11/10/2014. I have nothing to Disclose. Covered Stents discussed are NOT FDA approved for the indications covered in my presentation

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1 I have nothing to Disclose Ramsey Dallal, MD, FACS Vice Chair Department of Surgery Chief Bariatric i and Minimally i Invasive Surgery Einstein Healthcare Network Nemacolin, PA 2014 Covered Stents discussed are NOT FDA approved for the indications covered in my presentation Bariatric Surgery is becoming one of the common general surgical procedures in the United States More than 200, procedures are performed every year Over the decades, numerous procedures have been performed, with each procedure having its own set of unique outcomes and complications Surgeons (and patients) tend to be awful at long-term follow-up Complications and complaints from surgery can develop many years later Many patients will see their PCP and eventually be referred to a gastroenterologist, some with very little experience dealing with the nuances of bariatric surgery 1

2 Acute complications can often be managed in conjunction with, or in lieu of surgical approaches greatly improving outcomes Chronic Problems often eventually are seen by medical specialists Jejunal Ileal Bypass Horizontal Gastroplasty Vertical Banded Gastroplasty Duodenal Switch Adjustable Gastric Band Gastric Bypass Gastric Sleeve Gastric Plication, Gastric Balloon, Intraluminal Sleeves First Performed in No longer performed Associated with diarrhea, liver failure, autoimmune disorders, bacterial overgrowth and abdominal pain Reverse these operations if you see complications Vertical Banded Gastroplasty performed frequently between Associated with poor long term weight loss (band too loose) High incidence of dysphagia and reflux (band too tight) NOT amenable to dilation don t bother Surgical revision to gastric bypass is treatment for dysphagia and reflux. 2

3 First FDA Approve in 2001 Currently very few are performed in the US as most patients are undergoing the sleeve gastrectomy Symptoms of complications GERD/Regurg/Pneu monia Dysphagia Abdominal Pain Band TOO TIGHT Gastroesophageal Reflux Asymmetric Prolapse Esophageal Dysmotility Esophageal and/or Pouch Dilation Dysphagia Aspiration Pneumonia, Asthma Upper Endoscopy or PPI therapy not indicated. Initial treatment should be deflation of the band. 3

4 Deflation of the Band Can be done with 21g needle (no need for Huber) Remove all the fluid (usually 5-10cc in place) Does not require local anesthesia BUT Can be very difficult for those without experience Options if YOU are uncomfortable Fluoroscopy Surgery Consults preferably bariatric surgeon Anatomic Complications Port Disconnect Uncommon cause of pelvic pain. Diagnosed on Plain X-Ray Requires removal Band Slippage Pain + Dysphagia + GERD that do not improve with deflation Band Erosion Fever, cellulitis around port site Diagnosed on Upper Endoscopy 4

5 All complaints should be managed first with Band deflation If symptoms persist despite deflation UGI indicated to r/o gastric prolapse (and often only plain radiographs necessary) Routine Upper Endoscopy does not require Band Deflation ACUTE Leak Ulcer Stricture Chronic Ulcer Internal Hernia Gallstone disease (CBD stone!) Kidney Stones Dysmotility Disorders Roux Stasis, Severe Constipation Nutritional Anemia Thiamine Deficiency 5

6 Surgical Correction can be difficult Drainage and control of infection Primary Goal Laparotomy often fraught with complications and should be avoided. Endoscopic Therapies Endoluminal covered Stents Endoscopic Clips Injection of glue Failures occur from Peri-Stent leak Re-stenting and addition of another stent reasonable to attempt Migration g a problem 20-50% Percent rate Successful in ~70-90% of leaks Oral Nutrition can be started immediately 6

7 Tricks If combined laparoscopic approach used, suturing stent in place with fast-absorbing suture reasonable Placement of two overlapping stents (23mm x 155cm) very helpful Most stent t Migrations will pass through h entire GI track, unless known to have intestinal adhesions. Wait 2-4 weeks before removing stent Complete control of infection the goal, if rapid resolution of sepsis syndrome is not seen, then further treatment mandatory Endoscopic Clipping Glue These are more often ineffective in the immediate post-operative setting, although chronic non-healing fistulas (weeks to months) may have a wider role. Occur in 5% of patients, but highly surgeon dependent. Almost always clinically evident within first month of surgery Any patient vomiting daily and unable to advance diet should be considered for early endoscopy 7

8 Dilation with 18mm balloon typically very effective. No need to slowly size up. Only a small percent of patients will require re-dilation Treat Every Patient with Thiamine! These patients are at risk!!! WK syndrome Timing While I have dilated rare strictures days after surgery, I would strongly recommend waiting at least 3 weeks post-op Outcomes 97% success. Can be done multiple times. Usually if no success by third time, surgery needed. No correlation between weight loss outcomes in those who had dilation and those that did not. Ulcer Can occur days to years after surgery 2% incidence, much higher in smokers and NSAID users Three presentations Incapacitating Pain and Nausea, invariably worse after eating Acute GI Bleed Perforation Etiology unclear, likely acid related, not ischemia Carafate, PPI and cessation of inciting Agent Very Rarely Reversal of gastric bypass necessary as resection commonly leads to recurrence. Gallbladder Disease 7% incidence of cholecystectomy in 10 years after surgery Biliary Dyskinesia Common! Symptoms may be atypical BILE LEAK, CBD stones treated very effectively with laparoscopic assisted transabdominal, transgastric ERCP. 8

9 High incidence of Kidney Stones GI Dysmotility disorders Esophageal Roux Stasis or other non-defined disorders Malnutrition requires reversal Severe Constipation Transit Marker studies normal Abnormal Anorectal physiology Aggressive Bowel Regimen necessary Internal Hernia! Gastric bypass is an extremely effective operation to treat GERD, but. Some patients develop severe GERD Dx with ph study Obtain manometry Treatment options are limited Duodenal is much more effective at absorbing iron then rest of gut Biggest Risk group for iron deficiency is Pre-menopausal women. 31% incidence at 4 years. Any Hb<10 treat with parenteral iron 9

10 Lower incidence of leak than GB, however, much more difficult to manage Re-operation usually fails Drainage, Stents, Clips, Glue, Prayers Lower incidence of iron deficiency Possibly Increase in B12 Deficiency Much higher incidence of GERD (20%, but usually transient) If not symptoms completely controlled by PPI therapy, revision to a gastric bypass is often curative. Usually tight at Incisura Not a true stricture, more a KINK Very difficult to dilated Can dilated with achalasia balloon Stent May require operative revision 10

11 Communication and teamwork with bariatric surgeon very helpful. Always y assume that a complaint that a patient has who had bariatric surgery is due to that procedure Abdominal Pain is abnormal Use Thiamine Liberally 11

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