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

Super-Sized in the ED:Bariatric Surgery Complications

Scott Bicek

University of Calgary

March 1,2007

Objectives:

• Obesity epidemiology

• Overview of bariatric surgeries

• Complications of bariatric surgery

• ED scenarios

Measuring Obesity

• BMI (Body Mass Index) = (body mass)/(height)2 = kg/m2

• Canadian Standards• < 18.5 = Underweight • 18.5 to 24.9 = Normal weight • 25.0 to 29.9 =Overweight •  ≥ 30.0 = Obese

Obesity Trends Among Canadian and U.S. Adults, 1990

Mokdad AH. Unpubliahed Data. Katzmarzyk PT. Can Med Assoc J 2002;166:1039-1040.

No Data <10% 10%-14% 15-19% 20%

Obesity Trends Among Canadian and U.S. Adults, 1994

Mokdad AH, et al. J Am Med Assoc 1999;282:16.Katzmarzyk PT. Can Med Assoc J 2002;166:1039-1040.

No Data <10% 10%-14% 15-19% 20%

Obesity Trends Among Canadian and U.S. Adults, 1996

Mokdad AH, et al. J Am Med Assoc 1999;282:16.Katzmarzyk PT. Can Med Assoc J 2002;166:1039-1040.

No Data <10% 10%-14% 15-19% 20%

Mokdad AH, et al. J Am Med Assoc 1999;282:16.Katzmarzyk PT. Can Med Assoc J 2002;166:1039-1040.

Obesity Trends Among Canadian and U.S. Adults, 1998

No Data <10% 10%-14% 15-19% 20%

Obesity Trends Among Canadian and U.S. Adults, 2000

Mokdad AH, et al. J Am Med Assoc 2000;284:13.Statistics Canada. Health Indicators, May, 2002.

No Data <10% 10%-14% 15-19% 20%

Obesity Trends Among Canadian and U.S. Adults, 2003

No Data <10% 10%-14% 15-19% 20%

Sources: Behavioral Risk Factor Surveillance System, CDCStatistics Canada. Health Indicators, June, 2004.

Pulmonary diseasePulmonary diseaseabnormal functionabnormal functionobstructive sleep apneaobstructive sleep apneahypoventilation syndromehypoventilation syndrome

Nonalcoholic fatty liver Nonalcoholic fatty liver diseasediseasesteatosissteatosissteatohepatitissteatohepatitiscirrhosiscirrhosis

Coronary heart diseaseCoronary heart disease

DiabetesDiabetes

DyslipidemiaDyslipidemia

HypertensionHypertension

Gynecologic abnormalitiesGynecologic abnormalitiesabnormal mensesabnormal mensesinfertilityinfertilitypolycystic ovarian syndromepolycystic ovarian syndrome

OsteoarthritisOsteoarthritis

SkinSkin

Gall bladder diseaseGall bladder disease

CancerCancerbreast, uterus, cervixbreast, uterus, cervixcolon, esophagus, pancreascolon, esophagus, pancreaskidney, prostatekidney, prostate

PhlebitisPhlebitisvenous stasisvenous stasis

GoutGout

Medical Complications of ObesityIdiopathic intracranial Idiopathic intracranial hypertensionhypertension

StrokeStroke

CataractsCataracts

Severe pancreatitisSevere pancreatitis

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

Vertical Banded Gastroplasty

Vertical Banded Gastroplasty

• purely restrictive procedure

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

Vertical Banded Gastroplasty

• purely restrictive procedure

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

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

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

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

Vertical Banded Gastroplasty

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

Laparoscopic Adjustable Gastric Banding (LAP-BAND)

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

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

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)

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?

Case 1:

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

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

Gastric Prolapse

• If the diagnosis is suspected (or confirmed late radiographically) what should your next step be?

The band MUST be completely deflated

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

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

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?

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

Complications After Laparoscopic Adjustable Gastric Banding

 Study

O’Brien [47] Belachew[50] Dargent[49] Vertruyen[51] Weiner[76]

No. Patients 1120 763 500 543 184

Mortality  0 0 0 0 0

Postoperative complications

1.5 12.3 2.2 1.5 9

Slippage 13.9 8.0 5.0 4.6 2.2

Erosion 3 0.9 0.6   1.1

Port Complications 5.4 2.5 1.0 2.9 3.2

Reoperation Rate 25.3 10.5 6.6 4.2 6.4

Gastric Perforation 0 0.5 0.8 0 0

Pulmonary Embolism 0 0 0 0 0

Wound Infection 0.9 0.1 1.0   2.2

All numbers except number of patients represent percentages.Townsend: Sabiston Textbook of Surgery, 17th ed.

LAP-BAND: Complications

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

Roux-en-Y Gastric Bypass

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

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

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

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

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?

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

Case 2:

• Vitals: T=37.9, HR=115, BP=110/65, RR=20

• Physical examination: very unremarkable

Complications After LaparoscopicRoux-en-Y Gastric Bypass

 

Study

Schauer et al.[

17]

Higa et al.[

33]

Wittgrove and Clark[18]

DeMaria et al.[

69]

Papasavas et al.[70]

Gould et al.[80

]

Oliak et al.[

81]

No. Patients 275 1500 500 281 116 223 300

Mortality 0.36 0.2 0 0 0.86 0 1.0

Gastrointestinal Hemorrhage

1.1 1.1     1.7    

Leak 4.4 0.9 2.2 5.1 2.6 1.8 1.3

Pulmonary Embolism

0.73 0.2   1.1 0.86   0.67

Small Bowel Obstruction

1.1 3.5 0.6 3.3 1.03 1.8 1.67

Stenosis 4.7 4.9 1.6 6.6 3.4 5.4 2.0

Wound Infection 8.7 0.13 5.6 1.1   7.6 6.67

Incisional Hernia 0.73 0.27 0 1.8   0.9  

Marginal Ulcer       5.1      

Splenectomy 0 0 0 0 0 0 0

Pneumonia 0.36 0.07         0.3

All numbers except number of patients represent percentages. Townsend: Sabiston Textbook of Surgery, 17th ed.

“The Big 3” Complications You Do NOT Want to Miss

“The Big 3” Complications You Do Not Want to miss

• #1 ANASTOMOTIC LEAK

• #2 DVT or PE

• #3 BOWEL OBSTRUCTION (INTERNAL HERNIA)

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

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

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

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?

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

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

Early Complications:

• Anastomotic leak

• DVT and PE

• Intraabdominal bleeding

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

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

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

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

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

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

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

Late Complications:

• Adhesive bowel obstructions

• Stricture/stenosis

• Internal hernias

• Reflux

• nutritional deficiencies (iron, vitamin B12, vitamin D, and calcium most commonly)

Late Complications:

• Adhesive bowel obstructions

• Stricture/stenosis

• Internal hernias

• Reflux

• nutritional deficiencies (iron, vitamin B12, vitamin D, and calcium most commonly)

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))

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))

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))

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

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

Computed tomography patterns in small bowel obstruction after open distal

gastric bypass.(Srikanth et al. Obes Surg. 2004 Jun-Jul;14(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

Computed tomography patterns in small bowel obstruction after open distal

gastric bypass.(Srikanth et al. Obes Surg. 2004 Jun-Jul;14(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)

What about the white count?

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

How good is CT in picking up internal hernia after gastic bypass?

• 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 (n=43,

95%) or Petersen’s defect (n=2, 5%) (the area between the mesentery of the Roux-limb and the transverse mesocolon)

Results:

• 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 97%of the patients

Any patient with unexplained abdominal pain, regardless of laboratory or

radiologic findings, should be considered for surgical exploration

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

Take Home Points:

• Laparoscopic Adjustable Gastric Banding (LAP-BAND):

(1) Gastric prolapse through the band presents via food intolerance, vomiting, regurgitation, heartburn, and epigastric painDeflate the adjustable bandGastrograffin swallow studyConsult surgery and GI (re: URGENT gastroscopy)

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)

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

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

Take Home Points:

• Roux-en-Y Gastric Bypass: (4) Gastric dilatation presents with obstructive symptoms

CT to confirm diagnosis

percutaneous decompression via interventional radiology

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. 2000;4:598-605.

• 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. 2003;197:536-544.

• Comeau E, Gagner M, Inabnet WB, et al. Symptomatic internal hernias after laparoscopic bariatric surgery. Surg Endosc. 2005; 19:34-39.

• Eric D. Edwards, MD Brian P. Jacob, MD, et al. Presentation and Management of Common Post–Weight Loss Surgery Problems in the Emergency Department. Ann Emerg Med. 2006;47:160-166.

• Garza, Jr., et al. Internal hernias after laparoscopic Roux-en-Y gastric bypass. The American Journal of Surgery 188 (2004) 796–800

• Landen MD,, Bernard M, et al. Complications of gastric banding presenting to the ED. American Journal of Emergency Medicine (2005) 23, 368–370

• 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. 2004;239:433-437.

References

• Olbers T, Lonroth H, Dalenback J, et al. Laparoscopic vertical banded gastroplasty: an effective long-term therapy for morbidly obese patients? Obes Surg. 2001;11:726-730.

• Spivak H, Favretti F. Avoiding postoperative complications with the LAP-BAND system. Am J Surg 2002;184:31S- 7S.

• Srikanth MS, Keskey T, Fox SR, et al. Computed tomography patterns in small bowel obstruction after open distal gastric bypass. Obes Surg. 2004;14:811-822.

• Susmallian S, Ezri T, Elis M, et al. Access-port complications after laparoscopic gastric banding. Obes Surg. 2003;13:128-131.

• 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. 2004;14:381-386

• Townsend: Sabiston Textbook of Surgery, 17th ed.

• Yoffe B, Sapojnikov S, Goldblum C. Gastric wall necrosis following late prolapse after laparoscopic banding. Obes Surg 2004;14:142- 4.