Not over when the surgery is done: surgical complications of obesity Gianluca Bonanomi, MD, FRCS Consultant Surgeon and Honorary Senior Lecturer Chelsea and Westminster Hospital London The Society for Acute Medicine, 7 th International Conference, 3-4 October 2013
Epidemic Proportions 64 % US Population Overweight (BMI > 25) 31 % US Population Obese (BMI > 30) Doubled in the last 20 years Emerging Pediatric Obesity National Health And Nutrition Examination Study - NHANES IV
Medical Complications of Obesity Lungs abnormal function obstructive sleep apnea hypoventilation syndrome Liver steatosis Steatohepatitis/NASH cirrhosis Gallbladder Ob/Gynae abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Skin Gout Idiopathic Intracranial Hypertension Stroke Eyes Cardiovascular Disease Type 2 Diabetes Dyslipidemia High Blood Pressure Pancreatitis Cancer breast, uterus, cervix, colon, esophagus, pancreas, kidney, prostate Phlebitis/Lymphedema venous stasis
Mortality 2.5 2.0 BMI and Risk of Mortality from Bray GA 1.5 Male Female 1.0 Moderate Very Low Low Moderate High 0 0 20 25 30 35 40 Body Mass Index (Kg/m 2 )
Fontaine KR et al. Years of Life Lost Due to Obesity. JAMA 2003;289:2
Obesity: A Multifactorial Disease 80% Type 2 DM related to overweight and obesity Environment Psychology Genetics Behavior
Rationale for Bariatric Surgery Produces durable weight loss Remission and improvements in medical comorbidities Prolongs life Reduces health care costs Consensus of Medicare Advisory Committee Surgical Review Corporation Agency for Health Quality and Research
Buchwald et al, JAMA 2004;292 Bariatric surgery: A systematic review and meta-analysis N=22,094 pts Complete resolution or improvement in: DM (84% gastric bypass, 48% banding) HTN Sleep apnoea Hyperlipidemia
Sjostrom et al, NEJM 2004;351 Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery Swedish Obese Subjects Study (SOS) N=4,047 with 2 y F/U, 1,703 with 10 y F/U Resolution of DM, hyperlipidemia, HTN for 10 yr F/U Improvement in quality of life
Sjostrom et al, NEJM 2007;357 Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects Prospective study involving 4,047 obese subjects (SOS Study) 2,010 underwent bariatric surgery / 2,037 conventional treatment (matched control group) 10.9 years average follow-up (99.9%)
129 deaths in control group vs 101 in surgery group (p = 0.04) 92% reduction in diabetes related deaths
Current Bariatric Procedures Adjustable Gastric Banding Sleeve Gastrectomy Roux-en-Y Gastric Bypass Duodenal Switch
Laparoscopic Surgery Benefits: Smaller scars Fewer wound complications Fewer hernias Less pain Quicker recovery Same weight loss as open
Epidemic of Obesity Epidemic of Bariatric Surgery? Estimated Number of Bariatric Operations Performed in the United States, 1992 2003. Data are from the American Society for Bariatric Surgery. Steinbrook R. Surgery for Severe Obesity. NEJM 2004;350:1075
Acute Medicine in Morbid Obesity The obese population Pre-operative management Post-operative management Follow up Long term
General Surgical Takes: The Bariatric Burden A retrospective analysis was performed of all referrals made to the emergency general surgical team over a 1 year period at Chelsea & Westminster Hospital. Patients with complications related to bariatric surgery were identified Over a 1 year period, the acute surgical team received 57 referrals with bariatric surgical complications. Gastric bypass or a gastric banding in 43% and 48% of patients, respectively. In 17.5% of cases it was performed in another Unit in the United Kingdom or abroad. The mean time of presentation was 7 months post operatively. Epigastric pain or vomiting was the main complaint in 60% of cases. The majority of cases could be managed conservatively. The commonest complications requiring surgical or endoscopic intervention were port site problems (12%), slipped gastric bandings (8.6%) and anastomotic strictures (5%). The most frequently performed investigations were gastrograffin swallows (37%), OGDs (35%) and exploratory laparoscopies (16%).
Difficulties with the Bariatric Patient The classical signs of peritonism are usually subtle or absent in the obese patient Problematic venous access Cuff measurements of BP are inaccurate May not fit into radiology suite or CT scanner Unfamiliarity with the anatomy of the procedure, specific complications and management Immobility Difficulty in transfer
Important To know The Anatomy If you are not the primary surgeon and need to know what operation has been performed CALL THE SURGEON or THE BARIATRIC CENTRE Importance of continuity of care and follow up
Complications of Bariatric Surgery Respiratory Anastomotic Leaks (< 1%) Anastomotic Strictures (5-15%) Ulcers (5%) Obstructions (1-7%) Bleeding/Haematomas (1-5%) Infections/sepsis Thromboembolic Disease (< 1%) Gastric Banding slippage (1-10%) Vitamin Deficiencies/Neurologic Biliary
Respiratory Acute respiratory failure Obstructive Sleep Apnoea (OSAS in 15-20%) Hypoventilation Syndrome Preoperative CPAP (duration undetermined) Chest infections
Leaks
Anastomotic Strictures
Anastomotic Ulcers
Bowel Obstructions Adhesions Internal Hernias Trocar Site Hernias Intussusception Bezoar
Mesenteric Defects and Internal Hernias A: Mesocolic B: Petersen s C: Mesenteric
Internal Hernias Early or late after gastric bypass surgery (even years!) Symptoms can be vague and aspecific: high level of suspicion Can lead to dramatic consequences with bowel perforation, necrosis or death CT scan can be negative or show only subtle changes: Swirling of the mesentery Distention of the excluded stomach Consider early surgical referral and laparoscopic exploration In one series 20% of internal hernias with normal imaging
Internal Hernias
Bleeding/Haematomas Stapler lines / Internal / External Melena/Haematemesis/Drop Hb/Unstable conditions May need Urgent Surgery or Endoscopy
Infection/Sepsis
Thromboembolic Disease Pulmonary embolism #1 cause of death Prophylaxis is important SCD s Enoxaparin Early ambulation Can occur late after discharge
Slippage/Erosion Gastric Banding Normal position Pouch dilatation Banding slippage
Gastric Banding Erosion
Vitamin Deficiencies/Neurologic Iron Vitamin B12/folic acid Ca/Vitamin D Vitamin B1/Thiamine Neurologic impairment in patients with long standing vomiting, excessive weight loss and starving Wernicke-Korsakoff Syndrome IV Thiamine
Biliary Complications Risk of gallbladder stones may double during rapid weight loss (from 15 to 30%) Biliary colic Acute Cholecystitis Pancreatitis
Conclusion: Bariatric Surgery Emergencies Tips Scary but relatively rare Unfamiliarity Try to contact operating surgeon or bariatric centre Determine the anatomy of the procedure Radiology studies are not always helpful Low threshold for exploratory laparoscopy Ensure availability of correct equipment Communication across specialties