GASTROINTESTINAL COMPLICATIONS AFTER BARIATRIC SURGERY

Stanley J. Rogers, MD, FACSAssociate Clinical Professor of SurgeryUniversity of California San Francisco

UCSF DEPARTMENT OF SURGERY

Original Article

Long-Term Mortality after Gastric Bypass SurgeryTed D. Adams, Ph.D., M.P.H., et al

University of Utah School of MedicineSalt Lake City, UT

N Engl J MedVolume 357(8):753-761

August 23, 2007

Original Article

Effects of Bariatric Surgery on Mortality in Swedis h Obese Subjects

Lars Sjöström, M.D., Ph.D., et al.Swedish Obese Subjects (SOS) Study

Sahlgrenska University Hospital, Gothenburg, Sweden,

N Engl J MedVolume 357(8):741-752

August 23, 2007

Overview�� The prospective, controlled Swedish Obese The prospective, controlled Swedish Obese

Subjects study enrolled 4047 subjects who Subjects study enrolled 4047 subjects who either underwent bariatric surgery or either underwent bariatric surgery or received conventional treatmentreceived conventional treatment

�� The results of followThe results of follow--up for up to 15 years up for up to 15 years suggest that bariatric surgery for severe suggest that bariatric surgery for severe obesity is associated with longobesity is associated with long--term weight term weight loss and loss and decreased overall mortalitydecreased overall mortality

Sjostrom L et al. N Engl J Med 2007;357:741-752

Unadjusted Cumulative Mortality

Sjostrom L et al. N Engl J Med 2007;357:741-752

0.76 (95% CI, 0.59 to 0.99; P = 0.04)

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Diabetes Hyperlipidemia HTN Sleep apnea

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Resolution of Comorbidities – 22,094 patientsBariatric Surgery – A Systematic Review and Meta-analysis

Buchwald H. et al.JAMA. 2004; 292(14):1724-37

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Laparoscopic vs. Open Gastric BypassComplications – Review of 3464 cases

Podnos YD et al. Arch Surg 2003;138: 957-961

Malabsorptive Procedures

� Duodenal Switch/Biliopancreatic Diversion

� Highest rate of longterm complications related to malnutrition / diarrhea

� Death rate highest of any bariatric procedure at 1.1 percent

Gastric Banding

Current Most-Used Bariatric Procedures

Roux-en-Y GB

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Laparoscopic vs. Open Gastric BypassComplications – Review of 3464 cases

Podnos YD et al. Arch Surg 2003;138: 957-961

No difference

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Laparoscopic vs. Open Gastric BypassComplications – Review of 3464 cases

Podnos YD et al. Arch Surg 2003;138: 957-961

No difference

Lap > Open

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Laparoscopic vs. Open Gastric BypassComplications – Review of 3464 cases

Podnos YD et al. Arch Surg 2003;138: 957-961

No difference

Lap > Open

Open > Lap

UCSF Bariatric Program (2004-2008 - 680 patients)

0

20

40

60

80

100

120

140

July04-June05 July05-June06 July06-June07 July07-June0 8

Lap GBPOpen GBPLAGBLap SleeveLap Revision

N=143 N=178 N=164 N=196

Gastric Band & Gastric Bypass

Advantages DisadvantagesLap Band

-ease/safety MIS -higher failure rate-adjustability -device complications-less nutritional cons. -esoph dil./ erosion

Lap GBP-better weight loss -greater peri-op risk-enhanced satiety -longer learning curve-longer term studies -nutritional deficiencies

Complications after Bariatric Surgery

1. G-J Stricture 4%2. Bleeding 2%3. Fistula 1%4. SBO 2%5. Slippage6. Erosion7. Esophageal Dilation8. Tubing/Port Infections

GASTRIC BYPASS

GASTRIC BAND

13.7

3.91.5

6.9

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All Grades Grade I Grade IIa Grade IIb Grade III Grade I V

% C

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Complication of Lap Gastric Bypass (n = 404)

Grade I - events carrying “minor risks”; requiring only bedside interventionsGrade IIa - events requiring use of drug therapy or blood transfusionsGrade IIb - events requiring therapeutic intervention and without lasting disability Grade III - complications resulting in organ resection or lasting disabilityGrade IV - death

Campos GM, Ciovica R, Rogers SJ, Posselt AM, Vittinghoff E, Takata M, Cello JP. Archives of Surgery 2007; 142(10):969-75.

Campos GM, Ciovica R, Rogers SJ, Posselt AM, Vittinghoff E, Takata M, Cello JP. Archives of Surgery 2007; 142(10):969-75.

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All Grades Grade I Grade IIa Grade IIb Grade III Grade I V

LAP GBP

Open GBP

% C

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Complications of Lap Gastric Bypass(n = 404) v. Open (n=74)

*

**

Campos GM, Ciovica R, Rogers SJ, Posselt AM, Vittinghoff E, Takata M, Cello JP. Archives of Surgery 2007; 142(10):969-75.

Complications after Bariatric Surgery

1. G-J Stricture 2. Bleeding3. Fistula4. SBO5. Gastric Erosion6. Gastric Slippage7. Esophageal Dilation8. Tubing/Port Infections

GASTRIC BYPASS

GASTRIC BAND

Blackstone R, et al. J Gastrointestinal Surgery, 2007,

Blackstone R, et al. J Gastrointestinal Surgery, 2007,

Takata, et al. Obesity Surgery, 2007; 17:878-884.

Predictors of G-J Stricture after Gastric Bypass

Takata, et al. Obesity Surgery, 2007; 17:878-884.

At the multivariate level, only the use of a

21-mm circular stapler was identified as

an independent predictor of a GJ stricture:

(odds ratio 11.3; 95% CI 2.2-57.3, P=0.004).

Predictors of G-J Stricture after Gastric BypassPredictors of G-J Stricture after Gastric Bypass

Takata, et al. Obesity Surgery, 2007; 17:878-884.

Predictors of G-J Stricture after Gastric BypassPredictors of G-J Stricture after Gastric Bypass

Takata, et al. Obesity Surgery, 2007; 17:878-884.

Complications after Bariatric Surgery

1. G-J Stricture 2. Bleeding3. Fistula4. SBO5. Gastric Erosion6. Gastric Slippage7. Esophageal Dilation8. Tubing/Port Infections

GASTRIC BYPASS

GASTRIC BAND

In our series, the rate of bleeding complications w as similar for laparoscopic and open cases (2.1% vs .4%,respective ly, P=.69)

The main potential sources of bleeding are:

1. Intraluminal : G-J, J-J, and gastric remnant staple lines

2. Intraperitoneal : Mesenteric staple line and dissection planes.

3. Abdominal Wall: Trocar insertion sites

Bleeding after GBP

Campos GM, Ciovica R, Rogers SJ, Posselt AM, Vittinghoff E, Takata M, Cello JP. Archives of Surgery 2007; 142(10):969-75.

NS

Mehran A, et al. Obesity Surgery 2003; 13:842-47Jamil LH, et al. Am J Gastro 2007;102:1–6

Bleeding after GBP – Proposed Algorithm

Suspected Bleed-Melena/UGI Bleed -Drain output-Drop HCT -Tachycardia/Low BP

Resuscitat., Serial HCT, Stop HeparinCheck coags, Type & Cross

Stop Bleed

Transfuse

Stop Bleed

Intubate and Return to O.R

Intra-luminal Intra-peritoneal

EGD/Enteroscopy Laparoscopy

GJ / JJ Bleed

Epi / Heater Probe 80% successful

Laparoscopy

Rem. Bleed IP Bleed

Remnant Gastrectomy

Bleeding after GBP – How to treat?

• While bleeding from the GJ may manifest as hematemesis and permit endoscopic intervention,

bleeding from the other sources may pose a diagnost ic and treatment challenge .

• The decision to transfuse , use therapeutic endoscopy or re-operation is based on a combination

of clinical factors and local experience .

• Post-operative protocols should actively pursue this diagnosis

Bleeding after GBP

Campos GM, Ciovica R, Rogers SJ, Posselt AM, Vittinghoff E, Takata M, Cello JP. Archives of Surgery 2007; 142(10):969-75.

Gastrointestinal Fistula / Leak after GBP: Literature

* Anatomotic leaks - 0.8 to 7%

* Suggested to be the most common preventable

cause of deathafter pulmonary embolism

* Leak-associated mortality ranging from 6% to 17%.

GI Fistula after GBP – Routine UGI Series??

7/634 = 1.1%Carter J, Tafreshian S, Campos GM, Tiwari U, Herbella F, Cello JP, Patti MG, Rogers SJ, Posselt AM.

Surgical Endoscopy 2007; 21:2172-77.

GI Fistula after GBP – Routine UGI Series??

Carter J, Tafreshian S, Campos GM, Tiwari U, Herbella F, Cello JP, Patti MG, Rogers SJ, Posselt AM. Surgical Endoscopy 2007; 21:2172-77.

Carter J, Tafreshian S, Campos GM, Tiwari U, Herbella F, Cello JP, Patti MG, Rogers SJ, Posselt AM. Surgical Endoscopy 2007; 21:2172-77.

SBO after GBP

• Incidence – 2%

• Sudden onset abdominal pain

• CAT Scan

• Internal Hernia

• Refer to bariatric surgeon

Campos GM, Ciovica R, Rogers SJ, Posselt AM, Vittinghoff E, Takata M, Cello JP. Archives of Surgery 2007; 142(10):969-75.

Complications after Bariatric Surgery

1. G-J Stricture2. Bleeding3. Fistula4. SBO5. Gastric Erosion6. Gastric Slippage7. Esophageal Dilation8. Tubing/Port Infections

GASTRIC BYPASS

GASTRIC BAND

Complication – Band / Port Erosion

Early Complications Within 30 Days After Operation

Weber M, Kuller M, Bucher T, et al. Ann Surg, 2005

Late Complications Within 30 Days After Operation

Weber M, Kuller M, Bucher T, et al. Ann Surg, 2005

Weber M, Kuller M, Bucher T, et al. Ann Surg, 2005

Late Complications Within 30 Days After Operation

BAND GASTRIC BYPASS

N 100 100

Female 71% 71%

Age (median, range) 47 (15-70) 46 (19-65)

BMI (median, range) 45 (36-66) 45 (36-67)

Type 2 Diabetes 34% 34%

Race, n 71% Caucasian 71% Caucasian

Operative technique Laparoscopic, 100% Laparoscopic, 99%

Conversion open, 1%

LOS, median, range 2 (1-5) 3 (2-8)

Results Results –– Band Versus Gastric BypassBand Versus Gastric Bypass

Rabl C, Palazzo F, Rogers S, Posselt A, Cello J, Campos GMLaparoscopic Gastric Bypass is as Safe as Laparoscopic Gastric Banding and Provides Superior Weight Loss Outcomes.

Obesity Surgery. 18 (4): 459, 2008.

Results Results –– ComplicationsComplicationsBAND GASTRIC BYPASS

Complications 8% 11%

Early Complications 3% 6%

Wound infectionTrocar site bleedingUrinary Retention

Wound infection (n=3)G-J Bleed

LUQ abscessPneumonia

Late Complications 5%�Port Malfunction�Port Erosion�Severe dysphagia�Band Erosion

�Conversion to Bypass

5%G-J Ulcer

G-J Strictures (n=2)G-J Bleed

�Small Bowel Obstruction

Re-operation 7 1

P =0.63

P =0.06

No Mortality

P =0.49

Rabl C, Palazzo F, Rogers S, Posselt A, Cello J, Campos GMLaparoscopic Gastric Bypass is as Safe as Laparoscopic Gastric Banding and Provides Superior Weight Loss Outcomes.

Obesity Surgery. 18 (4): 459, 2008.

Laparoscopic Conversion Band to BypassLaparoscopic Conversion Band to Bypass

1 2

3 4

�� Lap Gastric Bypass has similar rates of Lap Gastric Bypass has similar rates of

early and late complications compared to early and late complications compared to

Lap BandLap Band

�� There was a strong trend to more reThere was a strong trend to more re--

operations in the Lap Band groupoperations in the Lap Band group

ConclusionsConclusions

Rabl C, Palazzo F, Rogers S, Posselt A, Cello J, Campos GMLaparoscopic Gastric Bypass is as Safe as Laparoscopic Gastric Banding and Provides Superior Weight Loss Outcomes.

Obesity Surgery. 18 (4): 459, 2008.

ConclusionsConclusionsWith the benefit of superior weight loss , greater resolution of type 2 DM , and similar rate of complications (and possibly lower rate of re-operations) , Lap Gastric Bypass may have a similar or lower risk-benefit ratio compared to Lap Band.

This information should be available when informing patients about surgical options available to treat morbid obesity.

Rabl C, Palazzo F, Rogers S, Posselt A, Cello J, Campos GMLaparoscopic Gastric Bypass is as Safe as Laparoscopic Gastric Banding and Provides Superior Weight Loss Outcomes.

Obesity Surgery. 18 (4): 459, 2008.

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