Roux-en-y gastric bypass - clinical perspectives Tom Mala Consultant surgeon Department of Gastroenterologic Surgery Oslo University Hospital
Bariatric surgery weight loss Sjøstrøm L, JAMA 2012
Five-year outcome after gastric bypass for morbid obesity in a Norwegian cohort. Aftab H et al. Surg Obes Relat Dis, 2014.
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.
JAMA 2015; 313: 62-70. Mortality rates 10 years; 13.8% vs 23.9%
Survival According to BMI in the Surgery and the Control Group HR 0.72 (95 CI 0.53-0.99, p= 0.05) HR 0.54 (95 CI 0.43-0.74, p< 0.001) Adams TD et al., N Engl J Med 2007; 357: 753-61
Morbid obesity and comorbidity Søvik T et al., Obesity Surgery 2009
Bariatric procedures worldwide 2003 2008 2011 2013 Total no 146.301 344.221 340.768 468.609 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
Bariatric surgery, Norway 3000 ++ Gastric bypass 55% Sleeve 45%* Unpublished data from the Norwegian society for bariatric surgery
Roux-en-Y gastric bypass Gastric pouch 25-20 ml Alimentary limb (100-150 cm) Biliopankreatic limb 50 cm Common channel Svanevik M, et al. Obes Surg 2015
Roux-en-Y gastric bypass Standard Distal Svanevik M, et al. Obes Surg 2015
The mini gastric bypass (no Roux en-y)
Gastric sleeve Hofsø D et al, Tidsskr Nor Laegeforen 2011
Roux-en-Y gastric bypass Gastric remnant Internal herniation Ulcus cholelithiasis
Perioperative complications Gastric bypass (26 173 patients) Stenberg E et al., Ann Surg 2014; 260: 1040-47 Morbidity 8.7% Leakage/abscess 1.8%
SOREG Scandinavian obesity surgery registry
Gastric remnant ==
=
Obstruction Enteroentero/biliopancreatic limb and duodeum Stenosis enteroentero Tumor Ulcus Adherances Other Symptoms Nausea Hyperamylasemia Vomiting? Pain/discomfort
Need for decompression Percutanously Surgical
Gastric remnnant bleedings Perioperatively Later Ulcus Tumours Diagnosis and therapy challenging
Internal herniation Mala et al., Tidsskr Nor Legeforen 2013; 133: 640-4
The enteroenteroanastomosis (EE) Blindløp Biliopancreatic limb Alimentary limb Common limb
Blindløp Mot Treitz Alimentært løp løftet til siden
Blindløp Mot Treitz Alimentært løp løftet til siden
Internal herniation Mala T, Kristinsson J: Tidsskr Nor Legeforen 2013; 133: 640-4
Intern herniation Symptoms Acute intense pain Often radiating to the back Often more located to the left Ev. atypic presentation
Internal herniation Acute sign of obstruction/iskemia Acute surgery required Intermitterent easier bypassing pain/symptoms Consider planned laparoscopy
Blindløp Blindløp Mot Treitz Alimentært løp løftet til siden Alimentært løp
Invagination
Ulcus (pouch/gastrojeunostomi)
Ulcus (pouch/gastrojeunostomy) Etiology Acid/helikobacter pylori Size of pouch NSAIDS Smoking Ischemia Reaction to surgical material (?)
Ulcus about 5% prevalence Patel Ra et al, Surg Obes Rel Dis 2009; 5: 317-22
Ulcus surgical treatment 2282 patients - 122 (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: 317-22
Gastrogastric fistula
cholelithiasis
Kolecystektomi totalt Etter fedmekirurgi 1149/13443 (8.5%) 5.5 (CI 5.1-5.8) hyppigere enn normalbefolkningen Imperativ kolecystektomi Etter fedmekirurgi 427/13443 (3.2%) 5.2 (CI 4.7-5.7) hyppigere enn normal befolkningen
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: 1532-38
Choledocholithiasis
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.
Potential causes of pain after Roux-en-Y gastric bypass Cholelithiasis Ulcus Internal herniation Urolithiasis Dumping/dysfunction Stenosis Others
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: 1341-3.
Gastric sleeve - leakages Treatment may be challenging Reoperation and drainage Stents and drainage (endoscopic intervention) Major revisional surgery
Gastric sleeve - leakages stent in stent in Stent Resection
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