BRIAN TIU - PGY 5 KING COUNTY HOSPITAL COMPLICATIONS OF LAPAROSCOPIC GASTRIC BANDING

PATIENT PRESENTATION HISTORY 36 yo female morbid obesity, laparoscopic gastric banding 2008 Mar 2015 small bowel resection, removal of band d/c from outside hospital 3 days prior hematemesis and syncope EGD x2; no active bleed, ulcers at the level of the band 2 units PRBC; discharge H/H of 7.9/25.6

PATIENT PRESENTATION WORKUP 2015.OCT.24 - BIBEMS with hematemesis, AMS, melena BP96/61 P85 R23 admitted to MICU, intubated abdomen obese, well healed scars, melena on DRE H/H 5.0/16.6; blood products given 10 / 8 / 2 EGD - unable to visualize source of active bleed BP dropped to 50s systolic

PATIENT PRESENTATION OPERATING ROOM MTP activated exploratory laparotomy adhesiolysis gastrotomy, two ulcers oversewn evacuation of 1.5L blood/clot blood products given 2 / 4 / 2 / 2

PATIENT PRESENTATION PATHOLOGY body type gastric mucosa w/ hemorrhage and mild chronic inflammation blood vessels w/ congestion and dilatation h pyl negative consistent with submucosal vascular malformation

PATIENT PRESENTATION POST OPERATIVE COURSE POD#0 - H/H 9.7/27.4 POD#4 - H/H 7.5/22.3, tolerating diet, ambulating, BM+ POD#5 nausea, hematemesis, tachycardia transfused 4 / 1 / 0 intubated bedside EGD

PATIENT PRESENTATION POST OPERATIVE COURSE POD#6 - repeat EGD POD#8 - re-bleed, transfused 6/2/0, repeat EGD, angio embolization of the L gastric artery for pseudoaneurysm POD#10 - OR to secure ETT, repeat EGD, Blakemore tube placement

PATIENT PRESENTATION POST OPERATIVE COURSE POD#18 - H/H 9.3/27.8, no further transfusions POD#22 - discharged home POD#25 - seen in clinic

QUESTION

BARIATRIC SURGERY OUTLINE overview indications bariatric surgery laparoscopic adjustable gastric banding complications

BARIATRIC SURGERY GOALS OF METABOLIC & BARIATRIC SURGERY treatment of severe obesity, i.e. weight loss treatment of metabolic conditions, e.g. DM

BARIATRIC SURGERY OBESITY second leading cause of preventable death in the US epidemic proportions in the US ~35% obese (78.6 million people)

BARIATRIC SURGERY MEDICAL MANAGEMENT caloric intake, energy expenditure safest lifestyle changes must continue through surgery identify/manage co-morbidities pharmacologic therapy after failure of lifestyle changes and dietary therapies

BARIATRIC SURGERY INDICATIONS

BARIATRIC SURGERY INDICATIONS BMI 40

BARIATRIC SURGERY INDICATIONS BMI 40 BMI 35 & co-morbid medical condition sleep apnea, cardiomyopathy, DM, HTN quality of life - employment, family, ambulation

BARIATRIC SURGERY INDICATIONS BMI 40 BMI 35 & co-morbid medical condition sleep apnea, cardiomyopathy, DM, HTN quality of life - employment, family, ambulation failed attempted weight loss treatments

BARIATRIC SURGERY INDICATIONS BMI 40 BMI 35 & co-morbid medical condition sleep apnea, cardiomyopathy, DM, HTN quality of life - employment, family, ambulation failed attempted weight loss treatments psychologically stable

BARIATRIC SURGERY CONTRAINDICATIONS ASA class IV psychologic instability drug/etoh addiction eating disorders, e.g. bulimia

BARIATRIC SURGERY PRE-OPERATIVE ASSESSMENT multidisciplinary team evaluation PCP, nutritionist, psychologist/psychiatrist, surgeon optimize medical condition work-up CAD, OSA, hypothyroidism

BARIATRIC SURGERY POST-OPERATIVE CARE short term follow-up - 2 years assist adjusting to new eating, exercise, and lifestyle patterns early identification of postoperative complications; trend weight loss, change in BMI resolution or improvement in medical co-morbidities

BARIATRIC SURGERY SURGERY restrictive laparoscopic adjustable gastric banding sleeve gastrectomy

BARIATRIC SURGERY SURGERY restrictive laparoscopic adjustable gastric banding sleeve gastrectomy malabsorptive biliopancreatic diversion jejunoileal bypass

BARIATRIC SURGERY SURGERY restrictive laparoscopic adjustable gastric banding sleeve gastrectomy malabsorptive biliopancreatic diversion jejunoileal bypass combined roux-en-y gastric bypass biliopancreatic diversion with duodenal switch

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING HISTORY 1993 - Belachew, 1st laparoscopic adjustable gastric banding operation 2001 - approved in the US by the FDA Current - 25% of bariatric procedures performed

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING OUTCOMES up to 50% weight loss in 24 months up 25% fail to lose weight within 5 years type II DM improved in up to 90%, medications eliminated in 64% inferior to roux-en-y gastric bypass in overall weight loss superior in morbidity and mortality

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING SURGERY pars flaccida approach retrogastric tunnel pars flaccida medially angle of His laterally decreased rate of band slippage more extraneous tissue (lesser curvature fat pad) incorporated into the band

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING SURGERY peroral calibration balloon placed fill to 15-25 cc of saline band fastened below this level create 15-25 cc pouch

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING POST-OPERATIVE CARE AND FOLLOW- UP exercise and diet progression plan band adjustments - band restriction by adding fluid <2 lb wt loss wk easily eat solid foods, little satiety, pronounced appetite over 2 year period

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING COMPLICATIONS pouch enlargement band slippage port-site infections port breakage band erosion

COMPLICATIONS POUCH ENLARGEMENT dilation of the proximal gastric pouch with or without change in the angle of the band no signs of obstruction seen with band overinflation or overeating sx - lack of satiety, heartburn, regurgitation, chest pain tx - band deflation, low-calorie diet, portion control

COMPLICATIONS BAND SLIPPAGE cephalad prolapse of the stomach or caudad movement of the band 2º insufficient anterior fixation or pressure in the pouch sx - dysphagia, vomiting, regurgitation. food intolerance necrosis, perforation, UGIB, aspiration tx - require operative intervention, removal/repositioning of the band

COMPLICATIONS PORT SITE infection - erythema, pain, edema tx - antibiotics, removal of port leakage damaged port septum or tubing loss of the injected fluid volume, loss of restriction local exploration, port replacement

COMPLICATIONS BAND EROSION rare gastric-wall injury or tight anterior fixation most patients are asymptomatic epigastric pain; sepsis, bleeding weight gain, multiple band adjustments, port infection tx - complete removal of the eroded gastric band

COMPLICATIONS BLEEDING 2º to migration/erosion; rare chronic ischemia 2º pressure chronic inflammation 2º reaction to silicon gastric band case reports regular follow-up - gastroscopy, barium swallow

COMPLICATIONS reoperation rate 36.5% repositioning 5.4 replacement 6.2 port related 13.9 band removal 10.0 conversion to other bariatric procedure 10.2

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING SUMMARY profound weight loss and improvement of metabolic derangements are possible with LAGB LAGB is a safe and reversible procedure re-operation rates are high close post-operative follow-up is paramount

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING QUESTION Which of the following is not among the requirements for bariatric and metabolic surgery? A. BMI 40 B. failed attempted weight loss treatments C. BMI 35 with co-morbid medical conditions D. age 18 E. psychologically stable

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING REFERENCES Bruce Schirmer; Philip R. Schauer. Chapter 27 The Surgical Management of Obesity. Schwartz's Principles of Surgery, 9e. The McGraw-Hill Companies, Inc. 2010. Eid, Iyad et. al. Complications associated with adjustable gastric banding for morbid obesity: a surgeon s guide. Canadian Journal of Surgery. FEB 2011. 54(1). p61-66. Shen, Xiaojun et. al. Long-term complications requiring reoperations after laparoscopic adjustable gastric banding: a systematic review. Surgery for Obesity and Related Diseases. 2015. 11. p956 964 Society of American Gastrointestinal and Endoscopic Surgeons Torab, FC et. al. Delayed life-threatening upper gastrointestinal bleeding as a complication of laparoscopic adjustable gastric banding: Case report and review of the literature. Asian Journal of Surgery. 2012. 35. p127-130