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B i t i S O ti li iBariatric Surgery: Optimalizing Outcome Results

Dr. B. DillemansAZ Sint-Jan AV Brugge-Oostende

‘THE OBESE PATIENT : A CHALLENGE FOR ANAESTHESIA’ , Ostend,14/11/09

BARIATRIC SURGERY

• 50’s : First Reported Bariatric Procedures• 90’s : ‘Unpopular Speciality’

* Public awareness

* Laparoscopic Access

* Reported Success

• 2005 : ‘Most Popular Speciality’epo ted Success

‘Bariatric Surgery Metabolic Surgery

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QUESTIONS and DOUBTS

• Obesity = Self inflicted disease• Obesity surgery = Life style surgery• On Whom ?• By Whom ?By Whom ?• Which type of Procedure ?

Is it allworthwhile ?

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FACTS

• Obesity = Disease• Obesity = Disease– Quantity of Life– Quality of Life

• Conservative treatment options do not provide sustained weight loss

• Surgery remains the only effective treatment for patients with morbid obesitypatients with morbid obesity– Weight Loss is dramatic– Comorbidity control substantial– Patient satisfaction greater than for any other general

surgical operation

BARIATRIC PROCEDURES

BARIATRIC SURGERY

RESTRICTIVERESTRICTIVE MALABSORPTIVE

* LAP BAND* LAP VBG

* LAP SLEEVE

RESTRICTIVE + MALABSORPTIVE

* Gastric Bypass

MALABSORPTIVE ( + RESTRICTIVE)

*Scopinaro*Duodenal Switch

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Adjustable Gastric Band

Vertical Banded Gastroplasty

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Sleeve Gastrectomy

Gastric Bypass

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BPD or DS

Which PROCEDURE to CHOOSE ?

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WHICH PROCEDURE ?

CONSIDERATIONS

• One unique, ‘super’ operation does not exist– Surgery remains a tool to lose weight.– Success ratio never 100 %– Every procedure has advantages

/disadvantages– Bariatric surgery still in development– Patient characteristics !

Is it the patient who has failed the pbariatric surgery ?

or the bariatric surgery that has failed the patient?

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Lap RNY Bypass <-> Lap Band

M i ifi t W i ht L

Conclusions

• More significant Weight Loss• More sustained Weight Loss• Better Improvement or Cure of associated

diseases• Better Quality of Life

But• Higher Postop Mortality• Higher Postop Morbidity• Less Reversible

OUTCOME MEASURES

• SAFETY• SAFETY– Hospital Mortality and Morbidity– Long Term Complications

• EFFECTIVENESS– Weight Loss

Improvement of Associated Diseases– Improvement of Associated Diseases– Quality of Life / Patient Satisfaction – Impact on Quantity of Life

• ECONOMIC/HEALTHCARE COSTS

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Patients for Bariatric Surgery

• Young • Working Very Low Mortality rates !• ‘Healthy’

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MULTIDISCIPLINARY APPROACH

• Indication /Follow up• Indication /Follow-up – Surgeon– Internist– Psychiatrist/Psychologist– Dietician

• Surgical Procedure – Surgical Team– Anesthesist

MULTIDISCIPLINARY APPROACH

• Indication /Follow up• Indication /Follow-up – Surgeon– Internist– Psychiatrist/Psychologist– Dietician

• Surgical Procedure – Surgical Team– Anesthesist

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What should the anesthesist has to know and has to do ?

• Knowledge of Different Types of Procedures/• Knowledge of Different Types of Procedures/ Complications/Risks

• Knowledge of Associated diseases/risks• Perioperative

– Difficult Intubations– Helping the Surgeon

• Increasing abdominal workspaceIncreasing abdominal workspace• Positioning gastric tube /Leak test• Elevating blood pressure

– Difficult extubations

• Postoperative

Our approach for the Lap RNY

• Completely standardizedexcept :

1° Antecolic, antegastric vs retrocolic, retrogastric 2° Length of alimentary limb

75 cm1m302m00

• Fully stapledCircular stapled gastro-jejunostomy (25mm CEEA) Linear stapled entero-enterostomy

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Standardization

• procedure split into different phases

• specific role for every participant (surgeon, assistants, scrub nurse, anesthesiologist)g )

• every single laparoscopic maneuver has been completely rationalized

Standardized maneuvers

Closure of the jejuno-jejunostomy

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Consistency

Results

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Data Collection

Between may 2004 – August 2008 : 4732 bariatric procedures

2645 lap gastric bypassF.U. (98.5%) : 2606 pt.

1078 lap gastric banding

798 lap VBG (~McLean)p ( )

190 Open gastric bypass

21 Lap Sleeve

Data Collection

• Data Collection : Retrospectively

• 539 male patients – 2067 female patients

• Age: 14 – 73 (mean 39.2)

• Mean BMI 41.44 kg/m² (range 23-75.5)

• Mean operative time: 63 min (35 – 150)

• Mean hospital stay : 3.35 days

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Results

Conservative management in 66 patients

• 1 mortality (0.04 %)

• 89 bleedings (3.42 %)

• 9 small bowel obstructions (0.35 %)

Early re-operation in 23 patients

Distinct bleeding source in 18 patients

Extra-luminal: 9 patients

Intra-luminal: 6 patients

Trocar site / mesentery: 3 patients

No clear source of bleeding in 5 patients

7 ‘lateral entrapments’ at the left trocar site

• 5 leakages (0.19 %)

• 5 DVT/PE (0.19 %)

• 2 pancreatitis (0.07%)

1 incarcerated umbilical hernia1 acute angulation at the jejuno-jejunostomy

4 at the level of the gastro-jejunostomy 1 at the level of the jejuno-jejunostomy

Results: mortality

Study Patients Mortality

MacDonald (1997)154 (open)

(retrospective)2.6% (perioperative)

Fernandez (2004)1431 (open)

580 (lap)

1.9% (open)

0.7 % (lap)

Zingmond (2005)60.077

(retrospective)0.33% (30 day)

Nguyen (2006)1.144

(retrospective)0.4% (30 day)

Flancbaum (2007)1.000 (open)

1.2% (30 day)Flancbaum (2007)(retrospective)

1.2% (30 day)

Flum (2009)

2.975 (lap)

437 (open)

(prospective)

0.2% (lap) (30 day)

2.1% (open) (30 day)

Kelles (2009)2.167 (open)

(retrospective)0.64% (30 day)

Dillemans (2009)2606 (lap)

(retrospective)0,04% (30 day)

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Results: leakage rate

1st Author, year No. of cases Overall anastomotic

leakage rate (%)leakage rate (%)

DeMaria, 2002 281 5.1

Hamilton, 2003 210 4.3

Marshall, 2003 400 5.25

Carrasquilla, 2004 1.000 0.1

Madan, 2006 300 3.0

Carucci, 2006 904 5.3

Gonzalez, 2007 3.018 2.1

Lee, 2007 3.828 3.9

Agaba, 2008 1.364 0.15

Ballesta, 2008 1.200 4.9

Durak, 2008 1.133 1.5

Dillemans, 2009 2.606 0,19

Conclusion

Maximal StandardizationFull Stapling

High Surgical Volume

Very low 30-day mortality & morbidity

Safe procedure

Easy reproducible

Effective for training

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Conclusion

THANKS !

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What is the problem with the Band in Belgium/Europe ?

• 1 Poor Indications• 1. Poor Indications• 2. Poor Patient Compliance • 3. Poor Follow-Up• 4. Poor Surgical Technique ?

– Underestimated Procedure– No Standardization of Technique

• Positioning of the Band – Too High (‘Virtual Pouch’)– Too Low

• Placement of Gastric–to–Gastric Sutures– Too Tighten– Too Loose

ab

c

Favretti et al, Obes Surg 1997

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LOSS OF QUALITY OF LIFE !

I bilit t h l– Inability to have a proper meal• No Meat /No Bread/ No….

– Substituting in sweet things• + Regain of Weight

– Vomiting –Pain -Dysfagia– Reflux– Impairement in social life

Benefits of the approach

• increased ease

• shorter surgical time

• shorter lag time between proceduresshorter lag time between procedures

• higher productivity

• lower complication rate and lower mortality

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Introduction

“Golden standard”

BUT:

• technically challenging procedure

• substantial morbidity and mortalitysubstantial morbidity and mortality

to improve outcome

fully stapled

fully standardized