3. Pre-operative
Indications of bariatric
surgery NIH -1991 criteria
BMI>40 or >35 with co-
morbidties*
1. DM
2. HT
3. Hyperlipidemia
4. GERD
5. Arthritis
6. IBS
7. OSA
8. NASH
C/I – Psychiatric disorders
Role of endoscopy
Undiagnosed UGI lesions -
may cause post op
complications
Clinically significant findings –
12%
Erosive esophagitis – 3.7%
Erosive gastritis – 1.8%
GU – 2.9%
DU – 0.7%
Gastric carcinoid 0.3%
Only 2/3rd of patients with
above findings symptomatic
4.
5. Management of postop complications
Ulcers
Post operative bleeding
Stenosis
Foreign body complications
Leaks and fistulae
Pancreatico-biliary disease
Weight regain
6. Ulcerations
Common complication(1-16%) – 20% after RYGB
Most common site GJ anastomosis
Usually seen with in first 3 months
Presentation
Pain , N/V, food intolerance, bleeds (occult/overt)
Causes
Acid from the pouch / Hp infection
Ischemia / Bile acid reflux
Foreign bodies – sutures/ bands
NSAIDS, alcohol and smoking
7. …ulceration
If with in 1st 2 weeks post op
Gastrograffin – endoscopy can cause stomal
disruption
Careful endoscopy with minimal insufflation can be
tried
Suspected Hp – pouch Bx or breath test may not
be useful – serology(Ag) better
8. Treatment
PPI – soluble PPI/ broken capsule BD X 6 mon
and then tapered
Sucralfate –solution(not tablets) – 1 gram QDS
Bile acids – Cholestyramine/ colestipol
If NSAIDS – PPI/ PGE1 therapy
Smoking/alcohol cessation
9. Postop GI bleeds*
UGI bleeds more common with RYGB(1.9%) than LAGB, SG and VBG
Sites
Pouch
GEJ
GJ/JJ anastomosis
Staple lines
Small intestine
Excluded stomach
Early bleeds – within 24hrs usually at staple lines of GJA/JJA or excluded
stomach
Significant proportion of early bleed is extraluminal h’dynamic instability,
oliguria and abdominal distension surgical intervention.
10. Late bleeding often – anastomotic ulcer bleed
Endoscopy – easily approached – esophagus, pouch and GJA.
Problem areas – excluded stomach, JJA – approached by – device
assisted enteroscopy
Early cases – endoscopy risk – perforation – minimal
insufflation/CO2 used
Treatment
Endoclips, Adr or dual therapy
Electrocautery – avoided
Upcoming – hemostatic powders/sprays
Angiographic interventions SOS – risk ischemia
11. Stenosis
Seen in 2-14% of cases with in 4-6wks
Presentations – early satiety, N/V, dysphagia,
retrosternal or abdominal pain
MC site GJA
If inciting factors – ulcers, foreign materials –
presentation delayed
Less common sites – JJA, intestinal adhesions
12. Definition– stenosis if a 9.5mm scope doesn’t pass beyond a
narrowing
Treatment – TTS balloon, Savary dilators, electrosurgical
incision.
Balloon MCly used – 90% success rate, some may require 2-3
procedures at 2-3wk interval
Waist obliteration most useful sign
Alternatively – dilatation upto 15mm safe at first procedure, 20mm
successful gradual approach ↓ risk of perforation
Removal suture material at mature GJA may be helpful
Stenosis in LAGB may be due to edema around the band or excess
tissue at the level of band Band removal/replacement/conversion to
13. Foreign body related complications
FB like – suture, staples, mesh
and bands – pain, ulcerations,
obstruction and migration of FB.
Chronic pain – removal of FB
Pain may be due to traction on
sutures of staples.
Immediate symptomatic relief in
71% after removal of foreign
body
Ryou, Surg obesity related dis
2010
14. Leaks and fistulae
Leaks – caused by discontinuity of tissue apposition immediate
post op period*.
Overall 1-5%,
Open RYGB 1.7-2.6%
Lap – RYGB – 2.1-5.2%
VGB – 1%, BPD – 1.8%
Sites
Pouch(10%)
GJA(MC 68%), JJA(5%)
Excluded stomach, duodenal stump, jejunal stump
Blind jejunal limb
Multiple site – 14%
Most leaks in SG – proximal 1/3 near GEJ(87.5%)
15. Mortality in leaks – 3.3-14%, 6x ↑ in hospital stay
↑ risk of infections, sepsis, AKI, int. hernia
Presentations
Fever (62%)
Pain
N and V (81%)
Tachycardia (72 -92%)
Leucocytosis (48%)
Raised CRP - >22.9 on POD – 2, 100% sensitivity for
leaks
16. Fistulae highest with divided
RYGB.
Gastro-gastric fistula between
the excluded stomach and
pouch
Course indolent
Heart burn
Acid reflux
Abdominal discomfort
Weight regain
17. Management
Dilatation of distal stenosis
Stents - excludes leak from lumen
allows leaks to heal, accelerates recovery, allows enteral
feeding (avoids TPN)
↓ peritoneal contamination ↓ pain and future adhesion risk
Stents – FC SEMS/SEPS can be used, metaanalysis n= 67
Successful leak closure with stents – 87.8%,
most needed one session, restenting seen in 4/7 studies
Failure – 9%,
Stent extraction 4-8 weeks
Stent migration 16.9%
Puli, GIE, 2012
18. other approaches
Clips – approximate tissue defects
Best deployed perpendicular to long axis of defect
Thermal ablation or mechanical scarping of margins results
in more firm seal
Newer clips – OVESCO – nitinol clips
Tissue anchor and twin grasper may be used in addition to
aid in clip placement
Results in full thickness apposition
Success rates 72-91%
Other methods in development – fibrin glue and fibrin
plugs
19. Pancreatico- biliary complications
Nearly 50% may develop stones within 3 months post
procedure
Prior to ERCP – characterization of anatomy of via
cross-sectional imaging important
ERCP with routine SVS feasible in LAGB, VBG & SG.
RYBG and PBD need special tools –
device assisted enteroscopy
Hybrid - Lap assisted ERCP
??? Transanal - ERCP
20. Weight regain
Weight loss post op plateaus after 1-2 year of surgery
Weight regain – neuroendocrine regulations, starvation induced ↑ appetite,
↓ satiety
Anatomical cause – Larger pouch size, greater GJA diameter or chronic GG fistulae
Treatment – endoluminal therapy –
TORe – Transoral Outlet Reduction, - Bard EndoCinch (endoscopic suturing) procedure –
RCT with sham procedure n=77, GJA >20mm
GJA ↓ to 10mm in 89.6%, wt. loss – 96%, 3.9% vs 0.2%(in sham group)
Thompson, Gastroenterology 2013
Another method Apollo OverStich technique – effective results
21. Endoscopic treatment for Obesity
Primary procedures for obesity - Restrictive procedures
Incision less operating
Transoral gastroplasty
ACE stapler
Transoral restrictive implants
Procedures for metabolic benefits - Malabsorptive
EndoBarrier duodenal –jejunal bypass liner
Bridge to bariatric surgery
Orbera intragastric balloons
Heliosphere BAG
Reshape Duo intragastric balloon
Obalon intragastric balloon
Satisphere
28. Space occupying devices
Procedure Weight loss(Kg) BMI
Orbera (n= 3698) 14.7 5.7
Heliosphere(n=60) - 4.2
Reshape Duo(n=21) 30% of patients had 25% EBWL compared
to 25% in control
Nitin Kumar, WJGE, 2015
29. Aspiration devices
RCT – n=29
Duration 1 year
Weight loss – 18.6%
Vs control 5%
Sulivan, gastroenterology
2013
30. DDW – 2016 abstracts
Spatz3 adjustable balloon,
approved for 1 year implantation – n=77, BMI 37,
balloon – 450-500
At 1 year – mean wt loss 17.2kg(15.9%), EWL –
42.9%, 1 pt had ulceration
ELIPSE balloon – procedure less balloon
n= 8, BMI >31, swallowed balloon (deflated), inflated
with 450ml with filling fluid.
6/8 – remained insitu for 6 weeks without any
complications, not special diet/change ADL needed
Results – demonstrated safety, actual wt. loss not
shown!!
31. EUS guided GJ using double balloon enteric
tube lumen apposing metal stent
Animal study
GJ created under EUS guidance
4/5 stents placed successfully
Necropsy showed successful adhesion between
stomach and jejunum
Itoi, GIE 2013
32. Dual path enteric bypass using Magnetic
Incisionless Anastomosis systems(IAS)
Through the scope self assembling magnets, that
create large calibre durable anastomosis
Octagonal - IAS magnets – delivered via
simultaneous enteroscopy and colonoscopy under
fluoroscopy guidance.
After stoma formation magnets expel naturally
Weight loss and HbA1c reduction significant vs
controls.
