George S. Ferzli, MDJoel Ricci, MD

Dramatic increase during last 2 decades

2/3 US individuals are overweight

50% of these are obese

5% morbidly obese Rapid growth in BMI

subgroups ≥ 35 and ≥ 40

Increase in comorbidities

2.5 million deaths per year worldwide from comorbidities

1. National Center for Health Statistics NHANES IV Report2. Flegal KM et al: Prevalence and trends in obesity among US adults 1999-2000. JAMA 2002; 288: 1723-1727

Derived from Center for Disease Control and Prevention website www.cdc.gov

Derived from Center for Disease Control and Prevention website www.cdc.gov

Obesity associated conditionsDiabetes

Hypertension

Sleep apnea

Congestive heart failure

Hyperlipidemia

Stroke

Coronary Artery Disease

Osteoarthritis

Gastroesophageal Reflux Disease

Non-alcoholic fatty liver

Psychological disturbances

BMI ≥ 35 kg/m²: Risk of death ≈ 2.5 times greater than if BMI

of 20-25 kg/m² BMI ≥ 40 kg/m²:

Risk of death 10 times greater

Obesity

2nd leading cause of preventable premature death in US (smoking)

1. Calle et al. N Eng J Med, 1999; (15)341:1097-105. 2. Ali H, Mokdad AH, et al. JAMA 2004;291:1238-1245.

Relatively ineffective: Diet with and without support organizations Pharmaceutical agents

Only long-term options: Bariatric surgery Metabolic surgery

1991 National Institute of Health Guidelines BMI ≥ 40 or ≥ 35 with significant

comorbidities1. North American Association for the Study of Obesity and the National Heart, Lung, and Blood

Institute. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Bethesda, Md: National Institutes of Health; 2000. NIH 00-4084.

2. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292: 1724-37.

3. National Institutes of Health Consensus Development Panel. Gastrointestinal surgery for severe obesity. Ann Intern Med. 1991; 115: 956-961

First line of treatment Calorie restriction Exercise regimen Behavior modification Pharmacotherapy

Avg. weight loss ≈ 5% to 10% initial body weight at 3 to 6 months

Regain weight after 1 to 2 years

1. Yanovski SZ, Yanovski JA. Obesity. N Engl J Med 2002;346: 591-602

Consensus Guidelines 2003 Surgical therapy should be considered for

individuals who: Have a BMI of greater than 40 kg/m² OR Have a BMI greater than 35 kg/m² with

significant comorbidities AND Can show that dietary attempts at weight

control have been ineffective

Derived from American Society of Bariatric Surgery website: www.asbs.org

Bariatric Surgery

Diet

Exercise

Behavior Modification

“Postoperative care, nutritional counseling, and surveillance should continue for an indefinitely long

period.”

Obesity related to a metabolic or endocrine disorder

History of substance abuse or major psychiatric problem

Surgery contraindicated or high risk Women who want to become

pregnant within the next 18 months

Period or DecadeIncidence of

surgeryReason for change

Late 1970’s Early 1980’s

25,000 procedures per year

Innovative procedures• gastroplasty• loop GBP• jejuno-ileal bypass

Late 1980’s1990’s

5,000 procedures per year

Multifactorial:• High M&M• Ineffective long-term• Perceived failure• Surgeon experience

2000’s80,000 to 110,000 procedures per year

Multifactorial:• Laparoscopy• Long-term data• Centers of Excellence1. National Hospital Discharge Survey Public-use data file and documentation. Multi-year data CD-ROM. National Center for Health

Statistics, 1979-1996.2. Nguyen et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg 2005; 140:

1198-202.3. Griffen et al. The decline and fall of the jejunoileal bypass. Surg Gynecol Obstet 1983; 157: 301-8.4. Shirmer et al. Bariatric Surgery Training: Getting Your Ticket Punched. J Gastrointest Surg 2007;11: 807-12.

StudyType and

sizeEffect on weight

Effect on comorbidities

Buchwald et al.

Meta-analysisn = 22,094 pts

Mean excess weight loss: 61%

Resolution of: •Diabetes: 70%• HTN: 62%• Sleep apnea: 86%

Swedish Obese Subject trial (SOS)

Prospective matched cohortn = 4,047 pts

At 10 years:• Med: 1.6% gain• Surg: 16% loss

Improved by surg:• Diabetes• Lipid profile• HTN• Hyperuricemia

1. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292: 1724-37.

2. SjostromL, Lindros AK, Peltonem M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351: 2683-93.

Jejuno-ileal bypass 70% excess wght

loss Reduced caloric

intake Malabsorption Dehydration Acidosis Electrolyte

abnormalities Liver failure Bacterial overgrowth

1. Griffen WO Jr, Bivins BA, Bell RM. The decline and fall of the jejunoileal bypass. Surg Gynecol Obstet 1983; 157: 301-8.

Loop gastric bypass Reduced

capacitance Aversive eating Dumping

syndrome Alkaline reflux

gastritis Esophagitis

Horizontal gastroplasty “Gastric stapling” 1970’s Regained weight Many pts left

GERD Obesity May seek re-

operation for correction anatomy

1. Salmon PA. Salvage of failed horizontal gastroplasty by the addition of a distal gastric bypass. Obes Surg 1993;3:45-51.

“Gold Standard” 80% of bariatric

proc. Lap vs Open Restrictive and

Malabsorptive: Reduced calorie

intake Macronutrient

malabsorption

Pouch formation: Small gastric pouch 15-30 mL Transect vs Stapling Re-inforcement of staple line

Roux limb creation: 15 to 100 cm distal to Ligament of Treitz Jejuno-jejunostomy 75 to 150 cm down Roux

limb Long limb bypass: ↑ weight loss from

malabsorption1. Brolin RE. Long limb Roux en Y gastric bypass revisited. Surg Clin North Am 2005;85:807-

17, vii.

Roux limb orientation: Antecolic vs Retrocolic Antegastric vs Retrogastric Surgeon’s preference Antecolic:

May lead to high tension gastro-jejunostomy Ischemic strictures and ↑ bile leak rate No literature supporting this hypothesis

No evidence of protection against internal hernias Retrocolic:

Shorter Creation of transverse mesocolic defect

1. Edwards MA et al. Anastomotic leak following antecolic versus retrocolic laparoscopic Roux-en-Y gastric bypass for morbid obesity. Obes Surg 2007;17:292-7.

2. Bertucci W, et al. Antecolic laparoscopic Roux-en-Y gastric bypass is not associated with higher complication rates. Am Surg 2005;71:735-7.

3. Carmody B, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 205;1:543-8.

Gastrojejunostomy Circular stapler

↑ risk of wound infection (10%) May be lower if protected stapler

Linear stapler Hand-sewn

Drainage placement Monitors for leak or post-op bleeding Surgeon’s preference

Post op water-soluble contrast study Evaluates for leaks before resuming po intake

1. Podnos YD, et al. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg 2003;138:957-61.2. Dallal RM, et al. Back to basics – clinical diagnosis in bariatric surgery. Routine drains and upper GI series are unnecessary. Surg

Endosc 2007;21:2268-71. Epub 2007 May 5.3. Katasani VG, et al. Water-soluble upper Gi based on clinical findings is reliable to detect anastomotic leaks after laparoscopic

gastric bypass. Am Surg 2005;71:916-8, discussion 918-9.

Controversy Study Type and size Results

Defunctionalized jejunum limb lenght

Brolin et al.

Prospective (n = 45)22 pts: 75 cm length23 pts: 150 cm lengthMean f/u: 43 ± 17 m

Mean exc. wght loss:• 50% for short limb• 64% for long limb• No difference in complications

Internal hernia • Lap vs Open• Roux limb position• Mesocolic closure

Higa et al.Retrospective (n = 2000)

Hernia site:• mesocolic: 67%• Jejunal: 21%• Petersen: 7.5%

Leaks or bleeding:• Drain placement• UGI series

Dallal et al.

Prospective(n = 352)

No drains or UGI

Small complication rate recognized from tachycardia

1. Brolin RE. Long limb Roux en Y gastric bypass revisited. Surg Clin North Am 2005;85:807-17, vii.2. Higa KD, Ho T, Boone KB. Internal hernias after laparoscopic Roux-en-Y gastric bypass: Incidence, treatment and

prevention. Obes Surg 2003;13(3):350–4.3. Dallal RM, et al. Back to basics – clinical diagnosis in bariatric surgery. Routine drains and upper GI series are

unnecessary. Surg Endosc 2007;21:2268-71. Epub 2007 May 5.

Popular in 80’s and 90’s Less common than RYGB Purely restrictive

Rapid sense of satiety Reduced calorie intake

Pouch creation Hole through anterior and posterior wall Staple line to angle of His Nondistensible band around distal neo-pouch

Randomized trials: VBG vs RYGB Better weight loss w/ RYGB Similar operative risks

Replaced by Adjustable gastric band Similar outcomes Technically easier

1. Hall JC, Watts JM, O’Brien PE, Dunstan RE, Walsh JF, Slavotinek AH, et al. Gastric surgery for morbid obesity. The Adelaide Study. Ann Surg 1990;211:419-27.

2. Howard L, Malone M, Michalek A, Carter J, Alger S, Van Woert J. Gastric bypass and vertical banded gastroplasty – a prospective randomized comparison and 5 – year follow-up. Obes Surg 1996;5:55-60.

Dr. Cadiere 1992 Technically simple Purely restrictive

Decrease hunger Early satiety Food aversion

Adjustment to stoma diameter

Pouch creation “Pars flaccida” technique

Proximal stomach dissection Band placement and fixation SQ port placement

Long-term follow up less studied Proper adjustement of band is paramount

Scopinaro (Italy) Significant weight loss

75% excess weight loss Maintained > 20 yrs

Super-morbid obesity BMI ≥ 60 kg/m²

Restrictive Malabsorptive Decreased hunger

Hormonal changes: distal delivery of nutrients1. Marinary GM, Murelli F, Camerini G, Papadia F, Carlini F, Stabilini C, et al. A 15 year evaluation of biliopancreatic

diversion according to the Bariatric Analysis Reporting Outcome (BAROS). Obes Surg 2004;14:325-8.2. Scopinaro N, Gianetta E, Adami GF, Friedman D, Traverso E, Marinari GM, et al. Biliopancreatic diversion for obesity

at eighteen years. Surgery 1996;119:261-8.

Partial gastrectomy 200 – 500 ml gastric pouch

Ileal transection 250 cm above ileocecal valve

Gastro-ileal anastomosis End-to-side ileoileostomy

50 cm proximal to ICV Alimentary channel = 200 cm Common channel = 50 cm

1988 Hess et al. Marceau et al.

Longer common channel

Pylorus preservation Restriction Malabsorption Decreases

Diarrhea Dumping syndrome Ulcerogenesis

Sleeve gastrectomy 150 – 200 ml reservoir Over 35 – 60 Fr bougie

Roux limb 150 cm

Distal common channel 100 cm “Duodeno-ileal switch”

Higher degree of difficulty Multiple enteric anastomoses

Supersuper obese (BMI > 55 kg/m²) 75% excess body weight loss 2 stage procedure:

1. Regan JP, et al. Early experience with two stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 2003;13:861-4.

2. Cottam D, et al. Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Surg Endosc 2006;20:859-63.

Induced weight loss: Improves comorbidities before 2nd operation

Silechia et al: 41 superobese pts 2nd stage operation 60% resolved comorbidities 24% resoved prior to 2nd procedure

Avoids complications: Anastomotic leak Stricture Internal hernia

1. Silechia G, et al. Effectiveness of laparoscopic sleeve gatrectomy (first stage of biliopancreatic diversion with duodenal switch) on comorbidities in super obese high-risk patients. Obes Surg 2006;16:1138-44.

2. Frezza EE, et al. Laparoscopic vertical sleeve gastrectomy for morbid obestiy. The future procedure of choice? Surg Today 2007;37:275-81.

OPEN ↑ post op pain Longer

hospitalizations ↑ wound

complications Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC ↓ post op pain Early mobility ↓ Wound

complications 2-3 day hospital

stay Return to work in 1-

3 weeks

1. Nguyen NT, et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg 2005;140:1198-202.

RYGB: Avg. % excess

weight loss = 70% at 1 year post op

Inversely related to preoperative BMI

50% maintenance weight loss up to 15 years post op

1. Pories WJ, Swanson MS, MacDonald KG, Long SB, Morris PG, Brown BM, et al. Who would have thought it ? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;22:339-50, discussion 350-2.

0

10

20

30

40

50

60

70

80

90

0 1 2 3 4 5 6 7 8 9 1011121314Year Post-Op

% E

WL

)

VBG vs LAGBSimilar % excess weight loss:

38% at 12 months 45% at 24 months 54% at 36 months

European trials: LAGB up to 70%

1. Ren CJ, Horgan S, Ponce J. US experience with the LAP-BAND system. Am J Surg 2002;184(6B):46S-50S.

2. Belachew M, Belva PH, Desaive C. Long term results of laparoscopic adjustable gastric banding for the treatment of morbid obesity. Obes Surg 2002;12:564-8.

RYGB vs LAGB Recent Italian randomized study 5 year follow-up RYGB: significantly lower weight and BMI

BPD or Duodenal switch Greater weight loss in super-obese 70% excess weight loss up to 25 yrs post op Minimal rebound at 10 yrs post op

1. Angrisani L, et al. Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5 year results of prospective randomized trial Surg Obes Relat Dis 2007;3:127-32, discussion 132-2.

2. Prachand VN, et al. Duodenal switch provides superior weight loss in the super-obese (BMI > 50) compared with gastric bypass. Ann Surg 2006;244:611-19.

3. De Maria EJ, Schauer P, Patterson E, Nguyen NT, Jacob BP, Inabnet WB, et al. The optimal surgical management of the super-obese patient: the debate. Presented at the annual meeting of the Society of American Gastroenterology and Endoscopic Surgeons, Hollywood, Florida, USA, April 13-16, 2005. Surg Innov 2005;12:107-21.

Surgical patients vs Control subjects Recent studies:

Mortality decreased by 40% in surgical group Long-term death lower in surgical group

Multiple studies: Weight loss and improved comorbidities

30% to 85% Reduced Mortality

compared to nonsurgical care

N=1041 year post op Number

Pre-op % Worse% No

change

% Improve

d%

Resolved

Osteoarthritis 64 2 10 47 41

Hypercholesterolemia

62 0 4 33 63

GERD 58 0 4 24 72

Hypertension 57 0 12 18 70

Sleep Apnea 44 2 5 19 74

Hypertriglyceridemia

43 0 14 29 57

Peripheral Edema 31 0 4 55 41

Stress Incontinence 18 6 11 39 44

Asthma 18 6 12 69 13

Diabetes 18 0 0 18 82

Average 1.6% 7.8% 35.1% 55.7%

90.8% Improved or Resolved Schauer, et al. Ann Surg 2000 Oct;232(4):515-29

Rapid decrease in serum blood sugar Decrease in medication requirements 66% to 75% complete resolution Increased insulin sensitivity Inhibits progression of disease Swedish Obese Subject Trial:

Reduced relative risk by factor of 30 compared to medically treated population

1. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292: 1724-37.

2. Pories WJ, Swanson MS, MacDonald KG, Long SB, Morris PG, Brown BM, et al. Who would have thought it ? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;22:339-50, discussion 350-2.

3. SjostromL, Lindros AK, Peltonem M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351: 2683-93.

50% complete resolution 25% reduced medications Swedish Obese Subject Trial: 2

years post opDecreased relative risk of new

onset HTN = 10 Time interval for resolution not

cleared1. SjostromL, Lindros AK, Peltonem M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and

cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351: 2683-93.

70% prevalence in gastric bypass pts

80% improvement No more CPAP Decreased pCO2 Increased pO2

1. Dixon JB, et al. Predicting sleep apnea and excessive day sleepiness in the severity obese: indicators for polysomnography. Chest 2003;123:1134-41.

2. Sugerman HJ, et al. Gastric surgery for respiratory insufficiency of obestiy. Chest 1986;90:81-6.

Non-alcoholic fatty liver: Resolution of steatosis Improved liver contour

Osteoarthritis: 50% reduced medication intake Decreased joint stress from weight loss Delayed operative joint intervention

Depression: High prevalence in obese Decreased medication use

1. Clark JM, et al. Roux-en-Y gastric bypass improves liver histology in patients with non-alcoholic fatty liver disease. Obes Res 2005;13:1180-6

2. Abu-Abeid S, et al. The influence of sugically-induced weight loss on the knee joint. Obes Surg 2005;15:1437-42.3. Sarwer DB, et al. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg

2004;14:1148-56.

SurgicalTechnical

errorsErrors in

judgmentType of

procedure

1. Mason EE, et al. Causes of 30-day bariatric surgery mortality: with emphasis on bypass obstruction. Obes Surg 2005;71:9-14.

MetabolicalMalabsorption

Nutrients Vitamins

0.5% to 4% rate DVT prophylaxis

HSQ LMWH

High pre-op risk: Heparin Coumadin IVC filters

1. Sapala JA, et al. Fatal pulmonary embolism after bariatric operations for morbid obesity: a 24-year retrospective analysis. Obes Surg 2003;13:819-25.

2. Prystowsky JB, et al. Prospective analysis of the incidence of deep venous thrombosis in bariatric surgery patients. Surgery 2005;138:759-63.

0.5% to 1% rate Obesity Cardiac comorbidities Pre-op stress testing Long term benefit out-weights

slightly increased risk

1. McCullough PA, et al. Cardiorespiratory fitness and short-term complications after bariatric surgery. Chest 2006;130:517-25.

2% to 4% incidence Gastrojejunostomy Gastric stapled line Systemic

symptoms Tachycardia Tachypnea Fever Hypoxia Extreme anxiety

1. Hamilton EC, et al. Clinical predictors of leak after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc 2003;17:679-84.

Prevention Intraoperative

Visual inspection Water-tight seal Re-inforce staple

line Recognition

Imaging CAT scan Contrast study

Exploration

1. Gonzalez R, et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg 2007;204:47-55.

1. Gonzalez R, et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg 2007;204:47-55.

4% incidence Acute Chronic ↑ Risk if

anticoagulation Prevention

Hemostasis Reinforce anastomosis

Recognition Physical Exam Drains Hgb/Hct EGD CAT Scan

5% to 20% incidence Less in laparoscopic vs open

Laparoscopic wounds heal faster Risk factors in obese:

Thick layer of SQ fat → liquefaction fat necrosis Lower SQ tissue Oxygen tension

5 to 20 days post op Wound opening & packing Revision of port site in LAGB

Rule out band erosion into gastric lumen EGD

1. Podnos YD, et al. Complications after laparoscopic gastric bypass: a review of 3464 case. Arch Surg 2003;138:957-61.

2. Anaya DA, et al. The obese surgical patient: a susceptible host for infection. Surg Infect (Larchmt) 2006;7:473-80.

3. Kabon B, et al. Obesity decreases perioperative tissue oxygenation. Anesthesiology 2004;100:274-80.

Early and Late Small bowel anastomosis 2% to 8% incidence ↑ with Laparoscopic approach Adhesions: months to years post op Internal hernias through defects:

Small bowel mesentery Transverse mesocolon

Obstruction Perforation of gastric remnant Blow-out duodenal stump

Prevention Closure of defects Substantial

anastomosis Loop orientation

Recognition Distention Nausea & Vomiting Contrast studies CAT scan

1. Arshava EV, et al. Delayed perforation of the defunctionalized stomach ater Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2006;2:472-6, discussion 476-7.

Complete vs Partial Type:

I: proximal roux limb II: proximal bile limb III: common limb

Cho et al. 1400 pts Antecolic-

antegastric 1.5% incidence of

internal hernias1. Cho M, et al. Frequency and management of internal hernias after laparoscopic antecolic antegastric

Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases. Surg Obes Relat Diseas 2006;2:2 87 – 91.

.

After gastric banding Early post op Band volume adjustment Outlet obstruction

Small band size Edema and inflammation

Non-operative management If persistent: re-operation

Excision of perigastric fat under band Replacement with larger size

1. Shen R, et al. Removal of perigastric fat prevents acute obstruction after Lap-Band surgery. Obes Surg 2004;14:224-9.

2. Patel SM, Shapiro K, Abdo Z, Ferzli GS. Obstructive symptoms associated with the Lap-Band in the first 24 hours. Surg Endosc 2004;18:51-5.

RYGB and BPD Bypass pyloric sphincter

After meals (sweets) Early: Osmotic gradient Late: Reactive hypoglycemia Lightheadedness Dizziness Sweating Bloating Diarrhea

Partial obstruction Gastrogastrostomy Gastrojejunostomy

5% to 15% incidence after RYGB 4 to 8 weeks after procedure Postprandial nausea & vomiting EGD Pneumatic balloon dilation

< 15mm → recurrent stenosis 70% to 80% cure rate Rule out ulcer

Persistent → Operative revision1. Schwartz ML, et al. Stenosis of the gastroenterostomy after laparoscopic gastric bypass. Obes Surg

2004;14:484-9.2. Peifer KJ, et al. Successful endoscopic management of gastrojejunal anastomotic strictures after

Roux-en-Y gastric bypass. Gastrointest Endosc 2007;66:248-52.

LAGB Recent studies:

25% incidence < 1% need to remove band Improved by deflation of band Achalasia-type symptoms

If suspected: Barium swallow Band deflation

Early resolution of Sx1. Dargent J. Esophageal dilatation after laparoscopic adjustable gastric banding: definition and strategy. Obes Surg

2005;15:843-8.2. De Maria EJ, et al. High failure rate after laparoscopic adjustable silicone gastric banding for treatment of morbid

obesity. Ann Surg 2001;233:809-18.

LAGB 2% to 4% incidence Obstructive symptoms Band orientation change

Plain film Posterior: perigastric technique Anterior: “pars flaccida”

Less common Deflation of band Laparoscopic revision

1. Khourseed M, et al. Slippage ater adjustable gastric banding according to the pars flaccida and the perigastric approach. Med Princ Prac 2007;16:110-113.

2. Keidar A, et al. Band slippage after laparoscopic adjustable gastric banding: etiology and treatment. Surg Endosc 2005;19:262-7.

Months to years after LAGB 1% to 2% incidence Epigastric pain Persistent port site infection EGD:

Black foreign body in cardia region Avoid plication sutures over buckle of

band

15% incidence in RYGB Less common after Duodenal Switch

Gastro duodenal continuity Epigastric pain

Heartburn Upper GI bleeding

Risk factors: NSAID’s Large pouch Non-absorbable sutures

EGD Contrast study

Rule out gastro-gastric fistula1. Rasmussen JJ, Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260

patients. Surg Endosc 2007;21:1090-4.2. Sacks BC, et al. Incidence of marginal ulcers and the use of absorbable anastomotic sutures in laparoscopic Roux-en-

Y gastric bypass. Surg Obes Relat Dis 2006;2:11-6.3. Capella JF, et al. Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes

Surg 1999;9:22-7.

Rapid weight loss → Gallstone formation 50% incidence

10% symptomatic Adjunt cholecystectomy

Cholelithiasis or cholecystitis at time or operation

Ursodeoxycholic acid: ↓ incidence of gallstones post op by 30%

Post op anatomy: Difficult management of pancreatitis, CBD

stones1. Sugerman HJ, et al. A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric bypass induced rapid weight loss. Am J Surg 1995;169:91-6.

2. Taylor J, et al. Is routine cholecystectomy necessary at the time of Roux-en-Y gastric bypass? Obes Surg 2006;16:759-61.

3. Ceppa FA, et al. Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2007;3:21-4.

RYGB Transected/Occluded Lumen

Recanalization → Fistula 2% to 25% incidence Risk factors:

Anastomotic leak LUQ abscess

Long-term consequence: Marginal ulcer Suboptimal weight loss Sudden weight gain

1. Carrodeguas L, et al. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Surg Obes Relat Dis 2005;1:467-74.

2. Gumbs AA, et al. Incidence and management of marginal ulcerations after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006;2:460-3.

GI contrast study EGD Indications for Rx:

Symptomatic ulcers Suboptimal weight loss

PPI’s Sucralfate Surgical revision

Laparoscopic Remnant Gastrectomy Cho et al. 1400 pts w/ RYGB 21 pts w/ GGF (1.5%) 15 underwent LRG No recurrence of GGF No mortality

1. Cho M, et al. Laparoscopic Remnant Gastrectomy: A Novel approach to Gastrogastric fistula after Roux-en-Y gastric bypass for morbid obesity. J Am Coll Surg 2007;4:617-24.

Carbohydrate

LipidProteins

Ca²+Fe ²+

B 12

A, D, E, K

Restrictive: Intolerance Inadequate weight loss Complications

Combined: Enlarged pouch Regained weight Gastro-gastric fistula

Band deflation Replacement size Conversion to RYGB Conversion to Duodenal Switch Multiple Short Studies

Short follow up Conversion is safe with significant

weight loss and lower BMI

Decrease pouch size Lengthen biliary limb Distal jejuno-ileal anastomosis

Increases malabsorption May increase weight loss

1. Mason EE, et al. Optimizing results of gastric bypass. Ann Surg 1975;182(4):405-14.2. Fobi MA, et al. Revision of failed gastric bypass to distal Roux-en-Y gastric bypass: a review of 65

cases. Obes Surg 2001;11(2):190-5.

Metabolic Surgery Surgical resolution for Diabetes?

Too fast to be accounted to weight loss alone

Duodenojejunal Bypass (DJB) Non-obese Rat models Complete resolution of diabetes

Intestinal bypass Hormonal regulation Foregut vs Hindgut hypothesis

1. Rubino F. Bariatric Surgery: Effects on Glucose Homeostasis. Curr Opin Clin Nutr Metab Care 9:497-507

Duodenum divided just below pylorus

Both limbs: 75cm Gastrojejunostomy:

50% hand-sewn 50% stapled

Duodenojejunostomy: 100% hand-sewn

Promising glucose control at 6 to 12 months

Non drug alternate maintenance for non obese diabetes

Resolution of: Metabolic

Syndrome

Endoscopic plication of the pylorus with laparoscopic gastrojejeunostomy

N.O.T.E.S Endoscopic plication of the pylorus Endoscopic transgastric gastric jejeunostomy

Human multicenter trials underway

1. Kantsevoy SV, et al. Technical feasibility of endoscopic gatric reduction: a pilot study in a porcine model. Gastrointes Endosc 2007;65:510-3.

2. Deviere J, et al. Safety, feasibility and weight loss after trans-oral gastroplasty (TOGA): first human multicenter study. Surg Endosc 2007;21(suppl 1): S303.