Daniel A.P. Smith, MDBariatric Surgery Director

Essentia Health Park RapidsSt. Joseph’s Center for Weight Management

Bariatric and Metabolic Conference

Bariatric Surgical Complications and Recent Trends in Outcome Data

Slippage

Erosion

Esophageal & gastric pouch dilation

Port / tubing problems

Long‐term: high rates of reoperations & failures

Laparoscopic Adjustable Gastric Band Complications

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Band Slippage

Stomach up under band

Normal location

3SOURCE: www.lap‐surgery.com/images

gastric_band_comp05.jpg

SOURCE: Laparoscopic Bariatric Surgery, 2004; INABNET, MD; DEMARIA, MD; IKRAMUDDIN, MD

Symptoms:

• Partial Gastric Obstruction

Intolerance to solids

Heartburn

Dysphasia, vomiting

Coughing, wheezing

• Gastric Necrosis

Severe abdominal pain

Peritonitis, sepsis

Band Slippage

If present, considercase an emergency.}

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Band Slippage

Self‐emptying pouch.5 SOURCE: lapbandfollowup.co.uk

Slipped band, changed angle.SOURCE: lapbandfollowup.co.uk

Band Slippage

6SOURCE: lapbandfollowup.co.uk

Slipped band with swallow. Note pouch and horizontal band.SOURCE: lapbandfollowup.co.uk

Treatment:

1) Deflate band

2) UGI X Ray

3) Surgery• Repositioning stomach around band

• Removal and/or replacement

Gastric Necrosis:• Laparotomy with gastric resection

& band removal

Band Slippage

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Symptoms:

• Usually insidious onset

• Weight gain/loss of satiety

• Band adjustments ineffective

• Port infection

• Workup suspected erosion

• UGI ‐ contrast around band

• EGD – band visible

Band Erosion

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Band Erosion

Endoscopic view of band erosion into lumen of stomach.

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SOURCE: lapbandfollowup.co.uk

SOURCE: Laparoscopic Bariatric Surgery, 2004; INABNET, MD; DEMARIA, MD; IKRAMUDDIN, MD

Treatment:

• Removal of band system, usually laparoscopically

• Closure damaged gastric wall

• Can sometimes be removed using UGI endoscopy

• Later band replacement or conversion to  gastric bypass

Band Erosion

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Normal location.

Esophageal & GastricPouch Dilation

Esophageal dilation.SOURCE: Bariatric Times. 2010; 7(11):8‐12

PONCE, MD & SMITH, DO, FACOS

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SOURCE: www.lap‐surgery.com/images/

gastric_band_comp05.jpg

Symptoms:

• Dysphasia, vomiting, severe reflux

• Pneumonia/wheezing

Workup:

• UGI X Ray

Esophageal & GastricPouch Dilation

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Treatment:

1) Deflate band

‐ if symptoms improve, slowly begin refilling after 2‐3 months

2) If deflation fails:

‐ Remove band

‐ Convert to gastric bypass

Esophageal & GastricPouch Dilation

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Malposition/flip of port

Leakage

Kinked tubing

Infection

Bowel obstruction/erosion around tubing

Port & Tubing Problems

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Europe: Emerging Theme from Late Follow-up Data

“LAGB has high re‐operation and failure rates”

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Re‐operation rate, 42%

Failure rate at 7 years, 57%

Conclusion: “With a nearly 40% 5‐year failure rate, and a 43% 7‐year success rate; LAGB should no longer be considered as the procedure of choice for obesity.”

OBESITY SURGERY 16:829‐35

Swiss (2006)

317 patients, 7‐year follow up

Europe: Emerging Theme from Late Follow-up Data

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Late complications, 40%

Failure rate at 10 years, 32%

Conclusion: “… the high complication, re‐operation, and long‐term failure rates lead to the conclusion that the LAGB should be performed in selected cases only...”

OBESITY SURGERY 20:1206‐14

Swiss (2010)

167 patients, bands placed 1998‐2009

Europe: Emerging Theme from Late Follow-up Data

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Late complications, 32%

Overall band removal, 30%

Conclusion: “LAGB should no longer be considered as the procedure of choice for obesity.”

SURG OBES RELAT DIS 6:51‐3‐26

Paris (2010)

907 patients, mean follow up 8.4 years

Europe: Emerging Theme from Late Follow-up Data

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Re‐operation rate, 53%

Only 54% had original band in place

Conclusion: “Long‐term…, gastric banding has a high complication and band‐loss rate.”

OBESITY SURGERY 20:1078‐85

Austria (2010)

276 patients, at least 9 years post‐op

Europe: Emerging Theme from Late Follow-up Data

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1/3 of patients underwent removal of band due to complications or inadequate weight loss

Only 1/3 of patients had functioning band after a mean of 10 years

Conclusions: “… an enormous heritage of re‐do bariatric surgery is in the making…

“… one should wonder whether the gastric band still has a future….”

SURG OBES RELAT DIS 6:51‐5‐26

Netherlands (2010)

201 patients, mean follow up 10 years

Cleveland Clinic – Florida(Obesity Surgery, 2010, 6: 391‐398)

Conclusion:

“LAGB appears to have a high incidence of complications requiring revisional surgery 

and/or band removal.”

Emerging U.S. Data Regarding Adjustable Gastric Banding

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Emerging U.S. Data Regarding Adjustable Gastric Banding

American Journal of Medicine (2008):Department of Internal Medicine review of data comparing LGBP and LAGB. *

Conclusions:

1. “In comparative trials, weight loss, resolution of obesity related co‐morbidities, and patient satisfaction all are greater for LGBP than LAGB.”

2. “Despite widespread marketing of gastric banding, no subgroup has been identified in whom LAGB performs better than LGBP.”

* Am. J. Med. (2008) 121:885

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Strictures gastrojejunostomy

Marginal ulcer

Small bowel obstruction

Leaks

Cholelithiasis

Thromboembolic

Nutritional deficiencies

Complications of Gastric Bypass

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Symptoms• Usually within 12 weekspost‐op

• Progressive food intolerance – first solids, later liquids

• Usually not much pain, but usually dehydrated

Strictures at Gastrojejunostomy

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SOURCE: RadioGraphics

Treatment:• Vitamin replacement – especially thiamine

• Early thiamine deficiency:a) Wernicke's Encephalitisb) Motor & sensory neuropathy

• Rehydration• Endoscopic balloon dilation

• Surgery rarely needed

Strictures at Gastrojejunostomy

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Marginal Ulcer

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SOURCE: Bariatric Times. 2010; 7(1):23‐25 RACU, MD, MPH & MEHRAN, MD, FACS, FASMBS

Marginal Ulcer

Incidence: 3‐5%

Most present with:

• Bleeding

• Epigastric pain, radiates to back

• Nausea / emesis

Diagnosis:• EGD best 

• Serum gastrin for refractory ulcer

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Medical management usually successful• Acid suppression:

• High dose PPI or H2 blocker• Carafate• Cytotec

• Stop smoking

• Stop NSAIDS• Surgery

• Perforation• Bleeding refractory to medical and endoscopic management• Chronic, intractable to medical management• Revise to very small pouch

Marginal Ulcer

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Potentially devastating complication:• Must diagnose & treat early

Incidence:• 3‐6 %• Most occur in first year

Causes:

• Internal hernia – most common

• Adhesions

• Incisional hernia

Small Bowel Obstruction

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Plain x‐ray will miss many obstructions:

• At biliopancreatic limb

• Proximal roux limb

• Volvulus through internal hernias

If any suspicion of SBO after gastric bypass, get CT of abdomen!

Small Bowel Obstruction

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Small Bowel Volvulus

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SOURCE: Laparoscopic Bariatric Surgery, 2004; INABNET, MD; DEMARIA, MD; IKRAMUDDIN, MD

Volvulus, CT scan

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Volvulus, CT scan

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Volvulus, CT scan

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Volvulus, CT scan

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Volvulus, CT scan

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Treatment• Replace thiamine – banana bags plus extra thiamine

• Rehydration – don’t give dextrose until after thiamine is replaced

• NGT if distended Roux limb or if given PO contrast

• Early diagnostic laparoscopy

• Persistent or severe abdominal pain after gastric bypass needs diagnostic laparoscopy!

Small Bowel Obstruction

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Site

• Usually gastrojejunostomy

• Can also be at jejunojejunostomy or bypassed stomach

• Usually early post op

‐ 5 to 7 days

Leaks

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Presentation:

• Tachycardia, fever, tachypnea, decreased urinary output

• Increasing pain – abdomen, left shoulder

• Dyspnea, hiccoughs, pleural effusion

• Change in character of drain output

• Sense/look of “impending doom”

Workup:

• CT abdomen with oral contrast

• If sick, explore even if negative radiologic workup

Leaks

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Treatment:

• If well‐drained & no sepsis → NPO, TPN, stents, fibrin sealant

• Surgery: 

• Gastrojejunostomy leaks:  +/‐ closure, provide wide drainage

• jejunojejunostomy: may be present with pelvic pain – all require surgery

• Excluded stomach:  close leak & drain

Leaks

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Increased incidence of gallstone formation during period of rapid weight loss

Presentation:• Acute cholecystitis

• Chronic cholecystitis

• Biliary dyskinesia

• Gallstone pancreatitis

• Sphincter of Oddi dysfunction

Cholilithiasis / Biliary Pain

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Signs & Symptoms:• Nausea• Pain – usually postprandial• RUQ, often radiating to back• Quite variable

Workup:• US, CCK stimulated HIDA scan

Treatment:• Cholecystectomy

• CBD stones/suspected SOD

• Transgastric ERCP

Cholilithiasis / Biliary Pain

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Low incidence/high mortality• 0.85 % / 40 to 60 %

Fatal PE occur sooner after surgery• Median interval for fatal PE was 3 days

• Median interval for non‐fatal PE was 10 days• Can occur up to months postoperatively

Maintain high index of suspicion

Workup ‐ Venous Duplex Scan, CT chest

Postoperative Thromboembolism

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Protein‐ lean body mass, 60+ g/day

Iron‐ Ferrous form• Microcytic anemia

Vitamin B12 and Folate• Megaloblastic anemia

• Neuropathy• Increased homocysteine

Thiamine – Don’t give dextrose to gastric bypass patientswith prolonged nausea

• Motor and sensory neuropathy

• Wernicke’s encephalopathy

Nutritional Deficiencies

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Calcium / Vitamin D

• Metabolic bone disease• ↓ urine calcium and vitamin D, ↑ PTH and Alkaline Phospatase

Zinc• Alopecia, dermatitis, diarrhea, emotional disorders

Pregnancy• Need to ↑ Folate to prevent neural tube defects

Nutritional Deficiencies

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Recent Trends

Bariatric SurgicalOutcomes

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Five-year Morbidity& Mortality

Condition/Disease

Bariatric Surgery(N = 1,035)

Nonsurgical Controls(N = 5,746)

% Change in Risk Surgeryvs.

Non‐surgical Treatment

Cancer 2.03% 8.49% ↓ 76%

Cardiovascular & Circulatory

4.73% 26.69% ↓ 82%

Diabetes 9.47% 27.25% ↓ 65%

Respiratory 2.71% 11.36% ↓ 76%

Musculoskeletal 4.83% 11.9% ↓ 59%

Infections Diseases 8.7% 37.33% ↓ 83%

Mortality 0.68% 6.17% ↓ 90%

Christou, 2004

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Effect of Bariatric Surgery on Mortality in Swedish Obese Subjects

NEJM, August 23, 200747

Long-term Mortality after Gastric Bypass Surgery

US Study

Mean follow‐up 7.1 years;

7,925 patients per group

Reoperation “Failure” = Removal or inadequate weight loss

Swiss (

Death due to disease 48 %

Death due to CV disease 48 %

Death related to diabetes 88 %

Death secondary to cancer 59 %

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NEJM Conclusion Statement

The Missing Link – Lose Weight, Live LongerGeorge A. Bray, MD

Conclusion statement:

… “Thus, the question as to whether intentional weight loss (bariatric surgery) improves life span has been answered, and the answer appears to be a resounding yes.”

NEJM, August 23, 2007

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Meta-analysis Bariatric Surgery

Procedure 30‐day mortality (%) Overall series

Banding 0.1 %

Gastric Bypass 0.5 %

Biliopancreatic Diversion 

/Duodenal Switch1.1 %

*Buchwald et al, JAMA, 2004

Revisional Literature 1990‐2003*

11,720

Patients

30 day op

Mortality

= 0.55%50

ASMBS Center of Excellence

Hospital must perform at least 125 bariatric surgeries per year collectively, and the surgeon must have performed at least 125 himself and perform at least 50 per year.

The Center must also have a dedicated, multi‐disciplinary bariatric team that includes surgeons, nurses, medical consultants, nutritionists, psychologists, and exercise physiologists.

The Center must report long‐term patient outcomes and have an on‐site inspection to verify all data.

®

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Primary Outcome Data

From first 55,567 patients in ASMBS COE program

Variable N %

Total patients 55,567 100

30 day mortality 165 0.29

90 day mortality 196 0.35

SJAHS – Park Rapids Jan. 2000 – Jan. 2011

Aggregate Outcome Data of the first 176 applicants for full approval by SRC.

Pories, June 2006

N %

1,540 100

3 0.19

4 0.25

N %

2,715 100

4 0.15

5 0.18

SJAHS – Park Rapids Jan. 2000 – Jan. 2006

Patients from St. Joseph’s Center for Weight Management program

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30-day Operative Mortality Rates

Bariatric Surgery

ASMBS COE Average 0.29 %

SJAHS – Park Rapids 0.15 %

Other common major surgeries US Hospital Averages*

Elective aortic aneurysm 3.9 %

CABG 3.5 %

Esophageal resections 9.1%

Hip replacements 0.3 %

Pancreatic surgeries 8.3 %

*Dimick et a., JAMA, 2004

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More Recent Outcome Data

30‐day Mortality

N

22

%

0.09 %

90‐day Mortality

N

45

%

0.112

57,918Bariatric Surgeries

St. Joseph’s Center for Weight Management Outcomes, 2007‐Feb. 2011

30‐day Mortality

N

1

%

0.09 %

90‐day Mortality

N

1

%

0.09

1,106Bariatric Surgeries

ASMBS Bariatric Outcomes Longitudinal Database, June 2007‐May 2009

30‐day mortality

0.55 %

0.09 %

Meta‐analysis 1990‐2003

Most recent data, 2007‐2009

An 86 % drop in operative mortality!

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Thank you!

St. Joseph’s Area Health ServicesCENTER FOR WEIGHT MANAGEMENT

CATHOLIC HEALTHINITIATIVES

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