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Case 1:

Case 1:. A 45-year-old woman c/o of acute retrosternal pain with dorsal radiation Past Medical History (+) for HTN, DMII, dyslipidemia Past Surgical History: 2 x C/S

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Case 1:

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  1. Case 1: • A 45-year-old woman c/o of acute retrosternal pain with dorsal radiation • Past Medical History (+) for HTN, DMII, dyslipidemia • Past Surgical History: • 2 x C/S • had undergone LAGB(Laparoscopic Adjustable Gastric Banding) for morbid obesity at another hospital 3 years previously; current BMI is approximately 35

  2. Super-Sized in the ED:Bariatric Surgery Complications Scott Bicek University of Calgary March 1,2007

  3. Objectives: • Obesity epidemiology • Overview of bariatric surgeries • Complications of bariatric surgery • ED scenarios

  4. Measuring Obesity • BMI (Body Mass Index) = (body mass)/(height)2 = kg/m2 • Canadian Standards • < 18.5 = Underweight • 18.5 to 24.9 = Normal weight • 25.0 to 29.9 =Overweight  •  ≥ 30.0 = Obese

  5. Obesity Trends Among Canadian and U.S. Adults, 1990 No Data <10% 10%-14% 15-19% 20% Mokdad AH. Unpubliahed Data. Katzmarzyk PT. Can Med Assoc J 2002;166:1039-1040.

  6. Obesity Trends Among Canadian and U.S. Adults, 1994 No Data <10% 10%-14% 15-19% 20% Mokdad AH, et al. J Am Med Assoc 1999;282:16. Katzmarzyk PT. Can Med Assoc J 2002;166:1039-1040.

  7. Obesity Trends Among Canadian and U.S. Adults, 1996 No Data <10% 10%-14% 15-19% 20% Mokdad AH, et al. J Am Med Assoc 1999;282:16. Katzmarzyk PT. Can Med Assoc J 2002;166:1039-1040.

  8. Obesity Trends Among Canadian and U.S. Adults, 1998 No Data <10% 10%-14% 15-19% 20% Mokdad AH, et al. J Am Med Assoc 1999;282:16. Katzmarzyk PT. Can Med Assoc J 2002;166:1039-1040.

  9. Obesity Trends Among Canadian and U.S. Adults, 2000 No Data <10% 10%-14% 15-19% 20% Mokdad AH, et al. J Am Med Assoc2000;284:13. Statistics Canada. Health Indicators, May, 2002.

  10. Obesity Trends Among Canadian and U.S. Adults, 2003 No Data <10% 10%-14% 15-19% 20% Sources: Behavioral Risk Factor Surveillance System, CDC Statistics Canada. Health Indicators, June, 2004.

  11. Medical Complications of Obesity Idiopathic intracranial hypertension Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Stroke Cataracts Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Coronary heart disease Diabetes Dyslipidemia Hypertension Severe pancreatitis Gall bladder disease Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Phlebitis venous stasis Skin Gout

  12. Bariatric Surgery • In 2001, approximately 30,000 weight loss procedures were performed in the U.S • increased to approximately 60,000 in 2003 • increase in bariatric surgery has also been fueled in part by the application of laparoscopic techniques

  13. Vertical Banded Gastroplasty

  14. Vertical Banded Gastroplasty • purely restrictive procedure • A small pouch is made along the lesser curvature of the stomach using surgical staplers

  15. Vertical Banded Gastroplasty • purely restrictive procedure • A small pouch is made along the lesser curvature of the stomach using surgical staplers

  16. Vertical Banded Gastroplasty • purely restrictive procedure • A small pouch is made along the lesser curvature of the stomach using surgical staplers • A nonadjustable band then constricts the outlet from the pouch

  17. Vertical Banded Gastroplasty • purely restrictive procedure • A small pouch is made along the lesser curvature of the stomach using surgical staplers • A nonadjustable band then constricts the outlet from the pouch

  18. Vertical Banded Gastroplasty • Procedure relies on reduced food intake to achieve weight loss • patients tend to lose approximately 50% of excess weight during the first 2 years postprocedure (Edwards et al., 2006) • Longterm follow-up of patients has revealed that it is not an extremely effective weight loss surgery

  19. Vertical Banded Gastroplasty • patients who undergo a vertical banded gastroplasty circumvent this restrictive procedure by eating soft, high-calorie foods

  20. Laparoscopic Adjustable Gastric Banding (LAP-BAND)

  21. LAP-BAND • the restrictive procedure of choice • adjustable silastic band that is positioned around the upper portion of the stomach • The band is connected to a port that is implanted under the skin

  22. LAP-BAND • port is similar to those used for vascular access and allows the band to be tightened or loosened, depending on clinical need • advantages over the vertical banded gastroplasty include: • No surgical stapling of the stomach (decreased risk of perforation or fistula formation) • Ability to regulate degree of restriction postoperatively • relative ease for reversibility

  23. Case 1: • A 45-year-old woman who had undergone LAGB for morbid obesity at another hospital 3 years previously • complains of acute retrosternal pain with dorsal radiation • w/u completed to r/o MI and PE (ECG, Troponin, CT-PE – all normal)

  24. Case 1: • Several hours after admission and only after insistent questioning did the patient mention the concomitant onset of severe food intolerance that she considered to be secondary to her chest pain • Any other investigations you would like to order?

  25. Case 1: • Gastrograffin swallow revealed strangulation of the stomach by the adjustable gastric banding device with dilatation of the upper gastric pouch (prolapse)

  26. Gastric Prolapse • characterized by enlargement of the upper gastric pouch due to herniation of the fundus upward through the band • Its incidence has decreased from 22% to 5% in recent years after modification in surgical technique and improved band adjustment protocols (Spivak and Faveretti, 2002) • manifests by food intolerance, vomiting, regurgitation, heartburn, and epigastric pain

  27. Gastric Prolapse • If the diagnosis is suspected (or confirmed late radiographically) what should your next step be? The band MUST be completely deflated

  28. Deflating the LAP-Band: • The access port is usually situated in the LUQ either subcutaneously or under the anterior sheath of the rectus abdominis muscle • In patients who have already lost weight, it can usually be palpated and stabilized between 3 fingers of the left hand using STERILE TECHNIQUE • A 20 GA needle on a 10 cc syring held in the right hand penetrates the port membrane at its center

  29. Deflating the LAP-Band: • Proper positioning of the needle within the port chamber is attested by the tactile feeling of the needle tip hitting the metallic chamber floor and by spontaneous outflow of fluid • The most commonly used model is the LAP-BAND 9.75 cm which can accommodate up to 5 mL of fluid (whereas other models contain as much as 9 mL) • Can be done under fluoroscopy guidance

  30. Case 1: • After the diagnosis of gastric prolapse was made with the gastrograffin study, the LAP-band was successfully deflated (4 cc was extracted from the port) • Urgent Surgical consult initiated • Would you like any other investigations?

  31. Gastric Necrosis and Erosion: • GI consult for URGENT gastroscopy because gastric necrosis and erosion has been demonstrated with gastric prolapse • In one large study, gastric erosion occurred in 6.8% of patients in isolation (Suter et al., 2004) • Patients may present with evidence of intra-abdominal sepsis caused by perforation with or without abscess, gastrocutaneous fistulas, and with ‘‘late’’ infection at the port site • Treatment for this problem consists of surgical removal and repair of the gastric perforation

  32. Complications After Laparoscopic Adjustable Gastric Banding

  33. LAP-BAND: Complications • Cumulative operative risks for the laparoscopic adjustable gastric band appear to be less than that for gastric bypass

  34. Roux-en-Y Gastric Bypass

  35. Roux-en-Y Gastric Bypass • most commonly performed operation for morbid obesity in the U.S. (performed both open and laparoscopically) • both a restrictive and subclinical malabsorptive procedure

  36. Roux-en-Y Gastric Bypass • a small proximal gastric pouch (15-30 ml) is made and is connected to the jejunum - a variable amount of proximal small bowel is bypassed

  37. Roux-en-Y Gastric Bypass • a small proximal gastric pouch (15-30 ml) is made and is connected to the jejunum - a variable amount of proximal small bowel is bypassed

  38. Roux-en-Y Gastric Bypass • a small proximal gastric pouch (15-30 ml) is made and is connected to the jejunum - a variable amount of proximal small bowel is bypassed

  39. Is Roux-en-Y Gastric Bypass Effective? • Comparing Roux-en-Y to laparoscopic adjustable gastric banding, it produces greater excess weight loss, 74.6% versus 40.4% at 18 months (Biertho et al., 2003) ...But is it safe?

  40. Case 2: • 45 year old, obese (BMI = 42) woman presents to the ED c/o feeling “feverish” and unwell x 12 hours • Past Medical History is (+) DMII, knee OA (bilateral) • Rou-en-Y gastric bypass performed in Medicine Hat 2 weeks earlier

  41. Case 2: • Vitals: T=37.9, HR=115, BP=110/65, RR=20 • Physical examination: very unremarkable

  42. Complications After LaparoscopicRoux-en-Y Gastric Bypass

  43. “The Big 3” Complications You Do NOT Want to Miss

  44. “The Big 3” Complications You Do Not Want to miss • #1 ANASTOMOTIC LEAK • #2 DVT or PE • #3 BOWEL OBSTRUCTION (INTERNAL HERNIA)

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