Flowers

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Case 1

• A 45-year-old woman c/o of acute retrosternal
  pain with dorsal radiation
• Past Medical History () for HTN, DMII,
  dyslipidemia
• Past Surgical History
• 2 x C/S
• had undergone LAGB (Laparoscopic Adjustable
  Gastric Banding) for morbid obesity at another
  hospital 3 years previously current BMI is
  approximately 35

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Super-Sized in the EDBariatric Surgery
Complications

• Scott Bicek
• University of Calgary
• March 1,2007

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Objectives

• Obesity epidemiology
• Overview of bariatric surgeries
• Complications of bariatric surgery
• ED scenarios

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Measuring Obesity

• BMI (Body Mass Index) (body mass)/(height)2
  kg/m2
• Canadian Standards
• lt 18.5 Underweight
• 18.5 to 24.9 Normal weight
• 25.0 to 29.9 Overweight 
•   30.0 Obese

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Obesity Trends Among Canadian and U.S. Adults,
1990
Mokdad AH. Unpubliahed Data. Katzmarzyk PT. Can
Med Assoc J 20021661039-1040.
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Obesity Trends Among Canadian and U.S. Adults,
1994
Mokdad AH, et al. J Am Med Assoc
199928216. Katzmarzyk PT. Can Med Assoc J
20021661039-1040.
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Obesity Trends Among Canadian and U.S. Adults,
1996
Mokdad AH, et al. J Am Med Assoc
199928216. Katzmarzyk PT. Can Med Assoc J
20021661039-1040.
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Obesity Trends Among Canadian and U.S. Adults,
1998
Mokdad AH, et al. J Am Med Assoc
199928216. Katzmarzyk PT. Can Med Assoc J
20021661039-1040.
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Obesity Trends Among Canadian and U.S. Adults,
2000
Mokdad AH, et al. J Am Med Assoc
200028413. Statistics Canada. Health
Indicators, May, 2002.
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Obesity Trends Among Canadian and U.S. Adults,
2003
Sources Behavioral Risk Factor Surveillance
System, CDC Statistics Canada. Health Indicators,
June, 2004.
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Medical Complications of Obesity
Idiopathic intracranial hypertension
Pulmonary disease abnormal function obstructive
sleep apnea hypoventilation syndrome
Stroke
Cataracts
Nonalcoholic fatty liver disease steatosis steatoh
epatitis cirrhosis
Coronary heart disease Diabetes
Dyslipidemia Hypertension
Severe pancreatitis
Gall bladder disease
Cancer breast, uterus, cervix colon, esophagus,
pancreas kidney, prostate
Gynecologic abnormalities abnormal
menses infertility polycystic ovarian syndrome
Osteoarthritis
Phlebitis venous stasis
Skin
Gout
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Bariatric Surgery

• In 2001, approximately 30,000 weight loss
  procedures were performed in the U.S
• increased to approximately 60,000 in 2003
• increase in bariatric surgery has also been
  fueled in part by the application of laparoscopic
  techniques

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Vertical Banded Gastroplasty
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Vertical Banded Gastroplasty

• purely restrictive procedure
• A small pouch is made along the lesser curvature
  of the stomach using surgical staplers

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Vertical Banded Gastroplasty

• purely restrictive procedure
• A small pouch is made along the lesser curvature
  of the stomach using surgical staplers

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Vertical Banded Gastroplasty

• purely restrictive procedure
• A small pouch is made along the lesser curvature
  of the stomach using surgical staplers
• A nonadjustable band then constricts the outlet
  from the pouch

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Vertical Banded Gastroplasty

• purely restrictive procedure
• A small pouch is made along the lesser curvature
  of the stomach using surgical staplers
• A nonadjustable band then constricts the outlet
  from the pouch

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Vertical Banded Gastroplasty

• Procedure relies on reduced food intake to
  achieve weight loss
• patients tend to lose approximately 50 of excess
  weight during the first 2 years postprocedure
  (Edwards et al., 2006)
• Longterm follow-up of patients has revealed that
  it is not an extremely effective weight loss
  surgery

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Vertical Banded Gastroplasty

• patients who undergo a vertical banded
  gastroplasty circumvent this restrictive
  procedure by eating soft, high-calorie foods

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Laparoscopic Adjustable Gastric Banding (LAP-BAND)
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LAP-BAND

• the restrictive procedure of choice
• adjustable silastic band that is positioned
  around the upper portion of the stomach
• The band is connected to a port that is implanted
  under the skin

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LAP-BAND

• port is similar to those used for vascular access
  and allows the band to be tightened or loosened,
  depending on clinical need
• advantages over the vertical banded gastroplasty
  include
• No surgical stapling of the stomach (decreased
  risk of perforation or fistula formation)
• Ability to regulate degree of restriction
  postoperatively
• relative ease for reversibility

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Case 1

• A 45-year-old woman who had undergone LAGB for
  morbid obesity at another hospital 3 years
  previously
• complains of acute retrosternal pain with dorsal
  radiation
• w/u completed to r/o MI and PE (ECG, Troponin,
  CT-PE all normal)

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Case 1

• Several hours after admission and only after
  insistent questioning did the patient mention the
  concomitant onset of severe food intolerance that
  she considered to be secondary to her chest pain
• Any other investigations you would like to order?

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Case 1

• Gastrograffin swallow revealed strangulation of
  the stomach by the adjustable gastric banding
  device with dilatation of the upper gastric pouch
  (prolapse)

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Gastric Prolapse

• characterized by enlargement of the upper gastric
  pouch due to herniation of the fundus upward
  through the band
• Its incidence has decreased from 22 to 5 in
  recent years after modification in surgical
  technique and improved band adjustment protocols
  (Spivak and Faveretti, 2002)
• manifests by food intolerance, vomiting,
  regurgitation, heartburn, and epigastric pain

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Gastric Prolapse

• If the diagnosis is suspected (or confirmed late
  radiographically) what should your next step be?
• The band MUST be completely deflated

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Deflating the LAP-Band

• The access port is usually situated in the LUQ
  either subcutaneously or under the anterior
  sheath of the rectus abdominis muscle
• In patients who have already lost weight, it can
  usually be palpated and stabilized between 3
  fingers of the left hand using STERILE TECHNIQUE
• A 20 GA needle on a 10 cc syring held in the
  right hand penetrates the port membrane at its
  center

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Deflating the LAP-Band

• Proper positioning of the needle within the port
  chamber is attested by the tactile feeling of the
  needle tip hitting the metallic chamber floor and
  by spontaneous outflow of fluid
• The most commonly used model is the LAP-BAND 9.75
  cm which can accommodate up to 5 mL of fluid
  (whereas other models contain as much as 9 mL)
• Can be done under fluoroscopy guidance

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Case 1

• After the diagnosis of gastric prolapse was made
  with the gastrograffin study, the LAP-band was
  successfully deflated (4 cc was extracted from
  the port)
• Urgent Surgical consult initiated
• Would you like any other investigations?

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Gastric Necrosis and Erosion

• GI consult for URGENT gastroscopy because gastric
  necrosis and erosion has been demonstrated with
  gastric prolapse
• In one large study, gastric erosion occurred in
  6.8 of patients in isolation (Suter et al.,
  2004)
• Patients may present with evidence of
  intra-abdominal sepsis caused by perforation with
  or without abscess, gastrocutaneous fistulas, and
  with late infection at the port site
• Treatment for this problem consists of surgical
  removal and repair of the gastric perforation

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Complications After Laparoscopic Adjustable
Gastric Banding
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LAP-BAND Complications

• Cumulative operative risks for the laparoscopic
  adjustable gastric band appear to be less than
  that for gastric bypass

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Roux-en-Y Gastric Bypass
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Roux-en-Y Gastric Bypass

• most commonly performed operation for morbid
  obesity in the U.S. (performed both open and
  laparoscopically)
• both a restrictive and subclinical malabsorptive
  procedure

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Roux-en-Y Gastric Bypass

• a small proximal gastric pouch (15-30 ml) is made
  and is connected to the jejunum - a variable
  amount of proximal small bowel is bypassed

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Roux-en-Y Gastric Bypass

• a small proximal gastric pouch (15-30 ml) is made
  and is connected to the jejunum - a variable
  amount of proximal small bowel is bypassed

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Roux-en-Y Gastric Bypass

• a small proximal gastric pouch (15-30 ml) is made
  and is connected to the jejunum - a variable
  amount of proximal small bowel is bypassed

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Is Roux-en-Y Gastric Bypass Effective?

• Comparing Roux-en-Y to laparoscopic adjustable
  gastric banding, it produces greater excess
  weight loss, 74.6 versus 40.4 at 18 months
  (Biertho et al., 2003)
• ...But is it safe?

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Case 2

• 45 year old, obese (BMI 42) woman presents to
  the ED c/o feeling feverish and unwell x 12
  hours
• Past Medical History is () DMII, knee OA
  (bilateral)
• Rou-en-Y gastric bypass performed in Medicine Hat
  2 weeks earlier

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Case 2

• Vitals T37.9, HR115, BP110/65, RR20
• Physical examination very unremarkable

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Complications After LaparoscopicRoux-en-Y
Gastric Bypass
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The Big 3 Complications You Do NOT Want to Miss
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The Big 3 Complications You Do Not Want to miss

• 1 ANASTOMOTIC LEAK
• 2 DVT or PE
• 3 BOWEL OBSTRUCTION (INTERNAL HERNIA)

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• Any patient who presents in the first weeks after
  a Roux-en-Y with tachycardia and fever might be
  harboring an anastomotic leak with associated
  abscess

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Roux-en-Y Gastric Bypass

• Reported anastomotic leak rates are as high as
  5.9 (Lujan JA et al., 2004) with the majority of
  these leaks occurring at the gastrojejunostomy

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Roux-en-Y Gastric Bypass

• Reported anastomotic leak rates are as high as
  5.9 (Lujan JA et al., 2004) with the majority of
  these leaks occurring at the gastrojejunostomy

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Roux-en-Y Gastric Bypass

• Reported anastomotic leak rates are as high as
  5.9 (Lujan JA et al., 2004) with the majority of
  these leaks occurring at the gastrojejunostomy
• Investigation of choice?

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Roux-en-Y Gastric Bypass Anastomotic Leak

• CT scan of the abdomen and pelvis, preferably
  with oral and intravenous contrast
• limited size of the gastric pouch, it is neither
  feasible nor advisable to have a patient attempt
  to consume the usual 1 L of oral contrast
• patient should sip contrast during 3 hours and
  scan the patient regardless of the absolute
  volume consumed

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What if the patient is to heavy for the CT
scanner?

• At the FMC the weight limit for the CT scanner is
  400 lbs and MRI is 350 lbs
• If the possibility of an anastomotic leak exists
  and the patient is too heavy for CT, an upper GI
  series with a water-soluble agent should be
  obtained

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Early Complications

• Anastomotic leak
• DVT and PE
• Intraabdominal bleeding

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GI Bleeding

• Develop bleeding from the staple lines at the
  gastrojejunostomy (most common), the
  jejunojejunostomy and even along the transected
  edge of the gastric remnant

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GI Bleeding

• Develop bleeding from the staple lines at the
  gastrojejunostomy (most common), the
  jejunojejunostomy and even along the transected
  edge of the gastric remnant

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GI Bleeding

• Develop bleeding from the staple lines at the
  gastrojejunostomy (most common), the
  jejunojejunostomy and even along the transected
  edge of the gastric remnant

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GI Bleeding

• Develop bleeding from the staple lines at the
  gastrojejunostomy (most common), the
  jejunojejunostomy and even along the transected
  edge of the gastric remnant

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GI Bleeding

• Management as per any GI bleed
• Consult GI for upper endoscopy to determine site
  of bleeding from the gastrojejunostomy
• Potential for surgery if site of bleeding not
  visualized, however most bleeding is self limited

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Case 3

• 36 year old man presents with crampy
  intermittent epigastric pain, which radiates to
  his back
• No N/V, no diarrhea, no sick contacts, no
  questionable ingestions, no recent travel
• Past Medical History healthy
• Past Surgical History gastric bypass-1999

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Case 3

• PE decreased BS no masses / organomegaly mild
  epigastric tenderness on palpation no rebound /
  guarding / peritoneal signs
• ECG normal
• CXR normal
• abdo (2 views) normal

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Late Complications

• Adhesive bowel obstructions
• Stricture/stenosis
• Internal hernias
• Reflux
• nutritional deficiencies (iron, vitamin B12,
  vitamin D, and calcium most commonly)

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Late Complications

• Adhesive bowel obstructions
• Stricture/stenosis
• Internal hernias
• Reflux
• nutritional deficiencies (iron, vitamin B12,
  vitamin D, and calcium most commonly)

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Internal Hernias

• small-bowel herniation through 1)the mesenteric
  defect created at the distal anastomosis or 2)
  through a surgically created space between the
  transverse colon mesentery and the mesentery of
  the small bowel that comprises the Roux limb
  (herniation through this space is 3 to 5
  (Comeau et al., 2005))

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Internal Hernias

• small-bowel herniation through 1)the mesenteric
  defect created at the distal anastomosis or 2)
  through a surgically created space between the
  transverse colon mesentery and the mesentery of
  the small bowel that comprises the Roux limb
  (herniation through this space is 3 to 5
  (Comeau et al., 2005))

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Internal Hernias

• small-bowel herniation through 1)the mesenteric
  defect created at the distal anastomosis or 2)
  through a surgically created space between the
  transverse colon mesentery and the mesentery of
  the small bowel that comprises the Roux limb
  (herniation through this space is 3 to 5
  (Comeau et al., 2005))

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Internal Hernias

• present with nonobstructive, intermittent,
  crampy, epigastric abdominal pain that often
  radiates to the back
• Unless the obstruction has led to ischemic
  compromise of the bowel, the abdominal
  examination is usually unrevealing
• If herniation involves afferent limb, then no air
  fluid levels on plain x-ray

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Internal Hernias

• Invesigation CT or upper GI series
• Findings include areas of intussusception,
  transition points, or the classic swirl sign
  created by twisting of the bowel mesentery

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Computed tomography patterns in small bowel
obstruction after open distal gastric
bypass.(Srikanth et al. Obes Surg. 2004
Jun-Jul14(6)811-22)

• retrospective chart review of 1,409 open distal
  Roux-en-Y gastric bypasses
• clinical and radiological findings in 29 patients
  with unusual forms of bowel obstruction
  (intussusception, internal hernias) identified on
  CT

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Computed tomography patterns in small bowel
obstruction after open distal gastric
bypass.(Srikanth et al. Obes Surg. 2004
Jun-Jul14(6)811-22)

• RESULTS
• 1 had peritonitis
• 1 had free air on plain film
• 9/14 patients (62) had "non-specific" findings
  on x-rays (7 of these had an internal hernia, 2
  with volvulus)

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What about the white count?

• Srikanth et al, WBC count was normal in 20/27
  patients (74) including 5/6 (83) with necrotic
  bowel

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How good is CT in picking up internal hernia
after gastic bypass?
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• A retrospective review of 1,000 Lap-RYGB
• identify postoperative internal hernias
• Results
• 45 internal hernias were identified (4.5) in 43
  patients
• Hernia location included transverse colon
  mesentery (n43, 95) or Petersens defect (n2,
  5) (the area between the mesentery of the
  Roux-limb and the transverse mesocolon)

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• Results

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• Results
• 86 of patients had a CT scan done before
  surgery, 10 had an upper GI, 7 had both studies
  done before surgery, and 14 did not have either
• When CT was used alone, 64 (22/34) were positive
  for an internal hernia
• Subsequent review of all imaging studies showed
  diagnostic abnormalities in 97of the patients

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• Any patient with unexplained abdominal pain,
  regardless of laboratory or radiologic findings,
  should be considered for surgical exploration

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Gastric Dilatation

• obstruction of the Roux limb that causes acute
  gastric dilatation (2o stenosis/stricture)
• Symptoms include abdominal pain, nausea, and
  vomiting if the distended stomach occludes the
  gastrointestinal tract by compression of the Roux
  limb
• diagnosis is confirmed by CT
• Management percutaneous decompression in
  interventional radiology

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Take Home Points

• Laparoscopic Adjustable Gastric Banding
  (LAP-BAND)
• (1) Gastric prolapse through the band presents
  via food intolerance, vomiting, regurgitation,
  heartburn, and epigastric pain
• Deflate the adjustable band
• Gastrograffin swallow study
• Consult surgery and GI (re URGENT gastroscopy)

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Take Home Points

• Roux-en-Y Gastric Bypass
• (1) anastomotic leaks MUST be considered in
  patients with tachycardia and fever in the first
  weeks after a Roux-en-Y
• Imaging of choice is CT with contrast (or upper
  GI series)

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Take Home Points

• Roux-en-Y Gastric Bypass
• (3) GI bleeding should be treated as per
  standard UGI bleed management
• Urgent GI consult for gastroscopy
• Bleeding is usually self-limited

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Take Home Points

• Roux-en-Y Gastric Bypass
• (2) Internal hernias present with
  nonobstructive, intermittent, crampy, epigastric
  abdominal pain that often radiates to the back
• Clinical examination, laboratory and imaging
  investigations have poor sensitivity

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Take Home Points

• Roux-en-Y Gastric Bypass
• (4) Gastric dilatation presents with obstructive
  symptoms
• CT to confirm diagnosis
• percutaneous decompression via interventional
  radiology

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References

• Balsiger BM, Poggio JL, Mai J, et al. Ten and
  more years after vertical banded gastroplasty as
  primary operation for morbid obesity. J
  Gastrointest Surg. 20004598-605.
• Biertho L, Steffen R, Ricklin T, et al.
  Laparoscopic gastric bypass versus laparoscopic
  adjustable gastric banding a comparative study
  of 1,200 cases. J Am Coll Surg. 2003197536-544.
• Comeau E, Gagner M, Inabnet WB, et al.
  Symptomatic internal hernias after laparoscopic
  bariatric surgery. Surg Endosc. 2005 1934-39.
• Eric D. Edwards, MD Brian P. Jacob, MD, et al.
  Presentation and Management of Common PostWeight
  Loss Surgery Problems in the Emergency
  Department. Ann Emerg Med. 200647160-166.
• Garza, Jr., et al. Internal hernias after
  laparoscopic Roux-en-Y gastric bypass. The
  American Journal of Surgery 188 (2004) 796800
• Landen MD,, Bernard M, et al. Complications of
  gastric banding presenting to the ED. American
  Journal of Emergency Medicine (2005) 23, 368370
• Lujan JA, Frutos MD, Hernandez Q, et al.
  Laparoscopic versus open gastric bypass in the
  treatment of morbid obesity a randomized
  prospective study. Ann Surg. 2004239433-437.

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References

• Olbers T, Lonroth H, Dalenback J, et al.
  Laparoscopic vertical banded gastroplasty an
  effective long-term therapy for morbidly obese
  patients? Obes Surg. 200111726-730.
• Spivak H, Favretti F. Avoiding postoperative
  complications with the LAP-BAND system. Am J Surg
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• Srikanth MS, Keskey T, Fox SR, et al. Computed
  tomography patterns in small bowel obstruction
  after open distal gastric bypass. Obes Surg.
  200414811-822.
• Susmallian S, Ezri T, Elis M, et al. Access-port
  complications after laparoscopic gastric banding.
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• Suter M, Giusti V, Heraief E, et al. Band erosion
  after laparoscopic gastric banding occurrence
  and results after conversion to Roux-en-Y gastric
  bypass. Obes Surg. 200414381-386
• Townsend Sabiston Textbook of Surgery, 17th ed.
• Yoffe B, Sapojnikov S, Goldblum C. Gastric wall
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