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
- 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.