Role of Gastroenterologist in managing obesity - PowerPoint Presentation

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Role of Gastroenterologist in managing obesity

Amir Hossein Faghihi Kashani, MDAssociate Professor, Iran University of Medical SciencesColorectal research centerMinimally invasive research center

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Outline

IntroductionPre-operative managementPost-operative managementAdvance in the Endoscopic management of obesity

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Introduction

Obesity has become a major public health problem Obesity is associated with various co-morbidities with negative impact on health condition and quality of lifeAs rates of obesity raises, so does the burden of other health complications and health care costs DiBaise J , Gastroenterol 2013 ; 7(5) ; 439-449

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Despite the fact that historically gastroenterologists were mainly involved in the pre-operative and post-operative care of patients undergoing bariatric surgery, nowadays gastroenterologists play an important role in evaluation and management of a variety of GI symptoms arising status post bariatric surgery

Gastroenterologists are also involved in the primary treatment of obesity Introduction

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Introduction

At the moment, more than 1 in 3 adults are considered to be obese in the U.S. and it has been estimated that more than half of the U.S. adult population will be obese in 2030.

The prevalence of BMI>25 Kg/m2 is about 57% in Iranian females and 42.8% in Iranian males. Sturm R, J.

obes

. 2012 ; 159

Janghorbani

M, Obesity 2007 ; 15; 2797-2808

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Obesity and it’s association with GI symptom

Obesity ( BMI ) and it’s association with GI SymptomsSigns and symptoms

Odds Ratio95% CIAbdominal pain OR = 2.65

1.23 – 5.72

Gastroesophageal reflux

OR : 1.89

1.7 - 2.09

Chest pain / heart burn

OR : 1.74

1.49 – 2.04

Diarrhea

OR : 1.45

1.26 – 1.64

Retching

OR : 1.33

1.1 – 1.74 Incomplete evacation OR : 1.32 1.03 – 1.71

Eslick

GD,

Obes

. 2012 ; 13(5)b; 469-479

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Gastrointestinal and liver disorders associated with obesity

GERD and it’s complications 2.5 fold increase:Regurgitation , Erosive esophagitis , Esophageal adenocaAnatomic and physiologic obesity – related changes:Reduced LES pressureIncreased transient LES relaxationPresence of a hiatal herniaIncreased intragastric pressure and presence of esophageal dysmotility

Friedenberg FK, Gut 61 2012 ; 337-343

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BMI > 30 Kg/m

2 is associated with about threefold increase in gallbladder stone formationBMI > 45 Kg/m2 is associated with a sevenfold increase in risk The prevalence of NAFLD in the obese patients is 13% in Japan and 30% in the U.S. (including 90% in the super obese individuals)

Gastrointestinal and liver disorders associated with obesity Stinton LM , Gut Liver 2012 ; 6(2) ; 172-187 Kant P, 2011 ;

Gastroenterol

8(4) ; 224-238

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Overall, RR Of CRC is 1.4 in obese patients compared to those with normal weight

BMI >30 Kg/m2 had a RR of 1.78 for diverticulitis and 3.19 for diverticular hemorrhage compared to those with a BMI <21 Kg/m2 Gastrointestinal and liver disorders associated with obesityDiBase J , Gastroenterol , 2013; 7(5); 439-451

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Pre -operative endoscopy

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Pre-operative endoscopy

Munzor R, Obesity Surg. 2009 ; 19 ; 427-31

UGIE findings

Prevalence

Hiatal hernia

8.6 – 40%

Esophagitis

9 –

30.8

%

Shatzki

ring

3%

Barrett’s esophagus

1 -3 %

Esophagus

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Gastric and Duodenum

Pre-operative endoscopy

UGIE findings

Prevalence

Gastritis

21 –

36.2

%

Polyp

0.6 – 5 %

Ulcer

1 –

3

%

GIST

0.7 %

Duodenitis

0.6 – 8 %

DU

0.7 –

7.5

%

Zeni

T,Obesity

surg. 2006 ; 16; 142-144

D’Hondt

M,

Acta

chirBelg

2013 ; 113(4) ; 249-253

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Gastric biopsy

Pre-operative endoscopy

Pathology findings

Prevalence

Inflammation

65.1 – 72.2 %

H pylori

37.5 – 53.2 %

IM or atrophy

11.1 – 16.7 %

Dietz J,

Arq

Gastoentrol

2012 ; 52-55

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According to the Sydney system , gastric mapping from 230 patients was done

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Findings

PercentageEsophagitis17.2Erythematous gastritis

30Erosive gastritis20

Peptic ulcer

Antrum

8.2

Incisura

0.9

Body

0.9

Gastric/duodenal

Polyp

2.7

Duodenal

ulcer8.2Duodenitis10.9

Endoscopic findings of 110 cases with morbid obesity

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Anatomic place

Acute gastritisChronic gastritisActive gastritisCardia47.396.438.2

Greater curvature of Corpus43.697.239.1

Lesser curvature of Corpus

51.8

96.3

46.3

Incisura

60.9

96.4

61.9

Greater curvature of

Antrum

62.8

98.2

59.1Lesser curvature of Antrum59.198.260

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Anatomic place

Intestinal metaplasiaAtrophyH. PyloriEsophagus0.9-

-Cardia0.91953.6

Greater curvature of Corpus

0.9

0.9

56.4

Lesser curvature of Corpus

4.5

4.5

56.4

Incisura

2.7

6.4

59.1

Antrum14.516.360Percentage of different pathologies findings in 110 morbid obese patients (Gastric mapping)

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ASGE*

and ASMBS** recommendation :The decision to perform preoperative endoscopy should be individualized in patients scheduled to undergo bariatric surgery after a thorough discussion with the surgeon , taking in the type of bariatric procedure performed * American Society for Gastrointestinal Endoscopy ** American Society of Metabolic and Bariatric surgery Gastrointestinal Endoscopy 2015; 81(5) ; 1063-1072

Pre-operative endoscopy

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Post operative endoscopy

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Vertical

Banded Gastroplasty VBG

Surgery for Obesity Restrictive

and

Malabsorptive Procedures

Adjustable Gastric

Band

AGB

Sleeve

Gastrectomy

SG

Biliopancreatic diversion

BPD

Duodenal

Switch

DS

Roux-en-Y Gastric

Bypass

RYG

Surgery

for Obesity

Restrictive Procedures

Gastric

Imbric

a

tion

GI

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Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic and Bariatric Surgery (AACE/TOS/ASMBS) recommendations of periodic laboratory tests post bariatric surgery

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American Association of Clinical Endocrinologists recommendation for replacement of calcium and vitamin D

postbariatric surgery

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GI signs and symptoms prompting endoscopy after surgery

Upper GI symptoms:Abdominal pain Nausea , vomitingDysphagiaBloatingHeartburnDumping syndromeDiarrhea

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Anemia / bleeding

Weight regainExcessive weight lossGI signs and symptoms prompting endoscopy after surgery

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GI complications prompting endoscopy after surgery

Marginal ulcerAnastomotic leaks Fistulae and StricturesBand stenosis, Erosion and Slippage

BezoarsCholedocholithiasis

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Anastomotic ulcer

Most occur about 3 months post bariatric surgeryOccur in 3 – 20 % of patients undergoing RYGBUsual presentation is epigastric pain, but nausea and vomiting may accompany pain or be the sole presenting symptomsUlcer on the jejunal side require careful endoscopic exam to detect the marginal ulcer Chaar

M. J obes-loss Medic 2015 ; 1(1) 1-6

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Marginal Ulcer

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Anastomotic ulcer, diagnosis:

Gastrografin In the first 2 weeks post-operationEndoscopy can be safeUBT, pouch biopsy may not be reliableSerology may be better to detect infection and fecal H pylori Ag to confirm eradication

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Anastomotic ulcer, management:

In patients with RYGB:Soluble PPI or capsule broken open taken twice daily and tapered over 6 months Sucralfate solution at 1g 4 times daily concurrently when possible *Bile acid bindersEradicate H pylori Rare cases require reoperation

Kumar N. Clinical Gastroenterology 2013 ; 11; 343-353

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Smoking cessation

Control of diabetesNSAID should be discontinuedVisible non-absorbable sutures should be extractedAnastomotic ulcer, management: Kumar N. Clinical Gastroenterology 2013 ; 11; 343-353

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Gastrointestinal bleeding

More common in RYGB (1.9 % of cases)Higher bleeding rate in LRYGB than open RYGBAnastomotic bleedingPouch – enteric anastomosisJejuno – jejunostomy anastomosis Peptic ulcer disease

Gastric pouchGastric remnantDuodenum

Rabl

C,

2011,

Obes

surg

2011 ; 21 ; 413-420

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Gastroscopy

Device – assisted enteroscopy Higher risk during push enteroscopyLaparoscopically – assisted endoscopy or surgeryGastrointestinal bleeding

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Dual therapy is preferred

Endoclips, epinephrine injectionElectrocautery should be avoided at fresh staple linesHemostatic powders may be another optionAngiographic intervention can be considered however , the resulting ischemia is a concern in patients with new anastomosis Gastrointestinal

bleeding TreatmentKumar N. Clinical Gastroenterology 2013 ; 11; 343-353

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Stomal Stenosis

A result of malfunction of prosthetic devicesA result of stricture formationOccurs in 5 – 12 % of patients undergoing LRYGBEarly satiety, nausea, dysphagia, post prandial retrosternal or abdominal pain Stricture arbitrarily defined as inability to pass standard 9.5 mm gastroscope

across anastomosis May be early complication (4-10 w) or late complication (Months – Years)Azagury

D, Tech

Gastrointest

Endosc

2010 ; 12; 124-129

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Endoscopic balloon dilation

Short through the scope dilation balloon, with or without guidewireStart 4 w post-surgical operationRepeat every 2 -3 w 2 – 3 procedureDilation to 15 mmSavary dilator

Elecrosurgical incisionStomal

Stenosis

treatment

Peifer

KJ ,

gastrointest

Endosc

2007; 66; 248-252

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Leaks and fistulas

Mechanical: within the first 2 days post operativelyIschemic: at 5 – 6 days post operatively

Type of surgical operationIncidence of Leaks and FistulaORYGB

1.7 – 2.6 %

LRYGB

2.1 – 5.2 %

SG

up to 5.1 %

Kumar

N,

Clin

Gastroenterol

Hepatol. 2013;11(4):343-353.

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Other than

PTE, are the most serious life threatening complications after bariatric surgeryLeaks are associated with a mortality rate of 6 % – 14.7 %One study found that mortality was 9% after leak incidents at the GJA, but 40% after leak incidents at the JJAMortality is higher after open RYGB than LRYBG

Lee S, Gastrointest surg 2007 ; ;11;708-713

Leaks and fistulas

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Increased drain output

CRP > 22.9 mg/dL 2 days after surgery sensitivity 100 %Leaks and fistulas, diagnosis:

Warschkow R, Gastrointest surg 2012; 16: 1128-1135

Sign

s and symptoms seen in patients with Leaks and Fistula

Incidence

Tachycardia

72 – 92

%

Nausea , vomiting

81 %

Fever

62%

Leukocytosis

48 %

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As a result of surgical management, morbidity up to

50 %, mortality 2 -10 % and conversion rate to open surgery 48 % , initial management moved toward conservation or endoscopic treatmentLeaks and fistulas

ManagementDapri G,

Surg

obes

, 2009; 5:675-683

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Dilation of distal stenosis

Exclusion techniques such as stent placementLeaks and fistulas can be closed with clips , suturing devices or sealantsVacuum – assisted drainageLeaks and fistulas, Management techniques:

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Stent placement

Covered self expanding metal stents SEMSPartially covered self expanding metal stents Covered self expanding plastic stents SEPS are usually left in place for 2 – 4 w Successful leak closure after stent removal 87.8 %Kumbhari

V, Endoscopy 2015;31:359-367

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Clips

should be deployed perpendicular to the long axis of the defect Starting at the either edge of defect and meeting at the centerOver the scope clips OVESCO Endoscopy AGClosure success rate 72 – 91 %

Endoscopic clips

Surace

M,

Gastrointest

Endosc

2011; 74:1416-1419

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Clips were applied over the

endoloop viatwo-channel endoscopy.

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Fibrin

Lippert et al reported a series of 52 patients with GI fistula, 36.5 % had sealing with fibrin alone and 55.7 % were cured with additional endoscopic therapy Cyanoacrylate

Sealants

Lippert E,

Colorectal

Dis

2011; 26:303-311

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Stomaphy

X suturing systemEndocinchApollo Overstitch

Endoscopic suturing techniques

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An emergent method for treatment of post-surgical leak

Vacuum - assisted sponge closure

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Endoscopic vacuum-assisted sponge device. Reprinted from Gastrointestinal Endoscopy

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Staple and suture material are common finding at endoscopy in patient who have undergone

GI surgeryAfter RYGB, remnant surgical material may contribute to marginal ulcer, stomal stenosis, unexplained abdominal pain or dysphagia Removal of material by using forceps and endoscopic scissors has improved symptoms in as many as 87 % Removal of material should only be considered after maturation of anastomosis

Foreign body complications

*

Ryou

M,

Surg

obes2010;6:526-531

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Food bezoars can occur in weight loss surgery, most commonly after gastric banding

They may form within the first months after surgery or present late with symptoms of nausea, vomiting and dysphagia Bezoars can be diagnosed and treated endoscopicaly with fragmentation and removal

Bezoars

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Bariatric surgery is effective in achieving durable weight loss, but weight regain post-operatively is a common and significant problem

Most experince weight loss Initial weight loss after bariatric surgery is often dramatic, a weight plateau is typically achieved in 1 – 2 years Approximately 20% of patients who don’t lose 50% of excess weight within one year of surgery 30% of patients experience weight regain by two years post operatively and 63.6% regain within 4 years

Weight regain and Dilated

Gastrojejunal

Anastomosis

Dayyeh

A,

Clin

Gastroenterol

2011;9:228-233

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As a result of postoperative changes in

neuroendocrine – metabolic regulation Decreased satiety Larger pouch size Gastrogastric fistula

Weight regain and Dilated Gastrojejunal Anastomosis

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Endoscopic

sclerotherapy by injecting Morrhuate sodium around GJA 2ml is injected circumferentially around the GJA, every 3 – 6 months, totally 10–30 ml until the GJA

measures less than 12 mm Endoscopic sutured revision of dilated GJA and gastric pouch (Bard,

endoCinch

)

Multi channel incisionless operating Platform

USGI Medical

(San Clemente CA

)

with full – thickness plication.

The

Apollo

OverStith

can place full – thickness by using a cap – based suturing system that fits over a standard double – channel endoscope

Weight regain and Dilated

Gastrojejunal

Anastomosis,

Endolumial

therapy:

Kumbhari

V, Endoscopy 2015;31:359-367

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Endoscopic management of obesity

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Advances in the Endoscopic management 0f obesity

Despite the clear benifits of bariatric surgery , There are some pitfulls - Significant morbidity - Substantial costs - Not available to patients with BMI < 35

, even if clinically significant comorbidities durability of bariatric surgery has been questioned with weight regain being not uncommon

Magro

D, Obesity surgery , vol. 18 no 6 , pp 648 – 651 , 2008

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Endoscopic Modalities in the treatment of obesity

Space occupying devicesGastric restrictive methodsMalabsorptive endoscopic proceduresRegulating gastric emptyingOther therapies

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Space Occupying Devices

Initial balloons 1 - Garren – Edwards gastric bubble air filled polyurethane balloon approved by FDA in 1985 but with drawn II - Bio Enterics Intragastric

balloons BIB , avalable in 1991 , saline /

methylene

balloon ,

400 – 700

ml has been used in

in those with a BMI of

40 kg/m

2

- Pretreatment to bariatric surgery , reducing anesthetic risk

- In patients with lower BMI that have contraindication to bariatric surgery

Behary

J, Gastroenterology

Reserch

& Practice 2015

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Space Occupying Devices

Several investigators have evaluated the efficacy of the BIB ine the management of obesity . In the largest series of BIB patients so far Gence et al , in a study of 2515

patients had reported a percentage excess weight loss %EWL of 33.8% ±

18.7 %

at 6 months of follow – up . In this period , there was improvement or resolution of diabetes

&

hypertensionin

86.9

and

93.7 %

of patients , respectively .

The complication rate was acceptable at 2.8 % including 5 ( 0.2 % ) patients in whom gastric perforation occurred ; 2 of whom diedGenco T, obesity surgery , vol 15, no 8 , pp 1161-1164 2008

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Balloon

implantation

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Space Occupying Devices

Two Other balloons with antimigration properties The ReShape DUO ( ReShape Medical , SanClemente

, CA )The Spatz Adujtable Balloon

(

Spatz

Medical , Great Neck , NY )

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Spatz

Balloon

Prevents migration

of balloon

Visible

on imaging

Retrievable

Adjustable

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ReShape

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ReShape

DuoDelivery System

ReShape

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Space Occupying Devices

Transpyloric Shuttle ( TPS ) The TPS is a non surgical device designed to enable significant weight loss . The TPS

is composed of silicone & consists of a large spherical bulb connected to a smaller cylandrical bulb by a flexible catheter The device is designed to self – positioned across the pyloric during peristalsis, resulting in

intermittent obstruction and delayed gastric emptying

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Transpyloric Shuttle

TPS™Intermittent sealing of pylorus in concert with peristalsis may:

Delay gastric emptying

Induce

early

satiety

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The

BAROnova

TransPlyoric

Shuttle in the pyloric position

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Gastric Restrictive Methods

Transoral GastroplastyTransoral Endoscopic Restrictive Implant System ( TERIS )

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Gastric Restrictive Methods

Transoral Endoscopic Restrictive Implant System ( TERIS) The procedure involves placement of a restrictor with 10 mm central channel for food passage at the gastric cardia , thereby creating a restrictive pouch

Legner et al conducted a prospective observational study of 13 patients % EWL was

22 %

after

3

months . Three patients experienced serious adverse effects , one developing gastric perforation requiring laparoscopic treatment ,

2

other developing

pneumoperitoneum

Legner

A, surgical Innovation ,

vol

21 , no 5 , pp 456- 463 2014

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BaroSense Transoral

Platform

Food

Outlet

•

TERIS

(

T

ransoral

E

ndoscopic

R

estrictive

I

mplant

S

ystem

)

Full

thickness plication anchor

ints

Creates

a

Small

proximal

Pouch distal

to

the

GE

junction

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Malabsorptive Endoscopic Procedures

Duodenal – Jejunal Bypass Linear EndoBarrier gastrointestinal linearSatiSphere

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Malabsorptive Endoscopic Procedures

SatiSphere The endoluminal mechanical device to delay transit time of nutrients through the duodenum A randomized controlled trial by Sauer et al in which the device was inserted in 21 patients , % EWL of 12.2 % at 3 m . The study was terminated early due to spontaneous migration of the device occuring

in 10 out of 21 patients , two requring surgical intervention

Sauer T, obesity surgery ,

vol

23 , pp 1727 – 1733 , 2013

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SatiSphere

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Duodenal-

Jejunal Bypass Liner (DJBL)

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EndoBarrier

Alteration of gastric outlet

Food goes down liner – duodenal

exclusion

Digestive juices

go

around

liner

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Regulating Gastric Emptying

Intragastric Botulinium Toxin InjectionGastric Electrical Stimulation

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BOTOX

Injection

In animal studies

-

delayed gastric

emptying from

antral

injections

Human

studies

showed

variable results for antral

injections

Adding

fundic

injection in

RCT: wt

loss

11 vs 5

kg;

p<0.001

BMI

reduction

4 vs

2; p<0.001 Delayed

stomach

emptying

Foschi D, et al. Int J Obes 2007; 31: 707-12

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Electrical

Neuro-modulationEnteroMedics

Leptos Biomedical

IntraPace

MetaCure

Medtronic

(Transneuronix)

Mechanisms:

increase

satiety

reduce appetite

and

food intake alter neuro-endocrine responses affect gastric

and intestinal

motility

Current surgical placement could evolve

to

endoscopic

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Other Techniques

Aspiration Therapy Endoscopic placement of a gastrostomy tube and the Aspire Assist siphon assembly to aspirate gastric contents 20 minutes after meal consumptionA study by forssell et al The effectiveness of this device in 25 obese men and women after 4 weeks of taking low caloric diet , At 6 months , mean weight loss was 16.5 ± 7.8 kg

in the 22 subjects who completed 26 weeks of therapy. The mean % EWL was 40.8 ± 19.8 %

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Aspire

BariatricsDivert ingested nutrient flow out of the body

BariAssist G-Shunt

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Future

DevelopmentsNOTES

Natural orifice

transluminal

endoscopic surgery

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Role

of NOTESCompartmentalizationGastrojejunostomy

Sleeve

Gastrectomy

“Human

transvaginal sleeve gastrectomy: initial

experience”

Ramos AC, Zundel N, Neto MG, Maalouf

M

Surg

Obes

Relat Dis.

2008

Sep-Oct;4(5):660-3

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The

endoscope advanced into the peritoneal cavity

A loop of

jejunum identified

and

pulled into the

stomach

Gastrojejunostomy

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The

loop of jejunum is secured with sutures to the stomach

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Incision

made into the jejunal loop using a needle-knife

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The open ends

of the incision are secured to the gastric incision with a second line of sutures completing the gastrojejunostomy

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Acknowledgement

With special thanks to Dr. Ali Kabir, Dr. Abdolreza Pazouki and National Obesity Surgery Database

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Singel

& doubel balloon assisted ERCP

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