Symptoms resolve 50-70% of time Marginal ulcer after Roux-en-Y gastric bypass: what have we really learned? Surgical Endoscopy October 2012, Volume 26, Issue 10, pp 2789-2796

Marginal Ulcer Failed Medical Management Bleeding Stricture Perforation Suture and drain Omental patch Resection

Framework Lap Roux-en-Y Gastric Bypass Lap Sleeve Gastrectomy Lap Band Early Late Early Late Early Late Leak Marginal Ulcer Stricture Internal Hernia Leak Stricture Obstruction Slip Erosion

Gastrojejunostomy Stricture Incidence: 3-27% Matthews BDSing RFDeLegge MHPonsky JLHeniford BT Initial results with a stapled gastrojejunostomy for the laparoscopic isolated roux-en-y gastric bypass. Am J Surg 2000;179 (6) 476-481 Dresel AKuhn JAWestmoreland MVTalaasen LJMcCarty TM Establish ing a laparoscopic gastric bypass program. Am J Surg 2002;184 (6) 617-620 Most patients successfully treated with outpatient endoscopic balloon dilatation 60% require only one session

Gastrojejunostomy Stricture

Stapling Versus Hand Suture for Gastroenteric Anastomosis in Roux-en-Y Gastric Bypass: a Randomized Clinical Trial Obesity Surgery October 2015, Volume 25, Issue 10, pp 1796-1801

Gastrojejunostomy stricture rate: comparison between antecolic and retrocolic laparoscopic Roux-en-Y gastric bypasssurgery for Obesity and Related Diseases Ribeiro-Parenti et al., Surgery for Obesity and Related Diseases, 2015 1500 patients 2000-2012 572 antecolic and 928 retrocolic Mean follow up 67.5 months 3.4% stricture versus 1.5% stricture (p<0.001)

Framework Lap Roux-en-Y Gastric Bypass Lap Sleeve Gastrectomy Lap Band Early Late Early Late Early Late Leak Marginal Ulcer Stricture Interna l Hernia Leak Stricture Obstruction Slip Erosion

Internal Hernia Incidence: 2% - 8% Large MEDLINE study from 1994-2006 11,918 patients in 26 combined publications Internal hernia rate 2.51% (300/11,918) Internal Hernia after Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity Obesity Surgery October 2006, Volume 16, Issue 10, pp 1265-1271

Internal Hernia Presenting symptoms Postprandial pain Nausea Vomiting Often Vague need high index of suspicion Internal hernias after laparoscopic Roux-en-Y gastric bypass Ernesto Garza, M.D., Joseph Kuhn, M.D., David Arnold, M.D., William Nicholson, M.D., Suraj Reddy, M.D., Todd McCarty, M.D. The American Journal of Surgery Volume 188, Issue 6, Pages 796-800 (December 2004)

Internal Hernia Laparoscopic Roux-en-Y gastric bypass surgery produces three potential sites for internal hernia formation: the defect in the transverse mesocolon through which the Roux loop passes (if it is placed in the retrocolic position) the mesenteric defect at the enteroenterostomy and behind the Roux limb mesentery placed in a retrocolic or antecolic position (retrocolic Petersen and antecolic Petersen type)

Internal Hernia

Internal Hernia Diagnosis CT ABD/Pelvis with IV and PO contrast Diagnostic Laparoscopy

Internal Hernia Swirl Sign

Internal Hernia J is Dilated jejunum C is Displaced colon Solid Arrow is stretched mesentary

Internal Hernia Curved arrow is whirl sign Straight arrow is dilated small bowel AC is displaced ascending colon J is jejunal loops displacing transverse colon (TC)

Internal Hernia J is dilated jejunum Arrow is displaced mesenteric vessels

Internal Hernia Management Operation When is doubt, operate

Framework Lap Roux-en-Y Gastric Bypass Early Late Leak Marginal Ulcer Stricture Lap Sleeve Gastrectomy Lap Band Early Late Early Late Internal Hernia Leak Stricture Obstruction Slip Erosion

Leak Following Gastric Sleeve, what is the incidence of leak? Review of 29 publications 4888 patients 115 leaks (2.4%) Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Surgical Endoscopy June 2012, Volume 26, Issue 6, pp 1509-1515

Leak Literature quotes leak rate between 0.0% and 7.0% Mortality of Gastric Sleeve Leak = 10% Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients Surgical Endoscopy January 2013, Volume 27, Issue 1, pp 240-245

Leak

Framework Lap Roux-en-Y Gastric Bypass Early Late Leak Marginal Ulcer Stricture Lap Sleeve Gastrectomy Lap Band Early Late Early Late Internal Hernia Leak Stricture Obstruction Slip Erosion

Stricture Following Lap Sleeve Gastrectomy, the expected stricture rate is: 1.8% - 3.5% Parikh A, Alley JB, Peterson RM, Harnisch MC, Pfluke JM, Tapper DM, et al. Management options for symptomatic stenosis after laparoscopic vertical sleeve gastrectomy in the morbidly obese. Surg Endosc. 2012;26:738 46.

Stricture

Stricture Following a Laparoscopic Sleeve Gastrectomy, the most common location of a stricture is: incisura angularis Management Endoscopic dilation Seromyotomy Wedge Resection Convert to Bypass

Stricture

Framework Lap Roux-en-Y Gastric Bypass Early Late Leak Marginal Ulcer Stricture Lap Sleeve Gastrectomy Lap Band Early Late Early Late Internal Hernia Leak Stricture Obstruction Slip Erosion

Laparoscopic Gastric Band

Laparoscopic Gastric Band A 50 y.o. female comes to the ED 6 months after a laparoscopic gastric band placement. She reports that she is vomiting 4-5 times per week. What is the best initial diagnostic study? What is your differential diagnosis?

Normal Lap Band

Abnormal Appearance Lap Band

Lap Band Slip Following laparoscopic gastric banding, what is the incidence of a band slip? 1%-22% Patient usually presents with dysphagia vomiting regurgitation and food intolerance Techniques for repair of gastric prolapse after laparoscopic gastric banding. Tran D, Rhoden DH, Cacchione RN, Baldwin L, Allen JW J Laparoendosc Adv Surg Tech A. 2004 Apr; 14(2):117-20.

Lap Band Slip Diagnosis is made by upper gastrointestinal series. Complications gastric perforation necrosis of the slipped stomach upper gastrointestinal bleeding aspiration pneumonia

Lap Band Slip Type Location Mechanism I Anterior Slip Downward migration of band II Posterior Slip Posterior stomach herniates through perigastric approach

Anterior Band Slip Results from upward migration of the anterior wall of the stomach through the band Mechanism: Insufficient anterior fixation and disruption of the fixation sutures Increased pressure in the pouch early solid food, vomiting overeating or too early (< 4 wk) band fill

Anterior Band Slip

Posterior Band Slip Definition: Herniation of the posterior wall of the stomach through the band. Mechanism: Related to surgical technique (perigastric approach) less frequent now with adoption of the pars flaccida approach

Posterior Band Slip

Lap Band Slip

Framework Lap Roux-en-Y Gastric Bypass Early Late Leak Marginal Ulcer Stricture Lap Sleeve Gastrectomy Early Late Internal Hernia Leak Stricture Lap Band Early Late Obstruction Slip Erosion

Band Erosion Incidence: <1% Mechanism The band gradually erodes through stomach wall into lumen Etiology Secondary to gastric wall injury at time of placement

Band Erosion What clinical findings would you expect in a patient with a band erosion? Loss of appetite restriction Port site infection

Band Erosion What is the best diagnostic study to confirm a band erosion? EGD

Band Erosion

Surgical Management of Band Erosion

Summary

Questions