Bariatric Surgery Richard S. Gordon, MD, FRCSC, FACS General, Minimally Invasive and Bariatric Surgery Tampa Bay Surgical Group

1954 First metabolic surgery: jejuno-ileal bypass 1966 modified RYGB was performed for ulcers 1980 first stand alone Duodenal Switch 1997 open sleeve gastrectomy was part of Duodenal switch

Early operations simulated short gut syndrome by bypassing small intestine to cause varying degrees of mal-absorption Remained the standard for next 20 years Long-term complications became known leading to newer procedures being developed

Most common procedures today Laparoscopic sleeve gastrectomy (>50%) 1 Roux-en-Y Gastric Bypass 2 Duodenal switch 3 Gastric banding (least common now) 4

Indications Most insurance companies based on CDC recommendations BMI > 35 (with comorbidities) or BMI >40 Comorbidities include DM, HTN, OSA, hyperlipidemia for the most part which insurance companies looking for History of failed diet attempts (reason why many patients have to do 3-6 months of preop dieting for approval) No reversible causes of obesity (e.g., hypothyroid, steroids) No uncontrolled psychiatric conditions Indications

Normal anatomy

Normal Anatomy

Roux-en-Y Gastric Bypass 15 to 25 ml gastric pouch with 1 cm outlet Bypass distal stomach, duodenum, first segment of jejunum Bypass 75 – 150 + cm jejunum Restrictive and Malabsorptive procedure Metabolic procedure: Changes in gut hormones, appetite hormones Can cause dumping

Normal Bypass on UGI

Sleeve Gastrectomy Large portion of stomach removed to leave a pouch that holds ~80 mls No disconnection from intestine as in RYGB so no need for anastomoses Restrictive procedure Metabolic procedure (similar to RYGB) May increase GERD, may improve Often repair associated hiatal hernia (unclear if benefit or not)

Normal Sleeve on UGI Normal imaging findings after sleeve gastrectomy. Supine spot image from single-contrast upper GI barium study shows tubular narrowing of gastric pouch (arrows) secondary to resection of greater curvature of proximal and mid stomach. Note relatively abrupt widening of gastric antrum, which is preserved.

Gastric Banding Band around upper stomach creates 15ml pouch No physiological changes or restrictions Port of adjustment attached to abdominal wall Inflate/deflate 6 times a year Restrictive procedure only No hormonal changes Day surgery Fallen out of favor in bariatric surgical community

Normal Band on fluoroscopy

Duodenal Switch Combination of sleeve and intestinal bypass Most technically challenging, especially laparoscopic Least common as a result Excellent weight loss results and diabetes resolution Restrictive and malabsorptive procedure Metabolic changes

Complications

Gastric Bypass Early (within 30 days): Leaks, bleeding, and early postop SBO Mortality 0.1% (similar to lap chole) Late (after 30 days): Internal hernia, strictures, and marginal ulcer, vitamin deficiencies

The top 3 concerns should be leak, leak, and leak; most commonly from the G-J anastomosis (RYGB) or near GE Junction (Sleeve) but can be from any anastomosis or staple line. With current techniques and technology in surgical stalking, leak rate now less than 1% Most early complications of laparoscopic gastric bypass or sleeve can be managed laparoscopically in experienced hands, but do not hesitate to convert to open as needed.

Late – leaks, stricture, vitamin deficiencies Sleeve Gastrectomy Early – leaks, bleeding Late – leaks, stricture, vitamin deficiencies

Leaks Signs of uncontained leak should prompt immediate surgical exploration, otherwise a contrast swallow study should be obtained (CT or combined UGI followed by immediate CT have highest sensitivity). reliable only for leaks from G-J (arrow in figure), can easily miss leaks from J-J or from gastric remnant (although these are fortunately much less common)

Leaks Management Early Leak Laparoscopic or open exploration with drainage If site identified can attempt repair Drain, drain, drain Control of sepsis is key Later leaks Usually can be managed conservatively Radiology or laparoscopic drainage of abscess/fluid collection Endoscopic stenting, flipping, fibrin glue, or combination Possible NPO/TPN, distal feeding tube Surgical revision if fails Leaks Management

Small Bowel Obstruction Not as much a concern after Sleeve gastrectomy but could get port-site hernia Early SBO after laparoscopic gastric bypass is rarely due to adhesions, and is more commonly due to: 1) technical error with narrowing or kinking of the J-J, 2) intraluminal obstruction from a formed hematoma, or 3) a port-site hernia. luminal J-J obstruction due to a formed hematoma can be a surgical emergency if completely obstructing early obstruction proximal to the J-J will cause afferent limb dilation and possible emesis - these are both risk factors for disrupting the G-J anastomosis if not promptly treated NG tube may help symptomatology but risk of NG placement early postop obstruction at or distal to the J-J will also dilate the both limbs and gastric remnant (GR in figure), which has no outlet for decompression. This is a surgical emergency

Gastric Remnant Dilation Rare complication of Gastric Bypass Presents with tachycardia, feeling of doom, pain – similar to uncontained leak Imaging shows dilated remnant Can perforate if left untreated IR or surgical decompression with G-tube

Strictures - Sleeve Uncommon esp if Bougie size >32F during surgery Can attempt dilation endoscopically Seromyotomy Revision to RYGB Strictures - Sleeve

Strictures/Ulcers – Gastric Bypass At the gastrojejunal anastomosis Often related to anastamotic ulcers Approximately 10% incidence Smoking, NSAIDS are risk factors for ulcers Treatment includes PPI’s, Carafate EGD for diagnosis and balloon dilation for treatment of strictures Often requires multiple attempts to give relief Revision of gastrojejunostomy in rare cases Strictures/Ulcers – Gastric Bypass

Bands - Slippage Late (after 30 days): Band slippage The primary reason for an acute emergent presentation with a prior AGB will be a slippage of the band causing gastric obstructive symptoms and possible strangulation of the stomach above the slipped band (Figure). *note band has slipped distally, and excess fundus/body is herniated upwards. In addition to obstructive symptoms this can cause acute gastric necrosis if left untreated

Bands Erosion Not common Can present as port site infection] Treated by removal of eroded lap band Can often be done endoscopically

Multivitamins, B12, and calcium are important life-long Vitamin D deficiency also common in sleeve/bypass patients Due to reduced stomach size, reduced binding enzymes (such as intrinsic factor), bypass of proximal small bowel Chronic deficiency can delete stores and cause serious neurological and other complications Vitamin Deficiencies

Results – weight loss and diabetes Procedure %EBWL @ 5 years %EBWL @ >10 years DM Remission @2 years DM Remission >5 years RYGB* 65% (range 42-93%) 59%(range 52-82%) 84% ~60% (range 29-82%) Sleeve* 58% (range 40-86%) 28% (range 28-81%) 81% ~60% (range 9-85%) BPD/DS* 66% (n=50)** 70% (n=373)** 98% ~98%(range 88-100%) Lap Band 48%**** 47.5% 73%*** 14% *ASMBS Position Statement on medium and long term disability of weight loss and diabetic outcomes after conventional stapled bariatric procedures. Dan Azagury, M.D., et al. SOARD 14 (2018) 1425-1441 **Limited data due to relative uncommonness of BPD/DS compared to RYGB and LSG; based on 1 study of indicated sample size. ***Resolution of Type 2 Diabetes Following Bariatric Surgery: Implications for Adults and Adolescents . Radha Nandagopal, M.D., et al. Diabetes Technol Ther. 2010 Aug; 12(8): 671–677. ****.The bariatric surgery and weight losing: a meta-analysis in the long- and very long-term effects of laparoscopic adjustable gastric banding, laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy on weight loss in adults. Golzarand M. et al. Surg Endosc. 2017 Nov;31(11):4331-4345.

Case Study 1 40 year old female c/o acute epigastric pain, nausea and vomiting. Previous gastric lap band.

Conclusion: Slipped lap band UGI swallow Dilated pouch Retained contrast Abnormal band position Conclusion: Slipped lap band

Case Study 2 28 year old female. 2 weeks post-op gastric sleeve, presents to ED with pain that has increased each day in left upper abd. Nausea. No vomiting. Fever 101.6 Pulse 112 UGI shows

Case Study 3 54 year female with history of Bypass surgery 8 years ago presents to ED with nausea, vomiting and abdominal pain for 4 days. CT shows: