Daniel A.P. Smith, MDBariatric Surgery Director
Essentia Health Park RapidsSt. Joseph’s Center for Weight Management
Bariatric and Metabolic Conference
Bariatric Surgical Complications and Recent Trends in Outcome Data
Slippage
Erosion
Esophageal & gastric pouch dilation
Port / tubing problems
Long‐term: high rates of reoperations & failures
Laparoscopic Adjustable Gastric Band Complications
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Band Slippage
Stomach up under band
Normal location
3SOURCE: www.lap‐surgery.com/images
gastric_band_comp05.jpg
SOURCE: Laparoscopic Bariatric Surgery, 2004; INABNET, MD; DEMARIA, MD; IKRAMUDDIN, MD
Symptoms:
• Partial Gastric Obstruction
Intolerance to solids
Heartburn
Dysphasia, vomiting
Coughing, wheezing
• Gastric Necrosis
Severe abdominal pain
Peritonitis, sepsis
Band Slippage
If present, considercase an emergency.}
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Band Slippage
Self‐emptying pouch.5 SOURCE: lapbandfollowup.co.uk
Slipped band, changed angle.SOURCE: lapbandfollowup.co.uk
Band Slippage
6SOURCE: lapbandfollowup.co.uk
Slipped band with swallow. Note pouch and horizontal band.SOURCE: lapbandfollowup.co.uk
Treatment:
1) Deflate band
2) UGI X Ray
3) Surgery• Repositioning stomach around band
• Removal and/or replacement
Gastric Necrosis:• Laparotomy with gastric resection
& band removal
Band Slippage
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Symptoms:
• Usually insidious onset
• Weight gain/loss of satiety
• Band adjustments ineffective
• Port infection
• Workup suspected erosion
• UGI ‐ contrast around band
• EGD – band visible
Band Erosion
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Band Erosion
Endoscopic view of band erosion into lumen of stomach.
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SOURCE: lapbandfollowup.co.uk
SOURCE: Laparoscopic Bariatric Surgery, 2004; INABNET, MD; DEMARIA, MD; IKRAMUDDIN, MD
Treatment:
• Removal of band system, usually laparoscopically
• Closure damaged gastric wall
• Can sometimes be removed using UGI endoscopy
• Later band replacement or conversion to gastric bypass
Band Erosion
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Normal location.
Esophageal & GastricPouch Dilation
Esophageal dilation.SOURCE: Bariatric Times. 2010; 7(11):8‐12
PONCE, MD & SMITH, DO, FACOS
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SOURCE: www.lap‐surgery.com/images/
gastric_band_comp05.jpg
Symptoms:
• Dysphasia, vomiting, severe reflux
• Pneumonia/wheezing
Workup:
• UGI X Ray
Esophageal & GastricPouch Dilation
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Treatment:
1) Deflate band
‐ if symptoms improve, slowly begin refilling after 2‐3 months
2) If deflation fails:
‐ Remove band
‐ Convert to gastric bypass
Esophageal & GastricPouch Dilation
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Malposition/flip of port
Leakage
Kinked tubing
Infection
Bowel obstruction/erosion around tubing
Port & Tubing Problems
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Europe: Emerging Theme from Late Follow-up Data
“LAGB has high re‐operation and failure rates”
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Re‐operation rate, 42%
Failure rate at 7 years, 57%
Conclusion: “With a nearly 40% 5‐year failure rate, and a 43% 7‐year success rate; LAGB should no longer be considered as the procedure of choice for obesity.”
OBESITY SURGERY 16:829‐35
Swiss (2006)
317 patients, 7‐year follow up
Europe: Emerging Theme from Late Follow-up Data
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Late complications, 40%
Failure rate at 10 years, 32%
Conclusion: “… the high complication, re‐operation, and long‐term failure rates lead to the conclusion that the LAGB should be performed in selected cases only...”
OBESITY SURGERY 20:1206‐14
Swiss (2010)
167 patients, bands placed 1998‐2009
Europe: Emerging Theme from Late Follow-up Data
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Late complications, 32%
Overall band removal, 30%
Conclusion: “LAGB should no longer be considered as the procedure of choice for obesity.”
SURG OBES RELAT DIS 6:51‐3‐26
Paris (2010)
907 patients, mean follow up 8.4 years
Europe: Emerging Theme from Late Follow-up Data
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Re‐operation rate, 53%
Only 54% had original band in place
Conclusion: “Long‐term…, gastric banding has a high complication and band‐loss rate.”
OBESITY SURGERY 20:1078‐85
Austria (2010)
276 patients, at least 9 years post‐op
Europe: Emerging Theme from Late Follow-up Data
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1/3 of patients underwent removal of band due to complications or inadequate weight loss
Only 1/3 of patients had functioning band after a mean of 10 years
Conclusions: “… an enormous heritage of re‐do bariatric surgery is in the making…
“… one should wonder whether the gastric band still has a future….”
SURG OBES RELAT DIS 6:51‐5‐26
Netherlands (2010)
201 patients, mean follow up 10 years
Cleveland Clinic – Florida(Obesity Surgery, 2010, 6: 391‐398)
Conclusion:
“LAGB appears to have a high incidence of complications requiring revisional surgery
and/or band removal.”
Emerging U.S. Data Regarding Adjustable Gastric Banding
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Emerging U.S. Data Regarding Adjustable Gastric Banding
American Journal of Medicine (2008):Department of Internal Medicine review of data comparing LGBP and LAGB. *
Conclusions:
1. “In comparative trials, weight loss, resolution of obesity related co‐morbidities, and patient satisfaction all are greater for LGBP than LAGB.”
2. “Despite widespread marketing of gastric banding, no subgroup has been identified in whom LAGB performs better than LGBP.”
* Am. J. Med. (2008) 121:885
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Strictures gastrojejunostomy
Marginal ulcer
Small bowel obstruction
Leaks
Cholelithiasis
Thromboembolic
Nutritional deficiencies
Complications of Gastric Bypass
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Symptoms• Usually within 12 weekspost‐op
• Progressive food intolerance – first solids, later liquids
• Usually not much pain, but usually dehydrated
Strictures at Gastrojejunostomy
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SOURCE: RadioGraphics
Treatment:• Vitamin replacement – especially thiamine
• Early thiamine deficiency:a) Wernicke's Encephalitisb) Motor & sensory neuropathy
• Rehydration• Endoscopic balloon dilation
• Surgery rarely needed
Strictures at Gastrojejunostomy
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Marginal Ulcer
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SOURCE: Bariatric Times. 2010; 7(1):23‐25 RACU, MD, MPH & MEHRAN, MD, FACS, FASMBS
Marginal Ulcer
Incidence: 3‐5%
Most present with:
• Bleeding
• Epigastric pain, radiates to back
• Nausea / emesis
Diagnosis:• EGD best
• Serum gastrin for refractory ulcer
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Medical management usually successful• Acid suppression:
• High dose PPI or H2 blocker• Carafate• Cytotec
• Stop smoking
• Stop NSAIDS• Surgery
• Perforation• Bleeding refractory to medical and endoscopic management• Chronic, intractable to medical management• Revise to very small pouch
Marginal Ulcer
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Potentially devastating complication:• Must diagnose & treat early
Incidence:• 3‐6 %• Most occur in first year
Causes:
• Internal hernia – most common
• Adhesions
• Incisional hernia
Small Bowel Obstruction
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Plain x‐ray will miss many obstructions:
• At biliopancreatic limb
• Proximal roux limb
• Volvulus through internal hernias
If any suspicion of SBO after gastric bypass, get CT of abdomen!
Small Bowel Obstruction
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Small Bowel Volvulus
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SOURCE: Laparoscopic Bariatric Surgery, 2004; INABNET, MD; DEMARIA, MD; IKRAMUDDIN, MD
Volvulus, CT scan
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Volvulus, CT scan
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Volvulus, CT scan
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Volvulus, CT scan
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Volvulus, CT scan
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Treatment• Replace thiamine – banana bags plus extra thiamine
• Rehydration – don’t give dextrose until after thiamine is replaced
• NGT if distended Roux limb or if given PO contrast
• Early diagnostic laparoscopy
• Persistent or severe abdominal pain after gastric bypass needs diagnostic laparoscopy!
Small Bowel Obstruction
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Site
• Usually gastrojejunostomy
• Can also be at jejunojejunostomy or bypassed stomach
• Usually early post op
‐ 5 to 7 days
Leaks
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Presentation:
• Tachycardia, fever, tachypnea, decreased urinary output
• Increasing pain – abdomen, left shoulder
• Dyspnea, hiccoughs, pleural effusion
• Change in character of drain output
• Sense/look of “impending doom”
Workup:
• CT abdomen with oral contrast
• If sick, explore even if negative radiologic workup
Leaks
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Treatment:
• If well‐drained & no sepsis → NPO, TPN, stents, fibrin sealant
• Surgery:
• Gastrojejunostomy leaks: +/‐ closure, provide wide drainage
• jejunojejunostomy: may be present with pelvic pain – all require surgery
• Excluded stomach: close leak & drain
Leaks
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Increased incidence of gallstone formation during period of rapid weight loss
Presentation:• Acute cholecystitis
• Chronic cholecystitis
• Biliary dyskinesia
• Gallstone pancreatitis
• Sphincter of Oddi dysfunction
Cholilithiasis / Biliary Pain
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Signs & Symptoms:• Nausea• Pain – usually postprandial• RUQ, often radiating to back• Quite variable
Workup:• US, CCK stimulated HIDA scan
Treatment:• Cholecystectomy
• CBD stones/suspected SOD
• Transgastric ERCP
Cholilithiasis / Biliary Pain
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Low incidence/high mortality• 0.85 % / 40 to 60 %
Fatal PE occur sooner after surgery• Median interval for fatal PE was 3 days
• Median interval for non‐fatal PE was 10 days• Can occur up to months postoperatively
Maintain high index of suspicion
Workup ‐ Venous Duplex Scan, CT chest
Postoperative Thromboembolism
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Protein‐ lean body mass, 60+ g/day
Iron‐ Ferrous form• Microcytic anemia
Vitamin B12 and Folate• Megaloblastic anemia
• Neuropathy• Increased homocysteine
Thiamine – Don’t give dextrose to gastric bypass patientswith prolonged nausea
• Motor and sensory neuropathy
• Wernicke’s encephalopathy
Nutritional Deficiencies
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Calcium / Vitamin D
• Metabolic bone disease• ↓ urine calcium and vitamin D, ↑ PTH and Alkaline Phospatase
Zinc• Alopecia, dermatitis, diarrhea, emotional disorders
Pregnancy• Need to ↑ Folate to prevent neural tube defects
Nutritional Deficiencies
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Recent Trends
Bariatric SurgicalOutcomes
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Five-year Morbidity& Mortality
Condition/Disease
Bariatric Surgery(N = 1,035)
Nonsurgical Controls(N = 5,746)
% Change in Risk Surgeryvs.
Non‐surgical Treatment
Cancer 2.03% 8.49% ↓ 76%
Cardiovascular & Circulatory
4.73% 26.69% ↓ 82%
Diabetes 9.47% 27.25% ↓ 65%
Respiratory 2.71% 11.36% ↓ 76%
Musculoskeletal 4.83% 11.9% ↓ 59%
Infections Diseases 8.7% 37.33% ↓ 83%
Mortality 0.68% 6.17% ↓ 90%
Christou, 2004
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Effect of Bariatric Surgery on Mortality in Swedish Obese Subjects
NEJM, August 23, 200747
Long-term Mortality after Gastric Bypass Surgery
US Study
Mean follow‐up 7.1 years;
7,925 patients per group
Reoperation “Failure” = Removal or inadequate weight loss
Swiss (
Death due to disease 48 %
Death due to CV disease 48 %
Death related to diabetes 88 %
Death secondary to cancer 59 %
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NEJM Conclusion Statement
The Missing Link – Lose Weight, Live LongerGeorge A. Bray, MD
Conclusion statement:
… “Thus, the question as to whether intentional weight loss (bariatric surgery) improves life span has been answered, and the answer appears to be a resounding yes.”
NEJM, August 23, 2007
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Meta-analysis Bariatric Surgery
Procedure 30‐day mortality (%) Overall series
Banding 0.1 %
Gastric Bypass 0.5 %
Biliopancreatic Diversion
/Duodenal Switch1.1 %
*Buchwald et al, JAMA, 2004
Revisional Literature 1990‐2003*
11,720
Patients
30 day op
Mortality
= 0.55%50
ASMBS Center of Excellence
Hospital must perform at least 125 bariatric surgeries per year collectively, and the surgeon must have performed at least 125 himself and perform at least 50 per year.
The Center must also have a dedicated, multi‐disciplinary bariatric team that includes surgeons, nurses, medical consultants, nutritionists, psychologists, and exercise physiologists.
The Center must report long‐term patient outcomes and have an on‐site inspection to verify all data.
®
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Primary Outcome Data
From first 55,567 patients in ASMBS COE program
Variable N %
Total patients 55,567 100
30 day mortality 165 0.29
90 day mortality 196 0.35
SJAHS – Park Rapids Jan. 2000 – Jan. 2011
Aggregate Outcome Data of the first 176 applicants for full approval by SRC.
Pories, June 2006
N %
1,540 100
3 0.19
4 0.25
N %
2,715 100
4 0.15
5 0.18
SJAHS – Park Rapids Jan. 2000 – Jan. 2006
Patients from St. Joseph’s Center for Weight Management program
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30-day Operative Mortality Rates
Bariatric Surgery
ASMBS COE Average 0.29 %
SJAHS – Park Rapids 0.15 %
Other common major surgeries US Hospital Averages*
Elective aortic aneurysm 3.9 %
CABG 3.5 %
Esophageal resections 9.1%
Hip replacements 0.3 %
Pancreatic surgeries 8.3 %
*Dimick et a., JAMA, 2004
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More Recent Outcome Data
30‐day Mortality
N
22
%
0.09 %
90‐day Mortality
N
45
%
0.112
57,918Bariatric Surgeries
St. Joseph’s Center for Weight Management Outcomes, 2007‐Feb. 2011
30‐day Mortality
N
1
%
0.09 %
90‐day Mortality
N
1
%
0.09
1,106Bariatric Surgeries
ASMBS Bariatric Outcomes Longitudinal Database, June 2007‐May 2009
30‐day mortality
0.55 %
0.09 %
Meta‐analysis 1990‐2003
Most recent data, 2007‐2009
An 86 % drop in operative mortality!
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Thank you!
St. Joseph’s Area Health ServicesCENTER FOR WEIGHT MANAGEMENT
CATHOLIC HEALTHINITIATIVES
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