Roux-en-y gastric bypass - clinical perspectives

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1 Roux-en-y gastric bypass - clinical perspectives Tom Mala Consultant surgeon Department of Gastroenterologic Surgery Oslo University Hospital

2 Bariatric surgery weight loss Sjøstrøm L, JAMA 2012

3 Five-year outcome after gastric bypass for morbid obesity in a Norwegian cohort. Aftab H et al. Surg Obes Relat Dis, 2014.

4 Benefits beyond weight loss Metabolic Type-2 diabetes (remission > 60%) Dyslipidemia (improved profiles about 60%) Sleep apnoea (Improvements most patients) Hypertention (remission 30-40%) Quality of life Physical activity Hira A et al, Surg Obes Relat Dis 2014; 10: 71-8.

5 JAMA 2015; 313: Mortality rates 10 years; 13.8% vs 23.9%

6 Survival According to BMI in the Surgery and the Control Group HR 0.72 (95 CI , p= 0.05) HR 0.54 (95 CI , p< 0.001) Adams TD et al., N Engl J Med 2007; 357:

7 Morbid obesity and comorbidity Søvik T et al., Obesity Surgery 2009

8 Bariatric procedures worldwide Total no RYGB 11% 39% 47% 45% Sleeve 0% 7% 28% 37% Adjustable band 64% 43% 18% 10% Duodenal switch 6% 5% 2% Minibypass - 1.5% Buchwald H and Angresani L et al., Obes Surg 2004, 2009, 2013 and 2014

9 Bariatric surgery, Norway Gastric bypass 55% Sleeve 45%* Unpublished data from the Norwegian society for bariatric surgery

10 Roux-en-Y gastric bypass Gastric pouch ml Alimentary limb ( cm) Biliopankreatic limb 50 cm Common channel Svanevik M, et al. Obes Surg 2015

11 Roux-en-Y gastric bypass Standard Distal Svanevik M, et al. Obes Surg 2015

12 The mini gastric bypass (no Roux en-y)

13 Gastric sleeve Hofsø D et al, Tidsskr Nor Laegeforen 2011

14 Roux-en-Y gastric bypass Gastric remnant Internal herniation Ulcus cholelithiasis

15 Perioperative complications Gastric bypass ( patients) Stenberg E et al., Ann Surg 2014; 260: Morbidity 8.7% Leakage/abscess 1.8%

16 SOREG Scandinavian obesity surgery registry

17 Gastric remnant ==

18 =

19 Obstruction Enteroentero/biliopancreatic limb and duodeum Stenosis enteroentero Tumor Ulcus Adherances Other Symptoms Nausea Hyperamylasemia Vomiting? Pain/discomfort

20 Need for decompression Percutanously Surgical

21 Gastric remnnant bleedings Perioperatively Later Ulcus Tumours Diagnosis and therapy challenging

22 Internal herniation Mala et al., Tidsskr Nor Legeforen 2013; 133: 640-4

23 The enteroenteroanastomosis (EE) Blindløp Biliopancreatic limb Alimentary limb Common limb

24 Blindløp Mot Treitz Alimentært løp løftet til siden

25 Blindløp Mot Treitz Alimentært løp løftet til siden

26 Internal herniation Mala T, Kristinsson J: Tidsskr Nor Legeforen 2013; 133: 640-4

27 Intern herniation Symptoms Acute intense pain Often radiating to the back Often more located to the left Ev. atypic presentation

28 Internal herniation Acute sign of obstruction/iskemia Acute surgery required Intermitterent easier bypassing pain/symptoms Consider planned laparoscopy

29

30

31

32

33 Blindløp Blindløp Mot Treitz Alimentært løp løftet til siden Alimentært løp

34 Invagination

35 Ulcus (pouch/gastrojeunostomi)

36 Ulcus (pouch/gastrojeunostomy) Etiology Acid/helikobacter pylori Size of pouch NSAIDS Smoking Ischemia Reaction to surgical material (?)

37 Ulcus about 5% prevalence Patel Ra et al, Surg Obes Rel Dis 2009; 5:

38 Ulcus surgical treatment 2282 patients (5.3 %) with ulcus 1/3 operated for ulcus Indikations for surgery pain (67 %) bleeding (21 %) Stricture (10 %) Perforation (2.5 %) Patel Ra et al, Surg Obes Rel Dis 2009; 5:

39 Gastrogastric fistula

40 cholelithiasis

41 Kolecystektomi totalt Etter fedmekirurgi 1149/13443 (8.5%) 5.5 (CI ) hyppigere enn normalbefolkningen Imperativ kolecystektomi Etter fedmekirurgi 427/13443 (3.2%) 5.2 (CI ) hyppigere enn normal befolkningen

42 Kolelithiasis 28 % develop gall bladder stone after bariatric surgery 9 % if with use of prophylactic ursodeoxycholic acid Uy MC et al., Obes Surg 2008; 18:

43 Choledocholithiasis

44 Balloon ERCP (n=32), laparoscopic assisted ERCP (n=24) Laparoscopy assistedercp superior Papille identifikasjon (100% vs 72%) Kannulering (100% vs 59%) Terapeutisk suksess (100% vs 59%) Posttherapy in hospital time, complications; comparable Schreiner MA et al. Gastrointestinal Endoscopy 2012; 75: 78-5.

45 Potential causes of pain after Roux-en-Y gastric bypass Cholelithiasis Ulcus Internal herniation Urolithiasis Dumping/dysfunction Stenosis Others

46 Gastric sleeve - leakages I one study of 20 patients the leakage was diagnosed mean 28 (3-77) days after surgery Nedelcu M et al., Obes Surg 2013; 23:

47 Gastric sleeve - leakages Treatment may be challenging Reoperation and drainage Stents and drainage (endoscopic intervention) Major revisional surgery

48 Gastric sleeve - leakages stent in stent in Stent Resection

49 Summary Gastric bypass Gastric remnant Internal herniation challenging diagnosis low treshold for surgery Cholelithiasis common, ERCP challenging Gastrojejunale ulcus and gastrogastric fistulas Gastric sleeve Gaining popularity Leakages challenging

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