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Conferences and Medical Updates

Bariatrics update

Morbid obesity and endoscopic management
·         Overweight, obesity 1, 2 and 3 – 25,30, 35 and 40
·         GLP1,  ghrelin and other hormones
·         Space occupying balloons –
·         Gastric remodeling
·         Gastric remodeling plication
·         Aspiration therapy – pump food out from PEG
·         Duodenal sleeve

Nutrition in post gastric bypass

  • Give patients gummy bear vitamins 2 of them daily, iron and folic acid to all patients after bypass and also check b12, folic, iron, and zinc 3 months post surgery.  Other deficiencies include chromium, cadmium, selenium

Barretts Ablation

  • Best response to ablation in less than 8 cm, normal P51 and no modularity

Post bariatric complications

  • Three types : Malabsorbptive, restrictive or mixed
  • RYGB : roux en Y gastric bypass.  Most common, it is mixed  It has 4 things, roux limb, gastric pouch, biliopancreatic limb and blind limb
  • Sided to side will have 3 openings and end to side will have 2 openings.  Side to side has 3 openings for afferent and efferent limb and the biliopancreatic limb
  • Gastric band :Band is placed in proximal stomach and a tubing to the band and the tubing to a reservoir.
  • Vertical band gastroplasty : It is fallen out of favor. Inferior long term weight loss.
  • Biliopancreatic diversion plus duodenal switch : It is reserved for extreme obesity.
  • RYGB : If you want to see the RY limb you need the enteroscope.
  • Complications of RYGB.  Marginal ulcer, stenosis
  • Marginal ulcer in 16% of patients
  • Causes of marginal ulcer : Gastro gastro fistula NSAID use, Hp +, ischemia, gastric acidity and gastric pouch size.
  • If marginal ulcer found check Hp, and look for gastro gastro fistula, use PPI, liquid carafate, stop smoking and NSAID. May need revision surgery
  • Stomal stenosis  : more common in lap RYGB surgery.  Size less than 1 cm.
  • Stenosis : use TTS and dilate to 12 to maximum 15 mm size.  Do not dilate if there is marginal ulcer.  Over stretching can lead to dumping syndrome.  Perforation rate Is 2-3%
  • Staple line dehiscence : or gastro gastro fistula.  Can appear like a gastric diverticulum!
  • Complications of gastric banding include pouch dilation, band erosion and GERD
  • Other complications of RYGB : gallstones in CBD, food impaction

Bariatric surgery in Obesity

  • Roux – en – Y(RYGP).
  • Endoluminal bariatric interventions.
  • Complications of bariatric surgery – gallstones, PUD, GERD, food impaction, band displacement, band erosion.  RYGP compllications includes biliopancreatic diversion
  • Gastric bypass – late complications are stomal stricture, stomal ulceration, marginal ulcer, stomal ulcer, staple line disruption, internal hernia.  Pouch is 3-5 cm long.
  • Anastomotic ulcer in RYGP – 3-20% of patients.  They have nausea, vomiting and epigastric pain.  Ulcers on jejunal side usually. Remember to wash well.  Anastomotic ulcer can occur within a few cm of the anastomosis also.
  • Treatment PPI high dose, carafate, eradicate Hp.  Use carafate suspension not tablet.  Rare cases will require resection.
  • Anastomotic stricture – less common than ulcer.  Non wire guided dilatation with balloon.  Try to dilate to 1 cm. Usually diagnostic scope will not traverse.
  • RYGP – staple line fistula or disruption.  Fistula is between gastric pouch and gastric remnant.  (gastro gastric fistula).  S/S weight gain and reflux are symptoms.  Contrast radiologic study.
  • Cutaneous fistulas can also occur.
  • May need to remove anastomotic suture material with applying traction and cutting suture material.  This way you can see the ulcers etc better.
  • GI bleeding is uncommon in RYGP fortunately.  If DU, can be hard to reach it endoscopically.
  • Laproscopic adjustable gastric banding – dome seen on retroflexion.  Complications include food impaction, band displacement or slippage, band erosion, gastric pouch dilatation, esophageal dilatation.
  • Sleeve gastrectomy complication  – Long staple line 10-12 cm long!
  • Endoscopic Mx of post bariatric surgery – CBD stone,  Can be very difficult to remove the stones.
  • If EGD does not give answer – then do CT, SBFT and MRCP or EUS.  Role of WCE is questionable.  Consider Agile patency capsule.
  • Suture scissors maybe needed.