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

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

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

4. Bariatric surgery: why?

5. Bariatric surgery: why?

6. 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

7. Bariatric surgery: how?
Restrictive / metabolic / both

8. Bariatric surgery: how?
Restrictive / metabolic / both

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

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

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

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

13. 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

14. 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

15. 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

16. 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

17. Endoscopic intervention
EUS-guided drainage of collections

18. Endoscopic intervention
Endoscopic closure of leaks/fistula
Clips

19. Endoscopic intervention
Endoscopic closure of leaks/fistula
Clips

20. Endoscopic intervention
Endoscopic closure of leaks/fistula
Clips

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

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

23. Endoscopic intervention
Endoscopic closure of leaks/fistula
Stents

24. 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

25. Endoscopic intervention
GI bleeding
Dual therapy with epinephrine and clips

26. Endoscopic intervention
GI bleeding
Dual therapy with epinephrine and Goldprobe

27. Endoscopic intervention
GI bleeding
Hemospray

28. 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

29. Endoscopic intervention
Anastomotic stricture
Dilatation

30. Endoscopic intervention
Anastomotic stricture
Dilatation

31. 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)

32. 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)

33. 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

34. 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)

35. Bariatric Endoscopy
Intragastric balloon treatment

36. 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

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

38. Bariatric Endoscopy Satisphere
Desgined to delay transit time through duodenum

39. Bariatric Endoscopy Aspiration therapy
Aspirate gastric content 20 min after meal

40. Bariatric Endoscopy
Gastric suturing/stapeling