1. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 1 Complications of Bariatric Surgery Presented by: Robyn Ache, D.O. Fellowship Trained Bariatric Surgeon January 29, 2015 PCOMS Annual Winter Seminar

2. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 2 Disclosures I have no financial relationship in regard to the content of this presentation I have no financial relationship in regard to the content of this presentation

3. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 3 Bariatric Surgery Restriction Restriction –gastric balloon –vertical banded gastroplasty –adjustable gastric banding –Sleeve Gastrectomy Malabsorption Malabsorption –biliopancreatic diversion  duodenal switch Combination Combination –Roux-en-Y gastric bypass

4. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 4 Surgical Incisions

5. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 5 Micro Laparoscopy (2.7mm)

6. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 6 Micro Laparoscopy 6 weeks after surgery 6 months after surgery

7. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 7 Da Vinci Robot

8. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 8 Vertical Banded Gastroplasty

9. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 9 BPD with DS

10. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 10 Human Digestive System

11. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 11 Most Common Surgical Options Gastric Bypass (GBP) Adjustable Gastric Band (AGB) Restrictive and Malabsorptive Restrictive and Adjustable

12. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 12 Newest Procedure- Gastric Sleeve (no long term data- non adjustable)

13. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 13 Ghrelin Ghrelin is produced in the fundus in the stomach and the proximal intestines Ghrelin is produced in the fundus in the stomach and the proximal intestines Ghrelin levels increase prior to meals and are suppressed postprandially in proportion to the amount of calories ingested Ghrelin levels increase prior to meals and are suppressed postprandially in proportion to the amount of calories ingested Obese patients have lower fasting ghrelin levels and significantly reduced postprandially ghrelin suppression compared to normal sized patients Obese patients have lower fasting ghrelin levels and significantly reduced postprandially ghrelin suppression compared to normal sized patients Resection of the gastric fundus in VSG significantly reduces ghrelin post-op. There is no change in RNY or AGB. Resection of the gastric fundus in VSG significantly reduces ghrelin post-op. There is no change in RNY or AGB. Marked suppression of ghrelin levels after VSG is associated with greater appetite reduction and excess weight loss during the first post-op year compared to RNY and AGB. Marked suppression of ghrelin levels after VSG is associated with greater appetite reduction and excess weight loss during the first post-op year compared to RNY and AGB.

14. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 14 The AGB Procedure Performed laparoscopically Performed laparoscopically Band is wrapped around the upper part of the stomach Band is wrapped around the upper part of the stomach Small pouch is created Small pouch is created The stomach holds less food The stomach holds less food Patients feel full faster and longer Patients feel full faster and longer

15. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 15 Benefits of an Adjustable Procedure Gradual, healthy weight loss Gradual, healthy weight loss Customized rate of weight loss Customized rate of weight loss Prolonged sense of fullness after small meals Prolonged sense of fullness after small meals Only weight loss surgery with a long-term tool to keep the weight off Only weight loss surgery with a long-term tool to keep the weight off

16. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 16 How is vertical sleeve gastrectomy performed?

17. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 17 Advantages of Both Procedures Band Least invasive Least invasive No intestinal rerouting No intestinal rerouting Adjustable Adjustable Reversible Reversible Low operative complication Low operative complicationSleeve No adjustment is required No adjustment is required No “dumping syndrome” like associated with bypass No “dumping syndrome” like associated with bypass No Implants No Implants Less follow-up than gastric banding Less follow-up than gastric banding No intestinal rerouting No intestinal rerouting

18. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 18 Disease Resolution Diabetes Diabetes Hypertension Hypertension OSA OSA Hyperlipidemia Hyperlipidemia Infertility Infertility Joint Pain Joint Pain DOE DOE

19. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 19 Risk of Band and Sleeve Procedures Band Band Slippage of the Band Slippage of the Band ( 3-7%) ( 3-7%) Erosion of the Band (less than 0.05%) Erosion of the Band (less than 0.05%) Sleeve Sleeve Gastric Leak (2.2%) Gastric Leak (2.2%) Fistula Fistula Stretching of the stomach Stretching of the stomach Stoma obstruction Stoma obstruction

20. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 20 Huber Needle for Adj. and Def.

21. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 21 Port Leak

22. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 22 Normal Band Xray

23. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 23 Dilated Esophagus Symptoms GERD GERD Dysphagia Dysphagia Nausea Nausea Vomiting Vomiting Able to eat larger amounts of food Able to eat larger amounts of food Asymptomatic Asymptomatic

24. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 24 Dilated Esophagus

25. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 25 Dilated Esophagus

26. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 26 Slipped Gastric Band Symptoms Nausea Nausea Vomiting Vomiting Reflux Reflux Abdominal Pain Abdominal Pain Able to eat larger amounts of food Able to eat larger amounts of food Asymptomatic Asymptomatic

27. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 27 Slipped Gastric Band

28. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 28 Slipped Gastric Band The “O” Sign Incorrect “Angle”

29. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 29 Slipped Gastric Band

30. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 30 Band Erosion Symptoms Decreased restriction Decreased restriction Increased feelings of hunger Increased feelings of hunger Weight regain Weight regain Port Site infection/abscess Port Site infection/abscess Band is overfilled Band is overfilled

31. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 31 Port Site Infections

32. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 32 Band Erosion

33. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 33 Normal Sleeve Xray

34. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 34 Gastric Sleeve Leak Symptoms Tachycardia Tachycardia Tachypnea Tachypnea Unequal breath sounds Unequal breath sounds Fever Fever Left shoulder pain Left shoulder pain Abdominal Pain Abdominal Pain Chest pain Chest pain Sepsis Sepsis

35. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 35 Gastric Sleeve Leak

36. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 36 Gastric Sleeve Stricture Symptoms Food Intolerance Food Intolerance Dysphagia Dysphagia Nausea Nausea Vomiting Vomiting Reflux Reflux

37. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 37 Gastric Sleeve Stricture

38. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 38 Fistula

39. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 39 Stent

40. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 40 Stent

41. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 41 Gastric Bypass Leak Symptoms Tachycardia Tachycardia Tachypnea Tachypnea Unequal breath sounds Unequal breath sounds Fever Fever Left should Pain Left should Pain Abdominal Pain Abdominal Pain Chest Pain Chest Pain Sepsis Sepsis

42. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 42 Gastric Bypass Leak

43. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 43 Anastomotic Stenosis

44. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 44 Marginal Ulcer

45. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 45 Jessica- Band Down 112 lbs!!!

46. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 46 Sara- Band Down 172 lbs!!!

47. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 47 Kelly- Band Down 70 pounds!

48. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 48 Molly- Band Down 76 lbs! Molly pre-op

49. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 49 Mike- Band Down 206 lbs!!!

50. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 50 Mick- Band Lost over 130 lbs!!!

51. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 51 Paul- Band Down 111 Pounds!

52. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 52 Paula- Band Down 125 lbs!

53. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 53 Alexandra - Band Down 140 lbs 1 yr after surgery!

54. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 54 Brian - Band Down 169 lbs 11mo after surgery!

55. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 55 Cherie- Sleeve Pre-Op 9 mo post-op (lost 100lbs)

56. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 56 Kenny- Sleeve Pre-Op 6 mo post-op 9 mo post-op (lost 118 lbs) (lost 152 lbs) (lost 118 lbs) (lost 152 lbs)

57. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 57 Robert- Sleeve Pre-Op 1 yr Post-Op (lost 102 lbs)

58. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 58 John Daly – professional golfer Before.

59. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 59 John Daly Now! Currently Down 116 lbs

60. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 60 Questions?