Bariatric Surgery Update - PowerPoint Presentation

1. Bariatric Surgery Update“The Remainder”Subiaco HospitalMay 21st 2019Alan Thomas (MB, ChB, BSc (Hons), FRCSI, FRACS, Dip Med Law)

2. AgendaNew theoriesNew procedures, reoperationsNew and “old” complicationsConclusion and thoughts

3. Biome theory – uncontrolled calorie absorptionEvery animal has inherent ability to control weight½ potatoe chip a day = 1Kg/yrWho become obeseCertain humans, pets, farm animals, human food carrionsObesity is a diseaseAbnormal condition that negatively affects the structure or function of part or whole organism. A dysfunction of the body’s homeostatic processes

4. Pathophysiology?Change in the ultrastructure of the brush border (insecticides, pesticides, preservatives, colourings, emulsifiers) and in the composition of bacteria in the small and large bowel (high fructose corn syrup)Autoimmune, allergies, neurotransmitters

5. Capped energy expenditureExercise does not cause weight loss in the obeseWeight loss is a result of radical calorie restriction – needs to be safeThermogenic adaption temporized for the first 6-9 months post surgery - leptin

6. Capped energy expenditure

7. Restrictive and MalabsorptiveProbably not!The sleeve probably works by increasing the speed of emptying of the stomach thereby effectively bypassing the first part of the intestineEmptying signals not fillingBlockage of sleeveTechnical aspect of procedureMinimizer rings

8. Minimizer ring

9. Restrictive and MalabsorptiveProbably not!The bypasses work by food reaching certain parts of the intestine quickly thus causing hormonal changes and up/down regulation of receptorsShort gut only issue if < 1.2M of intestine14” x 4” operation had failures to loose weightMore that is bypassed more deficiencies and potential problems

10. Jejunoileal bypass14 inches4 inches10% did not achieve significant weight loss!Recidivism!

11. Determinants of weight loss after surgeryGenetic variation (can’t choose your family!)Technical performance (you can choose your surgeon!!!)Total calories ingested (Patient control)Quality of calories ingested (Patient control)

12. Front line operations in AustraliaSleeve gastectomy (without minimizer or band!)“Laparoscopic Adjustable gastric band”Roux en Y or single anastamosis gastric bypass

13. Lesser known/revision proceduresMangenstrasse and MillGastric transit bipartition (Roux or single)SADI, SADI-S, SIPS, SIPS-SDuodenal SwitchEndoscopic sleeve gastroplasty (ESG)

14. Mangenstrasse and Mill“Almost a sleeved stomach”No stomach removedPrecursor of the sleeve gastrectomy

15. Gastric transit bipartition300 cmsSleeved stomachIleum anastamosed to the antrumIleo ilial anastamosis 80 cms from the IC valve

16. SADI, SADI-S, SIPS, SIPS-SSleeved stomach300 cms1st part of duodenum transected and stapled shutDuodeno ileal anastamosis

17. Duodenal switchWide sleeve stomach 60F1st part duodenum transected and stapledIleo ilial anastamosis at 80cms from IC valve220 cmsDuedeno ileal anastamosis

18. Revision planSleeve is the standard revision for a bandOmega loop, DS – NORoux en Y – uncontrolled reflux and heartburnBipartition, SADI, – massive weight and metabolic syndrome in exceedingly compliant patient

19. Overstitch deviceStoma reductionPouch reductionClose perforations

20. ESG

21. ESG

22. Orbera intra gastric balloonSaline filledEndoscopy to place and remove

23. Reshape Duo Saline filledEndoscopy to place and remove

24. Obalon and Elipse swallowed balloonsGas filled balloonEndoscopy to removeSaline filledSelf deflating in 4 months

25. Aspire Assist

26. Transpyloric shuttle

27. New and “old” problemsAcute surgical problemsChronic surgical problemsMedico psychological problems

28. Acute post operative surgical problemsAfter lap bariatric operation if patient still requiring analgesia 2-3 days after discharge there is something wrongTemperature and/or tachycardia after discharge is worryingCRP > 50 at home there is something wrongHave low threshold to order a CT scan. IV and (oral contrast in dept. about 100mls only)Risk of radiation grossly overstatedMorbidly obese may have few clinical signs

29. Acute surgical ProblemsInternal hernias in Roux or single anastamosisSevere pain +- vomiting CT scan, no air fluid level on plain filmsStomal ulcers causing pain, bleeding and perforations Smokers, no Asprin or NSAID’sNeed high dose PPI and Sucralfate

30. Chronic surgical problemsAny major query with a band let all fluid outPreferably with Huber needle - safe Worsening volume reflux and heartburn after bandThink proximal dilatation, oral contrast CT is bestRefer for endoscopy with bariatric surgeon endoscopistEpigastric pain increased hunger may indicate erosionRefer for endoscopy and removal (?endoscopically)Same symptoms in any patient with minimizer is an erosion irrespective of procedure (more common as staple line contact)

31. Chronic surgical problemsObstruction causes dilatation

32. Chronic surgical problemsVolume reflux and heartburn after sleeve or bypass patientsAbout 10% of my patients need PPI’s early onIf not controlled by PPI consider technical issue especially if early or revision or not lost weightNocturnal reflux may be hiatal hernia or retained pouchSilent aspiration more common that thoughtDifficult to diagnose hiatal hernia, cant “J” scope, CTTechnical aspects need a knowledge of procedure and its endoscopic appearanceHiatal hernia repair and pouchectomy difficult but should precede any other operation. May need 2 surgeon op with simultaneous endoscopy

33. Hiatal herniaCameron’s ulcerLeft lobe of liverStomachHiatus

34. Sumped proximal pouchBand outlineFood festeringAspiration risk

35. Staple line leak in sleeveStaplesSuture from attempted repair by surgeon

36. Staple line leak in sleeveLedge from missed or undissected tunnel from band

37. VBG a cautionary tailyou can not be an expert at everything, refer to a surgeon that performs the operations for an endoscopy

38. VBG a cautionary tailyou can not be an expert at everything, refer to a surgeon that performs the operations for an endoscopyFailed to visualise here

39. Salvage sleeve gastrectomy, splenectomy, distal pancreatectomy, left hemi colectomy, partial diaphragmatic resection and left segment ii and iii hepatectomy

40. Medico psychological problemsFe def/ Vit B12 anaemia common 3-5yrs post bariatric surgery. sleeve< Roux< SIPS<DSOdd vitamin deficiencies will be occurring as more extensive operations performedIncreased falls and #, car accidents and sudden deaths after RouxAlcohol addiction after Roux 8-10% at 2-10 yrs (5x others)Rat experiment too drink alcoholASMBS guidelines Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients

41. Summary 1Bariatric procedures are probably not restrictive or malabsorptiveFunction depends on accurate performanceAccurate performance depends on care, attention to detail and timeSurgery is only worthwhile if low complicationsComplications will occur

42. Summary 2Aggressively investigate and refer potential complicationsEvery patient needs multivitamin supplementation lifelongSuspected complications should have specialist bariatric and endoscopic assessmentLong term support medically and psychologically is requiredThe answer to the treatment of morbid obesity is often surgery; Your BMI40 pt. has under a 0.5% chance of loosing weight without surgery. The answer to recidivism needs careful reassessment

43. Summary 3Surgeons get paid to operate and reoperateAdded procedures are also attract medicare feesIf a surgeon’s numbers are so high ask them how many do they perform in a day (or at the same time- dual lists) and how much time do they or can they give to each patient?There is a 10 fold difference in complication rates in WA!Surgery like your patient’s food choices should be like a quality well prepared meal without the trimmings not a fast food production line! Patients deserve betterTHANK YOU FOR YOUR TIME!!