Bariatric i Surgery: Optimalizing Outcome Results. Dr. B. Dillemans AZ Sint-Jan AV Brugge-Oostende BARIATRIC SURGERY

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1 Bariatric i Surgery: Optimalizing i Outcome Results Dr. B. Dillemans AZ Sint-Jan AV Brugge-Oostende THE OBESE PATIENT : A CHALLENGE FOR ANAESTHESIA, Ostend,14/11/09 BARIATRIC SURGERY 50 s : First Reported Bariatric Procedures 90 s : Unpopular Speciality * Public awareness * Laparoscopic Access * Reported Success 2005 : Most Popular Speciality Bariatric Surgery Metabolic Surgery 1

2 QUESTIONS and DOUBTS Obesity = Self inflicted disease Obesity surgery = Life style surgery On Whom? By Whom? Which type of Procedure? Is it all worthwhile? 2

3 FACTS Obesity = Disease Quantity of Life Quality of Life Conservative treatment options do not provide sustained weight loss Surgery remains the only effective treatment for patients with morbid obesity Weight Loss is dramatic Comorbidity control substantial Patient satisfaction greater than for any other general surgical operation BARIATRIC PROCEDURES BARIATRIC SURGERY RESTRICTIVE * LAP BAND * LAP VBG * LAP SLEEVE RESTRICTIVE + MALABSORPTIVE * Gastric Bypass MALABSORPTIVE ( + RESTRICTIVE) *Scopinaro *Duodenal Switch 3

4 Adjustable Gastric Band Vertical Banded Gastroplasty 4

5 Sleeve Gastrectomy Gastric Bypass 5

6 BPD or DS Which PROCEDURE to CHOOSE? 6

7 WHICH PROCEDURE? CONSIDERATIONS One unique, super operation does not exist Surgery remains a tool to lose weight. Success ratio never 100 % Every procedure has advantages /disadvantages Bariatric surgery still in development Patient characteristics! Is it the patient who has failed the bariatric surgery? or the bariatric surgery that has failed the patient? 7

8 8

9 Lap RNY Bypass <-> Lap Band Conclusions More significant ifi Weight Loss More sustained Weight Loss Better Improvement or Cure of associated diseases Better Quality of Life But Higher Postop Mortality Higher Postop Morbidity Less Reversible OUTCOME MEASURES SAFETY Hospital Mortality and Morbidity Long Term Complications EFFECTIVENESS Weight Loss Improvement of Associated Diseases Quality of Life / Patient Satisfaction Impact on Quantity of Life ECONOMIC/HEALTHCARE COSTS 9

10 Patients for Bariatric Surgery Young Working Very Low Mortality rates! Healthy 10

11 MULTIDISCIPLINARY APPROACH Indication /Follow-up Surgeon Internist Psychiatrist/Psychologist Dietician Surgical Procedure Surgical Team Anesthesist MULTIDISCIPLINARY APPROACH Indication /Follow-up Surgeon Internist Psychiatrist/Psychologist Dietician Surgical Procedure Surgical Team Anesthesist 11

12 What should the anesthesist has to know and has to do? Knowledge of Different Types of Procedures/ Complications/Risks Knowledge of Associated diseases/risks Perioperative Difficult Intubations Helping the Surgeon Increasing abdominal workspace Positioning gastric tube /Leak test Elevating blood pressure Difficult extubations Postoperative Our approach for the Lap RNY Completely standardized except : 1 Antecolic, antegastric vs retrocolic, retrogastric 2 Length of alimentary limb 75 cm 1m30 2m00 Fully stapled Circular stapled gastro-jejunostomy (25mm CEEA) Linear stapled entero-enterostomy 12

13 Standardization procedure split into different phases specific role for every participant (surgeon, assistants, scrub nurse, anesthesiologist) every single laparoscopic maneuver has been completely rationalized Standardized maneuvers Closure of the jejuno-jejunostomy 13

14 Consistency Results 14

15 Data Collection Between may 2004 August 2008 : 4732 bariatric procedures 2645 lap gastric bypass F.U. (98.5%) : 2606 pt lap gastric banding 798 lap VBG (~McLean) 190 Open gastric bypass 21 Lap Sleeve Data Collection Data Collection : Retrospectively 539 male patients 2067 female patients Age: (mean 39.2) Mean BMI kg/m² (range ) Mean operative time: 63 min (35 150) Mean hospital stay : 3.35 days 15

16 Results 1 mortality (0.04 %) 89 bleedings (3.42 %) Conservative management in 66 patients Early re-operation in 23 patients Distinct bleeding source in 18 patients Extra-luminal: 9 patients Intra-luminal: 6 patients Trocar site / mesentery: 3 patients No clear source of bleeding in 5 patients 9 small bowel obstructions (0.35 %) 5 leakages (0.19 %) 5 DVT/PE (0.19 %) 2 pancreatitis (0.07%) 7 lateral entrapments at the left trocar site 1 incarcerated umbilical hernia 1 acute angulation at the jejunojejunostomy 4 at the level of the gastro-jejunostomy 1 at the level of the jejuno-jejunostomy Results: mortality Study Patients Mortality MacDonald (1997) Fernandez (2004) Zingmond (2005) Nguyen (2006) Flancbaum (2007) Flum (2009) Kelles (2009) Dillemans (2009) 154 (open) (retrospective) 1431 (open) 580 (lap) (retrospective) (retrospective) (open) (retrospective) (lap) 437 (open) (prospective) (open) (retrospective) 2606 (lap) (retrospective) 2.6% (perioperative) 1.9% (open) 0.7 % (lap) 0.33% (30 day) 0.4% (30 day) 1.2% (30 day) 0.2% (lap) (30 day) 2.1% (open) (30 day) 0.64% (30 day) 0,04% (30 day) 16

17 Results: leakage rate 1st Author, year No. of cases Overall anastomotic leakage rate (%) DeMaria, Hamilton, Marshall, Carrasquilla, Madan, Carucci, Gonzalez, Lee, Agaba, Ballesta, Durak, Dillemans, ,19 Conclusion Maximal Standardization Full Stapling High Surgical Volume Very low 30-day mortality & morbidity Safe procedure Easy reproducible Effective for training 17

18 Conclusion THANKS! 18

19 What is the problem with the Band in Belgium/Europe? 1. Poor Indications 2. Poor Patient Compliance 3. Poor Follow-Up 4. Poor Surgical Technique? Underestimated Procedure No Standardization of Technique Positioning of the Band Too High ( Virtual Pouch ) Too Low Placement of Gastric to Gastric Sutures Too Tighten Too Loose a b c Favretti et al, Obes Surg

20 LOSS OF QUALITY OF LIFE! Inability to have a proper meal No Meat /No Bread/ No. Substituting in sweet things + Regain of Weight Vomiting Pain -Dysfagia Reflux Impairement in social life Benefits of the approach increased ease shorter surgical time shorter lag time between procedures higher productivity lower complication rate and lower mortality 20

21 Introduction Golden standard BUT: technically challenging procedure substantial morbidity and mortality to improve outcome fully stapled fully standardized 21

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