“Complicaties na bariatrische ingrepen” Refereeravond: Sedatie bij de obese patiënt Dr WL Curvers, MDL-arts

Content Bariatric surgery: why, who and how? Bariatric complications and Endoscopy Bariatric endoscopy

Bariatric surgery: why? Obesity and DM type 2 are a worldwide epidemic

Bariatric surgery: why?

Bariatric surgery: why?

Bariatric surgery: who? Adults with BMI ≥ 40 kg/m2 Adults with BMI ≥ 35 kg/m2 with obesity-related comorbiditeis (e.g. Hypertension, DM type 2, OSAS) difficult controlled with life-style of drugs Elibilge pts must have tried and failed non-surgical weight loss measurements

Bariatric surgery: how? Restrictive / metabolic / both

Bariatric surgery: how? Restrictive / metabolic / both

Bariatric surgery: how? Restrictive / metabolic / both Sleeve Gastrectomy

Bariatric surgery: how? Restrictive / metabolic / both Duodenunal-jejunal bypass

Bariatric surgery: how? Restrictive / metabolic / both Biliary pancreatic division combined with gastrectomy

Bariatric surgery: how? Restrictive / metabolic / both Roux en-Y Gastric Bypass

Complications Local Systemic Intra-operative Splenectomy (0,4%) Peri-operative Anasomotic leakage (1,1%) GI hemorrage (2,5%) Trocar injury (0,1%) DVT (1%) PE (0,5%) Bowel obstruction (1,7%) Wound infection Pneumonia (0,2%) Carida event Mortality (2%) Late Anastomotic strictures (3-12%) Marginal ulcer (0,5%-20%) “Candy Cane” syndrome GERD Bowel obstruction (2,5%) Incisional hernia (0,5-8%) Internal hernia (1-3%) Cholecystitis/gallstones Dumping syndrome (up to 30%) Anemia Vitamine deficienies

Complications Local Systemic Intra-operative Splenectomy (0,4%) Peri-operative Anasomotic leakage (1,1%) GI hemorrage (2,5%) Trocar injury (0,1%) DVT (1%) PE (0,5%) Bowel obstruction (1,7%) Wound infection Pneumonia (0,2%) Carida event Mortality (2%) Late Anastomotic strictures (3-12%) Marginal ulcer (0,5%-20%) “Candy Cane” syndrome GERD Bowel obstruction (2,5%) Incisional hernia (0,5-8%) Internal hernia (1-3%) Cholecystitis/gallstones Dumping syndrome (up to 30%) Anemia Vitamine deficienies

Endoscopic managment Local Systemic Intra-operative Splenectomy (0,4%) Peri-operative Anasomotic leakage (1,1%) GI hemorrage (2,5%) Trocar injury (0,1%) DVT (1%) PE (0,5%) Bowel obstruction (1,7%) Wound infection Pneumonia (0,2%) Carida event Mortality (2%) Late Anastomotic strictures (3-12%) Marginal ulcer (0,5%-20%) GERD Bowel obstruction (2,5%) Incisional hernia (0,5-8%) Internal hernia (1-3%) Cholecystitis/gallstones Dumping syndrome (up to 30%) Anemia Vitamine deficienies

Anastomotic leaks Early leaks (< 14 days postoperative) Generaly surgical emergency Intermediate leaks (2-6 weeks) Surgical mangement has high mortality 10%, morbidity (50%) and conversion rate. Conservative supportive care Medical treament of sepsis/antibiotics, nil per mounth, tube feeding or TPV Radiological or endoscopic drainge of collections Endoscopic treatment

Endoscopic intervention EUS-guided drainage of collections

Endoscopic intervention Endoscopic closure of leaks/fistula Clips

Endoscopic intervention Endoscopic closure of leaks/fistula Clips

Endoscopic intervention Endoscopic closure of leaks/fistula Clips

Endoscopic intervention Endoscopic closure of leaks/fistula Over-the-Scope-Clip (OTSC)

Endoscopic intervention Endoscopic closure of leaks/fistula Over-the-Scope-Clip (OTSC)

Endoscopic intervention Endoscopic closure of leaks/fistula Stents

GI BLeeding Early bleeding Late bleeding Intrabdominal bleeding Surgical of radiological intervention Intraluminal bleeding Endoscopic treatment Late bleeding Mariginal ulcers (RYGB) Ulcers in remant stomach

Endoscopic intervention GI bleeding Dual therapy with epinephrine and clips

Endoscopic intervention GI bleeding Dual therapy with epinephrine and Goldprobe

Endoscopic intervention GI bleeding Hemospray

Anastomotic strictures Multifactorial Technical factors (stapler>hand-sewn), local ischemia, inflammatory reponse No passage of diagnostic endoscope Most strictures occur in first 2-3 months

Endoscopic intervention Anastomotic stricture Dilatation

Endoscopic intervention Anastomotic stricture Dilatation

Marginal ulceration Multifactorial Most common in first 2-4 months Gastric acidity, pouch size, fistel, ischemia, NSAIDs, Helicobacter Pylori, smoking, alcohol Most common in first 2-4 months Management Exclude fistel Treat Helicobacter Pylori Cessation of smoking and NSIAD use PPI treatment (addition of ulcogant)

Marginal ulceration Multifactorial Most common in first 2-4 months Gastric acidity, pouch size, fistel, ischemia, NSAIDs, Helicobacter Pylori, smoking, alcohol Most common in first 2-4 months Management Exclude fistel Treat Helicobacter Pylori Cessation of smoking and NSIAD use PPI treatment (addition of ulcogant)

Gastro-esophgeal reflux disease Obesity is major riskfactor GERD RYGB shows improvement of GERD symtpoms Sleeve Gastrectomy may increase GERD Especialy in patients with pre-existing GERD Hiatal hernia without repair is a contraindication for SG Pathogensis: inefeccteive persitalsis, increased (non-acid) reflux

Bariatric Endoscopy Early intervention in obese patients (BMI ≥ 30kg/m2) Primary intervention in subjects eligible for surgery but refuse surgery or have no access to surgery Secondary intervention as bridge to elective surgery (BMI ≥ 40kg/m2) or as bridge to bariatric surgery (BMI ≥ 50kg/m2)

Bariatric Endoscopy Intragastric balloon treatment

Bariatric Endoscopy Intragastric balloon treatment Early ballon 1980s many complications Maximum duration of 6 – 12 months Most weight loss supposed by gastric adaptation After 30 years still not covered by existing evidence based guidelines

Bariatric Endoscopy Duodenojejunal bypass liner Mimics effects of gastric bypass bycreating a physical barrier that allows bypass of the duodenum an jejunum

Bariatric Endoscopy Satisphere Desgined to delay transit time through duodenum

Bariatric Endoscopy Aspiration therapy Aspirate gastric content 20 min after meal

Bariatric Endoscopy Gastric suturing/stapeling