L URGENTISTE CONFRONTE A UNE URGENCE BARIATRIQUE Conférences Urgences IRIS 20/04/2010 Jean-Jacques Houben BruSurg CHIREC CAVELL SEMINAIRES IRIS

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1 L URGENTISTE CONFRONTE A UNE URGENCE BARIATRIQUE Conférences Urgences IRIS 20/04/2010 Jean-Jacques Houben BruSurg CHIREC CAVELL Dr. T. Ballet Dr. R. Fastrez Dr. J.J. Houben Dr. P. Lachowsky Dr. D. Lipski C.H.I.R.E.Cavell

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3 Bariatric surgery and emergency 1. PREEXISTING DISEASES As long as the bariatric procedure does not solve the medical risk of morbid obesity, the collateral diseases will be encountered in the emergency room NIHCC WHO C.H.I.R.E.Cavell

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5 Bariatric surgery and emergency 1. PREEXISTING DISEASES 2. POST OP COMPLICATIONS 3. LATE MEDICAL EVENTS 4. LATE SURGICAL EVENTS NIHCC WHO C.H.I.R.E.Cavell

6 Bariatric surgery and emergency 1. PREEXISTING DISEASES Associated increased prevalence of: NIHCC WHO cardiovascular risk factors such as hypertension, diabetes mellitus, hypertriglyceridemia, hyperinsulinemia coronary heart disease cardiac dysfunction pulmonary problems (Sleep Apnoea disorders, asthma, atelectasia, ) digestive diseases (GOR, duodenal ulcers, steatohepatitis..) endocrine disorders obstetric, orthopaedic, and dermatologic complications. cancer mortality endometrium (5.4 times), gallbladder (3.6 times), uterine cervix (2.4 times), ovary (1.6 times), breast (1.5 times), colorectum (1.7 times), prostate (1.3 times). Psychologic instability C.H.I.R.E.Cavell

7 Bariatric surgery and emergency 1. PREEXISTING DISEASES leading to the increase of medical post-operative complications.. The obesity (excess weight > 20 %) increases statistically every post anaesthetic problem. Central Venous access Peridural catheter Lung compliance Pickwick Syndrome Heart disease (Right ventricular hypertrophy) Thromboembolic risk Drug pharmacokinetic NIHCC WHO C.H.I.R.E.Cavell

8 SRVG BANDING BPBP BPG GL (p) 3210 publications

9 S.R.V.G. AGB GBP SLEEVE AUTEURS Alper (2000) Closset (2004) Vishne (2004) Lee (2007) Salinas (2005) Expérience cumulée Camerini (2004) Landen (2005) Mognol (2005) Miller (2007) Naef (2007) Favretti (2007) Angrisani (2007) Jan (2007) Mognol (2005) Suter (2006) Murr (2007) Flancbaum (2007) DeMaria (2007) Mason (2007) Milone (2005) Baltasar (2005) Hamoui (2006) Roa (2006) Mognol (2006) Silecchia (2006) Lee (2007) Ou Yang (2007) Morbidité post-op 11 % 8 % 15 % 10 % Mortalité 0.5 % 0.15 % 1.2 % (0.2 8 %) Complications tardives Taux de ré opérations et de conversion 5-10 ans Chute moyenne du BMI > 5 ans 0.5 % 23 % % 14 %? 27 % %? 3 % BMI - 15 BMI - 8 BMI - 14 BMI 12 BAROS % 70 % 77%?

10 Bariatric surgery and emergency 2. POST OP COMPLICATIONS SPECIFIC Staple breakdown and leak Stomal oedema or stenosis Hemmorhage on stapple line G.I. Bleeding hemoperitoneum Bowel obstruction C.H.I.R.E.Cavell

11 L URGENTISTE CONFRONTE A UNE URGENCE BARIATRIQUE C.H.I.R.E.Cavell

12 L URGENTISTE CONFRONTE A UNE URGENCE BARIATRIQUE M+=0.1 % M+ 3 % Nausea Vomiting Cramping pain Gastric perforation Bowel obstruction C.H.I.R.E.Cavell

13 L URGENTISTE CONFRONTE A UNE URGENCE BARIATRIQUE C.H.I.R.E.Cavell

14 L URGENTISTE CONFRONTE A UNE URGENCE BARIATRIQUE M+= % Morbidité immédiate réduite mais gravissime: Perforation gastrique iatrogène C.H.I.R.E.Cavell

15 L URGENTISTE CONFRONTE A UNE URGENCE BARIATRIQUE M+= % M+ 38 % Related to the material Pouch dilation slippage 20 % Port complications (infection. 6 % Leakage 1.7 % Oesophagitis 3 % Migration 0-11 % C.H.I.R.E.Cavell

16 L URGENTISTE CONFRONTE A UNE URGENCE BARIATRIQUE C.H.I.R.E.Cavell

17 GASTROPLASTIE VERTICAL SELON MASON Silastic Ring Vertical Gastroplasty Silastic Ring Vertical Gastroplasty

18 Silastic Ring Vertical Gastroplasty Personal M+= % Pubmed M+ 17 % (minor) M+ 0 % (major) Long term: 37 % 50 % Related to the ring Oedema stenosis 15 % Delayed staple disruption 10 % Ring Migration 5 % Oesophagitis 8 % Wall defect (mini lap) 3 %

19 Fréquence des vomissements gastroplasties 44% bypass 93% 56% 7% fréquents rares

20 OEDEMATOUS POSTOP OUTLET

21 POST OP LEAKAGE

22 POST ENDOSCOPIC LEAKAGE

23 STAPLE LINE DISRUPTION

24 L URGENTISTE CONFRONTE A UNE URGENCE BARIATRIQUE C.H.I.R.E.Cavell

25 Roux-En-Y Gastric Bypass ( RYGB ) Personal M+= % Pubmed M+ 9 % (minor) 20 % M+ 18 % (major) Long term: Anastomotic GJ dehiscence % Jej-Jej dehiscence 0 3 % Obstruction 4 % Bleeding GI 1 % Abdominal 1 % Anastomotic Ulcer Internal hernia

26 L URGENTISTE CONFRONTE A UNE URGENCE BARIATRIQUE Ex. Clin: Que faire devant un patient obèse en post op d une anastomose laparoscopique délicate? (GBP, DS, Mini BP, Sleeve, Scopinaro ) ASP: Drainage abdominal: Paramètres vitaux: Echographie per cutanée: Biologie: CT Scanner: OED transit: Epreuve au bleu: Problèmes ventilatoires Sensibilité abd diffuse Liquide trouble Tachycardie CRP Fuite de gastrografine C.H.I.R.E.Cavell

27 Suivi des bilans sanguins : le FER gastroplasties 35% bypass 65% 70% 30% Taux abaissé Taux normal

28 Suivi des bilans sanguins : VIT. B12 gastroplasties 95% 80% 5% bypass 20% Taux abaissé Taux normal

29 L URGENTISTE CONFRONTE A UNE URGENCE BARIATRIQUE C.H.I.R.E.Cavell

30 Bilio-pancreatic By pass ( Scopinaro) M+= % Post op m+: 2 %???? Late m+: Anemia Peptic ulcer Bone demineralization Neurologic complications (Wernicke) Protein malnutrition

31 MORBID OBESITY PREBYPASS LIVER STRUCTURE STEATOSIS Macrophages PERIPORTAL INFLAMMATION EXCESSIVE BACTERIAL PROLIFERATION JEJUNAL PERMEABILITY LPS absorption CYTOKINES activation HEPATITIS Excessive WEIGHT LOSS PROTEIN INTAKE Kwashiorkor LIPID PEROXYDATION LIPID INTOXICATION HEPATOCYTE DYSFUNCTION

32 L URGENTISTE CONFRONTE A UNE URGENCE BARIATRIQUE C.H.I.R.E.Cavell

33 L URGENTISTE CONFRONTE A UNE URGENCE BARIATRIQUE Laparoscopic duodenal switch The procedure that is the less performed The difficult st laparoscopic procedure The longest procedure Some times performed in two steps M+: % M+: Leak: 1-5 % Obstruction: 2 3 % Bleeding: 6 10 % Embolism: % Anastomotic ulcer: 3 11 % Rhabdomyolisis rare (50 % +) 12 To 32 % C.H.I.R.E.Cavell

34 L URGENTISTE CONFRONTE A UNE URGENCE BARIATRIQUE C.H.I.R.E.Cavell

35 SLEEVE GASTRECTOMY M+=0.4 % M+ 14 % Leak of the staple line Bleeding Gastric edema or stenosis GI Bleeding Splenic injury

36 L URGENTISTE CONFRONTE A UNE URGENCE BARIATRIQUE C.H.I.R.E.Cavell

37 L URGENTISTE CONFRONTE A UNE URGENCE BARIATRIQUE Complications de la gastrectomie linéaire (sleeve) et de la suture gastro-jéjunale du By Pass Reflux biliaire C.H.I.R.E.Cavell

38 REDOS AND THREEDOS Reoperations for non Compliance (disruptions or dilatations) may lead to total gastrectomy in rare cases

39 REDOS AND THREEDOS Les conversions de banding en by pass, de sleeve en by pass ou duodenal switch voire de gastroplasties en by pass sont des interventions à haut risques. Aux complications de l obésité morbide, des sutures laparoscopiques s ajoutent les dévascularisations, les échecs des agraphages mécaniques,.etc. La récidive de l obésité morbide constitue; quelque soit le traitement choisi, un défi médico-chirugical majeur.

40 3. LATE MEDICAL EVENTS? Insuffisance hépatique Cirrhose Déminéralisation, Lithiase biliaire Anémie ferriprive Carences prot RGO Anémie ferriprive RGO Proctologie Lithiase biliaire Anémie ferriprive Carences Anémie ferriprive RGO Ac Folique Carences Fe, Vit, Dumping R Biliaire Anémie, Ulcères

41 Bariatric surgery and emergency 4. LATE SURGICAL EVENTS Cholecystitis Stenoses Dehiscence of STAPLING LINE Adhesions Volvulus Cosmetic problems C.H.I.R.E.Cavell

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