BMI » postoperative

A BMI PATIENT’S FEEDBACK

ramana — Tue, 06 Dec 2011 04:00:06 +0000

At BMI, we don’t generally talk about our successes. We focus, instead, on the science, the details that are not covered in counseling sessions with patients and their families. This is probably why we are on the first page of Google on most of the search terms for bariatric surgery.

Once in a while, we should (I think) take a break from this natural reluctance to brag. Not with the objective to actually brag, but with the aim of revealing what it feels from the other side: the patient’s side. Seriously. Take my word for it.

(yeah, the smiley is too big, but I can’t edit it to fit. Sue me!)

Enough said. Here is Sharon, from Ireland, who looks good enough to be a show-stopper and has actually done skydiving post-surgery:

It is now nine months since I have given birth to my new body. Well if its good enough at the start of life, its a good enough now because in many ways I have been reborn.

I travelled to India from Northern Ireland in January 2011. Little did I know the course my life would take during the nine months from entering the Bellvue Clinic that day. The gorgeous Saul made the wait in between assessments easy and he is a terrific ambassador for Drs Ramana and Baig. Surgery and post surgery care was incredible and if anyone from the UK National Health Service reads this – please take note because the NHS could learn a lot from these guys.

Back in Northern Ireland my life took on a new meaning. As the pounds dropped off my self confidence and esteem grew. It is a true saying – nothing tastes as good as slim feels. I was down several dress sizes before the summer and for the first time in over thirty years I bought a bikini for my holiday to Mauritius.

I was so happy to see the look of love my husband, Devendra had when he saw me wearing it because whilst in Mauritius he passed away. One of the hardest things I have ever had to do was to carry my darling husband’s ashes home to Northern Ireland. That was three months ago and I am coming to terms with losing Dev.

But what has all this got to do with bariatric surgery? EVERYTHING is the answer. As a butterfly must emerge from its chrysalis, so my inner strength was releashed. I am no longer the Sharon who hides her emotions under the kilos. The surgery and resultant weight loss has given me the liberation to expect the right to be respected for the woman I am. To misquote the line: ‘No one puts Sharon in the corner anymore’.

So far 2011has been an emotional rollercoaster ride, and its not over yet. In two weeks time, I shall be travelling to New Zealand to see my son Mark, who I have not seen since May 2009. As you can imagine, I can hardly contain my excitement at the thought of our reunion. As part of his itinerary for my trip, he has organised a tandem skydive for me. It would have been impossible for me to do this if I had been my weight at the beginning of the year and therefore will be a defining moment in this new chapter of my life.

What a fitting memorial to my wonderful husband.

Blondiexxxx

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REDUCING MORTALITY IN BARIATRIC SURGERY

ramana — Sun, 09 Oct 2011 13:52:52 +0000

As you may or may not know, mortality in bariatric surgery occurs at a very acceptable 0.2-0.3% rate. Compare this to gall bladder or appendix surgery (0.3 to 0.4%).

This means that in this class of obese people, if we operate on a thousand, two will die. If you take these same thousand people and just let them carry on the same way (with medical treatment, etc.) HALF of them would be dead in 20 years! In fact, the five year mortality of these patients is high enough to justify bariatric surgery.

Even though this is pretty impressive stuff to demonstrate how life-saving and life-altering bariatric surgery can be, what happens to an individual case where the patient dies? For that family, the mortality rate is 100%! Can things be any worse for them? No.

Therefore, if we could try and reduce the mortality of surgery even further, why would we not do it?

If we could weed out the highest risk cases, it would be half the battle won. We could then simply try not to operate on this high-risk class of patients, UNLESS there is a clear and explicit understanding and acceptance that they have a significant chance of dying within a month of surgery.

So the highest risk is seen in these groups:

Elderly
Males
High BMI
Smokers, alcoholics
History of pulmonary embolism/DVT
Re-do bariatric surgery

Recently, a paper showed statistics that suggest that bariatric surgery in elderly men does NOT offer the benefits other patients derive from it.

Why do patients die?

The most common reason is Pulmonary Embolism. Obese patients are prone to get blood clots in the leg and pelvic veins (Deep Vein Thrombosis) that can fragment and go into the blood stream before they get trapped in the lungs and obstruct the right heart’s main artery (pulmonary artery). To prevent this, we employ three common methods in hospital:

Chemical prophylaxis: injections of heparin or low molecular wight heparin (LMWH) daily under the skin till the patient is mobile and ambulant.
Mechanical prophylaxis: Sequential Compression Device (SCD) is used universally. The legs get compressed serially from below up by a machine that pumps air under pressure into stockings worn on the lower limbs.
Mobilisation: pre- and post-op movement out of bed is strongly encouraged. In special situations (paralysis, orthopedic handicap) the mobilisation may be done by a special physiotherapist.

Statistically, DVT/PE occurs even at home two weeks after the patient gets discharged. This clearly suggests that there is a chance of PE two weeks after stopping DVT prophylaxis. As this chance is maximal in the first month or so, it may be appropriate to continue LMWH injections for 30-45 days at home, especially when the patient falls into the high-risk category.

At BMI, we have now adopted this policy clearly for the higher risk patients.

In patients with a history of deep vein thrombosis or PE, further episodes of PE may be avoided by placing an umbrella in the IVC (the Inferior Vena Cava — the great vein carrying blood from the lower limbs and pelvis to the heart). This is done through a needle puncture in the groin.

Coronary heart disease is also a major cause of mortality. Obviously, the disease is pre-existing in these patients. Appropriate specialist care is needed, again obviously. It may be mentioned that almost all the risk factors for a heart attack are improved after bariatric surgery.

Among the surgical causes of death, leaks take the cake. Apart from that, intra-abdominal abscesses and bowel obstruction following gastric bypass or BPD/DS are important causes.

It has been said that most deaths following any surgery do not result from a single gigantic error, but rather from a series of small errors, each of which compounds and amplifies the complication leading to the patient’s demise. Suffice it to say that while the surgical complications mentioned above themselves are significant, they become lethal because of delayed diagnosis in two-thirds of cases. Negligence has been noted in nearly a third of such deaths.

Association of suicides with bariatric surgery has been a source of controversy, as we have discussed before.

As far as the surgical strategies to reduce mortality are concerned, we need to reduce leaks and obstructions and detect them early when they occur. Leak prevention includes using staple-line buttresses, suturing, avoiding too narrow a tube, and avoiding thermal injuries. Bowel obstruction prevention largely deals with closure of internal defects at the time of gastric bypass and avoiding the retrocolic approach.

References:

Causes of 30-day bariatric surgery mortality: with emphasis on bypass obstruction– Mason EE, Renquist KE, Huang YH, Jamal M, Samuel I.
The SOS Study: Sjöström
The Pennsylvania bariatric mortality study
Long-Term Mortality after Gastric Bypass Surgery: Ted D. Adams, et al.
Medicolegal analysis of 100 malpractice claims against bariatric surgeons: Cottam D, Lord J, Dallal RM, Wolfe B, Higa K, McCauley K, Schauer P.

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LEAKS AFTER GASTRIC BYPASS

ramana — Sun, 25 Sep 2011 23:06:00 +0000

Almost all people (with the exception of some bariatric surgeons) believe that the sleeve gastrectomy is a safer operation than the gastric bypass because of the ease and simplicity of the procedure, as also the possibility of leaks in the latter case (multiple staple lines). At the root of the confidence of many surgeons is the view that the stomach, being a vascular organ, would be a safe bet in healing.

This is an oversimplification, IMO.

I have mentioned before that the sleeve, in spite of being an easier and faster procedure, may be more problematic in terms of leak alone. The leak rate of the sleeve is around 2-3 percent, while that of the bypass is around the same, but the leaks behave differently.

The sleeve leak (as discussed in details before) is a high pressure leak, occurring usually at the angle of His, and tends to persist unless stented.

The bypass leak occurs at multiple possible sites, half in the gastrojejunostomy, but being a low pressure leak, tends to dry out on its own once the surgical re-exploration is done and issues sorted out.

(pic from referenced article)

Leaks after a bypass are usually detected on Day 3, give or take some. The detection may be because of routine dye study, but usually the patient already has a high pulse rate, fever, abdominal pain, dirty drain output, etc. It is important to remember that around a third of patients may have no clear evidence of a leak in spite of CT scan or dye test or both. In fact, in an older study, only a pulse rate over 120 and a rapid breathing rate were consistent in patients with leaks, and only 2 out of 9 leaks showed up on the dye study. This means that a laparoscopic re-exploration is the most reliable of investigations for a leak!

Upon detection of a leak after the bypass, the patients is usually re-explored laparoscopically. The procedure may include any or all of the following:

Re-suture of leak with omental graft
Re-do the full anastomosis
Partial remnant gastrectomy (in case of remnant staple line leak)
Drainage
Gastrostomy

While around 2 percent of bypasses may leak, when they do occur, they inflict considerable collateral damage: gastrogastric fistula, wound complications, lung problems, DVT/PE, etc.

It is also important to remember that a downstream problem like an obstruction of the jejunum may cause leaks from the staple line above.

Are there groups which have a predictably higher leak rate?

Yes, it may be said that the leak risks are higher in:

Revisional bariatric surgeries (around 13-14%)
Males.
Higher BMI.
Multiple co-morbidities.
Patients with previous abdominal operations.
Circular stapled anastomoses (hand-sewn method has the lowest leak rate of 0.4%): controversial!
Inexperienced surgical hands.
Those who have had an intraoperative mishap (colon/splenic injury, for example).
One leak may predispose to another.
Buttressed staple lines may have an advantage in leak rates.

The mortality of jejuno-jejunal leaks is close to 40-50 percent, while a GJ leak has a 10% mortality.

What happens once a leak is detected and the patient re-explored? Initial days may be stormy or tense, spent in the ITU with ventilatory support given to some patients (remember, many of these patients are already sick with other co-morbidities), and then the sepsis gets controlled and the nutrition support started (through the gastrostomy tube or through a central vein in the neck, etc.). The patient recovers slowly and the leak heals with time. In the rare case, if a leak persists beyond a month, a stent may be required.

With this post, our continuing exploration of the Achilles heel of all bariatric operations has been, you will admit, rather thorough. If this and the other articles frighten you, then be assured that this was and is not the goal of my writing. We at BMI believe that an informed patient is the best one, and we owe it to you to even out the information asymmetry in this highly technical branch of medical care. All surgeries have side effects, but they occur in a small minority of patients. In the given case, each complication hits hard, and a prepared patient handles it better. As bariatric surgeons, we need to brief you adequately as to the possible downsides of what is otherwise a transformational event in life.

Ref:

Diagnosis and Contemporary Management of Anastomotic Leaks after Gastric Bypass for Obesity

J Am Coll Surg

Rodrigo Gonzalez, MD, Michael G Sarr, MD, FACS, C Daniel Smith, MD, FACS, Mercedeh Baghai, MD, Michael Kendrick, MD, Samuel Szomstein, MD, FACS, Raul Rosenthal, MD, FACS, Michel M Murr, MD, FACS

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LEAKS AFTER SLEEVE GASTRECTOMY (PART THREE)

ramana — Thu, 22 Sep 2011 14:55:03 +0000

After the initial (and highly popular, if I may say so) posts on the subject (see Parts One and Two), we will now talk about what we have gained in terms of experience and insight about this subject.

I had jokingly noted how BMI has not had a leak in many years. This year (obviously our busiest year so far) we have had three leaks, each unique in mechanism, presentation and treatment.

I will discuss the cases separately later in my posts, and share some thoughts about this important topic.

Sleeve gastrectomy leaks behave totally differently compared to any other type. The reasons are multiple, and all lead to a persistent and nagging leak that may end up as a fistula (a tract between the stomach and the skin).

The causative factors are:

The pylorus (ring of muscle that acts a the gateway from the stomach into the duodenum) is normally closed, and the pressure in the gastric tube increases because of that, especially when a peristaltic wave builds up in the organ. The pressure may be as high as 45 mm Hg pressure, whereas the lower esophageal pressure is 20 mm Hg at most. The resultant gradient of pressure is from the pyloric end towards the esophagus. This leads to high pressure acting on the highest end of the staple line (near the GE junction). Greater the pressure, the higher the leak rate.
The GE junction area is least supplied by blood vessels. This would lead to relatively weaker healing.
The intrathoracic pressure is negative, and the pressure differential in the upper stomach, therefore, is high.
The gastric tube may twist in a corkscrew manner in the postoperative phase, perhaps as a result of the staple line running in different directions and the muscle layers getting transected at different levels.
The incisura of the stomach may be narrowed by the stapling. This would not only lead to high pressure build up in the stomach but also make leak management doubly difficult.

Whatever be the cause, leaks may increase mortality (10%), and certainly do increase hospitalisation and costs of treatment. In fact, in the Indian context, where insurance is nowhere in the picture, it is scary to imagine a leak in a patient with limited resources.

Some other points about sleeve leaks:

* The most leaks occur when both staple line buttresses and overrunning sutures are used (Gagner).

* Intersections of staple lines must always be oversewn to prevent leaks.

* The narrow sleeves leak the most compared to the wider ones (typically 32 Fr versus 40 Fr).

* Leaks may occur even as late as 2 to 4 weeks after operation, though this is not common.

* A leak mandates immediate re-exploration, drainage and insertion of a feeding tube (nasojejunal or jejunostomy or parenteral). Many experts now routinely insert a stent intraoperatively during the re-exploration. This possibly reduces hospital stay.

* A chronic leak persisting over three months is not amenable to endoscopic stenting and would need surgery.

Endoscopic stent management of sleeve leaks (some major points to bear in mind):

For stents to work, the defect should be less than 3 cm or less than 50% of the circumference of the organ.

As mentioned above, the consensus seems to be emerging that leaks should be stented during the re-exploration. At this re-exploration, an attempt may be made to identify the leak, suture it with an omental pedicle as buttress and drain the area. If the leak is not easily visible, one should not hunt it, for fear of causing injuries in the friable and inflamed area.

If a stricture is present along with a leak, two stents may be used to cover the entire sleeve, or the single stent has to reach up to the incisura/stricture.

SEMS for Sleeve Leak (video)

The stents used may be Self Expanding Plastic Stents (SEPS) known as Polyflex or SEMS (self expanding metal stents). The problem with the Polyflex or plastic stents is that they tend to migrate, while the SEMS stents are very difficult to remove. To this end, the two stents have different problems and different solutions have been tried successfully: to prevent migration of the SEPS stent, a thread is passed through the edge of the stent and brought out through the nose and tied to the patient’s ears (!). Ingenious and cheap. With the SEMS stent, double coating may make for easier removal. I have seen one presenter at IFSO 2011 at Hamburg mention and show esophageal avulsion injury during removal of a metal stent.

Stents cause problems:

Reflux
Salivation in the morning
Chest pain
Dislodgment
Erosion
Difficult removal

Stenting should be accompanied by endoscopic pyloric dilatation, using 20 psi pressure. This reduces the intra-sleeve pressure.

Checking the stent position every week or month (depending on the policy) is necessary.

Endoscopic methods other than stents:

For leaks less than 1 cm, several injections of fibrin sealant may lead to 100% success rates.
For the same kind of leak, argon laser coagulation has also been used (Basso).
Through-the-scope clips may be used for defects less than 1 cm.
Over-the-scope clips may be used for larger defects.
A Brazilian center advocates an endoscopic septotomy (division of a ridge like elevation that forms beside a chronic fistula) and cleaning up of the abscess adjoining the fistula, thereby leading to an internal drainage of the leak. This allows immediate removal of the drain. This is an unorthodox method of treatment.

Surgery:

For a chronic leak, surgery may be a last resort.

The simplest is to connect a jejunal loop to the fistula defect
The sleeve is converted to a gastric bypass and the fistula is left untouched. This converts the high pressure sleeve leak to a low pressure bypass leak. The fistula then dries out.
Conversion to bypass and stoma constructed at the leak site.
Total gastrectomy with esophagojejunostomy (Neto).

I hope this series has been educational for you, whether you are a patient, relative, doctor or student.

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MAKING THE MOST OUT OF LIFE AFTER BARIATRIC SURGERY

ramana — Sun, 08 May 2011 13:26:34 +0000

Those who undergo or contemplate bariatric surgery do so essentially as a second chance at life. I mean that the severely obese man or woman feels that he (or she) has lost out in life on multiple fronts. Here are a few examples:
Loss of body contour/beauty: you can’t forget how you were once before the fat started piling on.
Poor self image: you hate the thing you see in the mirror.
Poor quality of life: you can’t dance, surf, skip, run or walk without some kind of pain or discomfort. Going up one floor makes you breathless. You avoid holidays where you would need to walk, especially on hilly terrain.
Sexual issues: whether it is inability or unwillingness of one’s partner, sex life may take a back seat or even come unseated!
Health loss: you suddenly have been diagnosed to be having diabetes or heart disease (or anything else) and, suddenly, life sucks!
Social alienation: Even though there have never been as many obese people in the planet as the present, the morbidly obese individual catches everyone’s eye the wrong way. People make jokes, there is job discrimination, and even marriages get burnt!
The need for bariatric surgery serves as the wake-up call. What many people don’t realise is that bariatric surgery should not (and is not) a short cut. You cannot eat all you want and stay slim after the surgery. Therefore, if you look at the long term figures of weight loss after bariatric surgery, it may be as low as 40 to 50 percent, though the initial weight loss achieved may be 75%.
Obviously, we know weight regain is an issue for patients, and has to be addressed properly.
Even better is if you can program your life to prevent weight regain.
An unnamed BMI patient (we take our patients’ privacy seriously) writes to me:

Seems like such a long time ago that I was through surgery. I am still learning what I can and cannot do regarding food. I have a different attitude towards food now, which I never would have believed possible. I find the Paleo Diet hard to follow but have taken some of it on board and restrict foods, such as bread and potatoes to a bare minimum (a couple of slices of bread per week) and I haven’t eaten rice since surgery. I eat an egg for breakfast and sometimes mushrooms. The days of a full Ulster fry-up are long since gone, and dinner is served on a small side plate. I see the portions people eat and shudder. I have seen me ask for a children’s portion and still not finish it. I still have some milk in coffee and I eat natural yoghurt, which is not permitted but in general, my eating habits have really improved. Fresh fruit and veg, and some fish or chicken. I can only digest minced red meat and even then, only in small quantities, but nothing can equal how I feel.

(Eat This!)

(And This!)

As I keep saying, eat natural foods and avoid man-made food products.

(Stay strong when life tempts you!)

She reflects the pursuit of that kind of eating style (like primitive or Paleo man) that I teach. In addition, she has taken up kettlebell training and getting active in general. What does a lifestyle like this (without chips, pizza, cakes and bread on a daily basis) feel to the mind?

I can’t really explain the change which has occurred inside. I have my positive attitude back and feel I can tackle the challenges with more confidence than I have had in ages. The fact I am free of all medication is also a tremendous bonus.

And the bonuses keep coming to keep you motivated.

I saw my cousin today and she couldn’t believe how well I looked since the last time she saw me. I didn’t tell about the surgery, reasoning it was my business and she didn’t need to know. She congratulated me but then admonished me not to put it back on again. I assured her that wasn’t going to happen and left it at that.
I’m enjoying being normal and, for the time being, I am happy about that. I remember you saying that was a very low priority but for the moment, I am content. I now weigh what I did in 1995 and most people have never seen me this size so it comes as a bit of surprise.

Thank you, my dear (you know who you are): these words have inspirational content that mere doctors can only hope to provide!

All photos are original property of BMI.

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GASTRIC BYPASS: CHOOSING THE STOMA

ramana — Thu, 21 Apr 2011 00:00:49 +0000

Weight loss after the lap gastric bypass is a well known fact. What is less known is that there is a certain degree of weight regain in some patients in the long term.

Before we proceed, do you know what is a lap gastric bypass all about?

An important factor to be considered by every patient/doctor involved in a gastric bypass is how the stoma for the pouch would be created, as it is one of the known factors leading to weight regain.

The stoma is the opening we create between the gastric micro-pouch and the upper small bowel (jejunum). Too big a stoma will lead to food exiting the pouch quicker and resultant weight regain. Too small a stoma would lead to obstructive symptoms and misery.

So what is the ideal stoma size: 12 mm, 14 mm, 18 mm, or 25 mm? And how would we create this stoma? Does the stoma size stay that way all life at the same size?

Easy, tiger, easy. One thing at a time!

Ideal stoma size:
Different people seem to be using different sizes. A popular way of creating the stoma is with the EEA circular stapler and the OrVil device. The stoma created is either 21mm or 25mm in size.
The stoma is a little big but it is known to contract in size later. The risk of stenosis being highest in the circular stapler group, it is perhaps better to keep stoma size around this level. A smaller stoma may stenose and cause obstructive symptoms. The incidence of stenosis is less than 3 percent.

The hand-sutured technique (my personal favorite) is known to stenose the least in the long term. Here the stoma size is 12 mm/36 Fr. In case you are wondering how we can measure in millimeters in lap surgery, we pass a 36 Fr gastric tube through the mouth into the pouch. The anastomosis between the pouch and the jejunum is fashioned over this tube.
A stoma can be created with the Linear Stapler. This leaves the anterior (front) walls open, and need hand-suturing to complete the process. The stoma also tends to be excessively wide, in my experience. Therefore, at BMI, we don’t favor this method, preferring the hand-sewn and EEA techniques instead.
So the keen patient here would be wondering, “Which is better or best?”
Like most things in life, it depends. Each method of stoma creation has its pros and cons.
The EEA circular stapled method is quick and mechanised, so suturing is not a major issue. The stoma is reliably and safely created, with minimal leak rates. However, it is expensive, needs the surgeon to be familiar with the device, and has the highest stenosis rates. On top of that, technical disasters are not unknown (study in colorectal context).

The hand-sewn method (best demonstrated by Kelvin Higa) is also safe, reliable and avoids mechanical stapler failures and disasters. It needs the highest level of skills in the surgeon, and is more time consuming in most hands. Experts, however, can complete this quickly.

The Linear Stapler method is easy for most surgeons, but has very little to recommend it.

One final issue with the stoma: do we need stoma to be buttressed, or glued? It may by nice to do and for us to see in the operating room, but it probably does not reduce leak rates significantly. In the high-risk patient we may choose to use it. Some studies do report significant benefits in reduction of bleeding, leaks and stenoses.

The bottomline is to ask your surgeon how he would create the stoma, and what he prefers. Then make up your mind to go for it. You have more to gain by that decision: that one thing that will transform your life.

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DOES BOUGIE SIZE IN SLEEVE GASTRECTOMY MATTER?

ramana — Mon, 07 Feb 2011 22:57:50 +0000

When we started out on doing the sleeve gastrectomy a few years back, it was typically over a 60Fr bougie. The important thing, we learnt, was not to leave any part of the fundus of the stomach behind. This was the important technical thing to check. Our old patients have all done well.

Since the last couple of years, however, it has become commonplace to do tight sleeves over bougies 32-36 Fr. The idea is that a tighter sleeve is more restrictive in terms of stomach capacity and would give faster and better weight loss.

This article examines the truth.

Gagner et al had published an article in Obesity Surgery in 2008 showing better safety profile in their own series for patients who had 60 Fr sleeves compared to those who had narrower 40 Fr sleeves. Today, however, we are talking of much tighter sleeves. The question, therefore, could be “Does a sleeve twice as tight as a conventional 60 Fr sleeve give better results?”

Recent studies have shown that tight sleeves have shown good results. In fact, many of us in India have no regrets doing tight sleeves, with equivalent weight loss in the short term and 85-100% resolution of diabetes mellitus.

At BMI, we use around 34 Fr or 38 Fr, but end up with a slightly tighter sleeve because of meticulous oversewing of the staple line.

The most important consideration in designing a tight sleeve is to ensure that there is no narrowing at the level of the incisura (the sag-point of the stomach where the organ turns horizontally towards the right of the patient). A narrowing will cause a leak at the GE junction or lead to persistent vomiting later, necessitating invasive treatment later. All in all, a highly regrettable outcome could ensue, so it is wise to leave a wider incisura than make it too tight.

Some new thoughts are also currently being aired on improving outcomes after the sleeve. Could the gastric tube, detached from its greater curve attachment of gastrocolic (“greater”) omentum, get coiled up later and impair emptying of the organ? Would it be wise to re-anchor the omentum to the stomach tube?

We really don’t know yet. Interesting possibilities abound, but the truth is by no means established.

In recent times, several studies have reported no increase in complications when the staple line is not reinforced with stitches. In fact the last one I read talked of zero leaks in more than 500 cases. At BMI, we have now switched from ”meticulous suturing of the staple-line” above to stitches placed at the junction of adjacent staple lines.

And, so far, we are free from the disaster of leaks (knocks on wood).

So, if we create tighter sleeves with a narrow bougie (between 32 and 36 Fr) would we have a higher rate of strictures? No. In a recent article in a journal, Zundel et al have reported a 0.26 % stricture rate. The cause of stricture may be:

1. A hematoma (blood clot) causing compression

2. Stitch causing narrowing

3. Ischemia due to inadvertent vascular injury to branches of the left gastric artery.

4. Kinking of the gastric sleeve (due to stitches, stapling technical errors, etc). This can occur regardless of sleeve size.

5. Fistula: the associated inflammation causes narrowing.

6. Band removal cases, usually associated with much fibrosis.

7. Mucosal edema and food impaction can also cause acute blockage.

References:

1. Gagner M, Deitel M, Kalberer TL, et al. The Second International Consensus Summit for Sleeve Gastrectomy, March 19-21, 2009. Surg Obes Relat Dis. 2009;5:476–485.

2. Frezza EE, Reddy S, Gee LL, et al. Complications after sleeve gastrectomy for morbid obesity. Obes Surg. 19:684–687.

3. Lalor PF, Tucker ON, Szomstein S, et al. Complications after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis. 2008;4: 33–38.

4. Zundel, et al. Strictures After Sleeve Gastrectomy.

Surg Laparosc Endosc Percutan Tec, Volume 20, Number 3, June 2010

5. DE Bellanger, FL Greenway. Laparoscopic Sleeve Gastrectomy: 529 cases without a leak.

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WEIGHT LOSS PLATEAU AFTER SLEEVE GASTRECTOMY: WHAT NOW?

ramana — Wed, 30 Jun 2010 16:09:41 +0000

Weight loss plateaus may occur in certain patients who have undergone a sleeve gastrectomy as a primary bariatric procedure. What are the causes? What is the next step?
What is the prognosis for these patients?

This article discusses these issues. Please buckle your seat belts!

First things first, who doesn’t know what a sleeve (as this operation will from now on be called) is and what it is for? Please refer to our Procedures page and also search this site for many other articles on this popular weight loss procedure.

Normally, the weight loss expected out of the sleeve is in the whereabouts of 50-80 percent of excess body weight. This is usually achieved in the vicinity of one year and may go on till three years, after which time there is usually no inherent weight loss from the surgery. This does not mean you will stop losing weight after that time. You could lose weight if your diet and exercise plans are on the spot. But in practice, weight loss plateaus in and around the third year. A recent study from India published in the journal SOARD reports a nearly 75 percent weight loss of the sleeve in three years.

(the stomach being stapled at BMI, Kolkata. Procedure done at Belle Vue Clinic)

So, the weight loss curve hits a plateau at a point in time. In itself, this is a benefit, as sleeve patients would shrink to oblivion otherwise! So, now that the weight loss plateau is upon you, what to do?

(the stapling process proceeds towards the direction of the foodpipe/esophagus)

Before we answer this, let us eliminate one important cause of weight regain* after the sleeve: a residual fundus. This means that the upper baggy part of the stomach, which is the source of the hunger hormone ghrelin, has not been fully removed by the surgery (usually a technical error). If this is detected, it is bad news.

*The definition of this is taken to be a weight regain of 10 kgs from the nadir (bottom) of the weight loss curve.

(the resected stomach being removed through one of the port sites)

In order to get the desired weight loss, re-surgery has to be undertaken. In such a case, we do one of the following:

1. Re-sleeve: using an endoscopic stapler, the extra fundus (the culprit) is excised. An option to create a narrower sleeve is also possible, but would mean more staplers, and higher cost.

2. Convert to a Roux-en-Y gastric bypass: especially if the patient is super-super-obese (BMI more than 60), where the sleeve is usually the first of a two-stage operative strategy. An alternative we can explore in the Western/Muslim/non-vegetarian super-super-obese patient is the Duodenal Switch (DS). The reason for this is that these patient classes usually eat enough proteins by way of meats. This is a very crucial consideration as the DS causes severe malabsorption of proteins and fats and can cause debilitating malnutrition in the vegetarian patient.

3. A banded sleeve. This adds an additional restrictive element to the sleeve, but has the disadvantages that a Lap Band normally carries (which is another full article). In short, high explantation rates, erosions, prolapse of gastric mucosa, esophageal dilatation, etc.

In a special section on sleeve gastrectomy published June 2010 in the journal Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, I quote:

Similar to the banded gastric bypass, a band can also be placed in SG performed as ‘‘primary banded sleeve gastrectomy,’’ as published by Alexander et al. In this series of 27 patients, a band of 6 cm length made of biologic tissue (AlloDerm) was placed approximately 6 cm below the gastro-esophageal junction.

This is same, but different, compared to the former “secondary” sleeve banding described by Greenstein.

In some cases, improper eating (large feeds, drinking colas and binge eating) can cause the gastric tube (sleeve) to become dilated. Though the initial surgery may have been perfect, the end result is similar to that of a residual fundus after primary surgery: inadequate weight loss, or an early weight loss plateau. This is the reason it is critical to screen patients before surgery for eating disorders and psychiatric conditions that make for unreliable post-op compliance (which means we don’t want to operate on patients who won’t listen to us, and are likely to screw up the results of surgery and give us a bad name).

Let’s get back to the originally asked question. If you underwent a gastric sleeve surgery, and there were no operation-related problems and you lost 70-75% of your excess body weight in, say, three and a half years, BUT you put back 5 kgs in the last few months, what to do?

First, we evaluate the stomach: is it dilated? Is there a residual fundus?

If there is no surgically significant problem, we must get back to basics.

Our strategy is simple:

1. Motivation: talk, talk and more talk. Help the patient understand how results should be the focus, not eating.

2. Eliminate processed foods, sugars, sweetened beverages, alcohol, and other such temptations.

3. Reserve grains as a cheat meal, not as a daily component of the diet.

4. Put some patients on a low-carb diet.

5. Careful food journaling and monitoring of nutritional intake. An online journal may be kept for free at www.fitday.com (or similar sites).

6. Fish oil capsule supplements: 1.8 to 3 grams daily (around 6-8 caps daily).

7. Activity guidance: walk, cycle, play, climb, skip. Don’t sit, slouch, drive, ride.

8. Exercise: strength training with cardio, both HIIT and long-slow cardio.

Once we hit the system with renewed vigor, you will soon be back on track with weight loss!

References:

1. Revisional bariatric surgery for inadequate weight loss. Gumbs AA, Pomp A, Gagner M. Obesity Surgery, Sept 2007.

2. Re-sleeve gastrectomy. Baltasar, et al. Obesity Surgery, Nov 2006.

3. The Spanish study on sleeve gastrectomy outcomes. Obesity Surgery, Sept 2009.

4. French prospective multicenter study: results at 1 and 2 years. Nocca, et al. Obesity Surgery May 2008.

5. LSG with minimal morbidity. Rubin, et al. Obesity Surgery Dec 2008.

6. Greenstein’s article link in SOARD.

7. Banded Sleeve Gastrectomy. Alexander et al. Obesity Surgery, Sept 2009.

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HAIR LOSS AFTER GASTRIC BYPASS SURGERY

ramana — Tue, 29 Jun 2010 04:38:14 +0000

Hair loss is one of the commonest laments in female patients after gastric bypass surgery (whether for weight loss or surgical cure of Type II Diabetes Mellitus), and is at once one of the least heralded topics in the subject. This is but natural: after all, surgeons are more bothered by complications that are life-threatening and serious.

(even men go crazy over hair loss!) Pic credit: here.

But who is man enough to tell a lady that her hair loss is not serious?

Though it is not possible to discuss the physiology of hair loss in any kind of detail in this platform, we should have a working knowledge of how and why this happens.

Hair follicles are the living part of hair, the latter being keratin strands without inherent blood and nerve supply. When hair follicles get less nutrition or blood supply, the hair falls off. The important things to understand here are that:

1. The hair follicle itself is capable of recovering fully and regenerating hairs, and

2. The hair loss that the patient notices is a reflection of the insult suffered by the hair follicle several weeks beforehand.

So, in practice, what happens is that a patient notices clumps of hair coming off in the bathroom or during sleep, three or more months after the gastric bypass. A panic appointment is made, and we take time to assuage the panic. Usually, women being women (please forgive the unintended sexism), the reassurance wears thin, as the hair loss continues. In the meantime, the visible scalp areas elicit comments in the patient’s family and circle (“OMG! What is wrong with you? My aunt had something like this, and they later said it was cancer!!” is one of the comments you may hear), and the panic washes up once too often (“But, doctor, you never told me about this!”).

True, as surgeons, while we dwell at length about leaks, thromboembolism, weight loss plateaus and other such major issues, we may not harp much on the hair loss thing. One of the reasons is that this is a reversible phenomenon. Once the weight loss is achieved and the patient’s nutritional intake comes to near normal, the hair loss stops and the regrowth is established.

Anecdotal reports of benefits exist for various supplements, including biotin, primrose oil and flaxseed oil and horsetail extract, among others. It is all up to you to experiment and find out which one would work magically for you!

One thing we do strongly advise is not to go for hair transplants and other major interventions like this. After all, there is such a thing called common sense: why over-think something that is self-correcting?

For a nice overview of nutritional and metabolic complications after bariatric surgery, read this article in Diabetes Care.

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LEAKS AFTER SLEEVE GASTRECTOMY: PART TWO

ramana — Mon, 24 May 2010 14:41:02 +0000

In Part One, we came to the reluctant conclusion that the sleeve, safe procedure though it is, has a near 3 percent leak rate. Incidentally, the two of us at BMI have not yet had a leak in nearly five years of practice. For whatever reason though it may be (luck?), we would like to think it is because of our superior technique!

We need to now examine why these leaks occur. Is it the make of the stapler?

All over the world, surgeons use either the Ethicon stapler (called Echelon) or the Covidien product (the legendary endo-GIA). In our experience, while both are world class products, the mechanical problems arise with reuse of the stapler guns. In India, not many patients want to pay for a new gun. Surgeons also tend to give lower packages in an effort to be patient-friendly, thereby giving short shrift to a new gun (something that may cost nearly 20,000 to 30,000 INR, or in the vicinity of 400-500 USD).

If you reuse a gun beyond its shelf life, you can have misfirings during the operation. This is a ghastly experience which no surgeon should have. I have even had occasions where the stapler failed to unlock after firing! Clearly, no surgeon should allow a situation like this to happen, but how can he prevent it? After all, the stapler gun doesn’t say, “Don’t use me now, I am gonna die!”

What I say now may be controversial, but this is my humble experience of using laparoscopic staplers over a decade. The Covidien gun tends to work better with reuse, while the Echelon stapler works best when new. If I use the latter product in a case, I make sure I buy a new gun and throw it off (after all, these products were not meant to be reused!) after the case. Obviously, this pushes up the cost of the operation, but what can we do except to hope that the patient understands the reasons?

To come back to the point, reusing staplers is a tricky and potential troublesome issue. I have found no evidence in the scientific literature linking leak rates with reuse, but I suspect that there may be a relationship in some cases, at least.

In a personal communication with the authors of the Chilean paper I referenced in Part One, they opine that leak rates may be related to thermal injuries. This means that when we seal off and divide the blood vessels of the stomach, we may cause some heat injury to the wall of the organ. If such a part is left behind (rather than removed as part of the specimen) it may leak in the post-op period.

Another mechanism of leak: if the gastric tube is too narrow at the region of the body ( a point called the incisura) the resultant increase in pressure in the upper part of the stomach tube may lead to a blowout at the most vulnerable part above. This is usually at the junction of the food pipe and the stomach (the GE junction). This is borne out in clinical practice. The commonest site of a leak is the GE junction.

Another site of a leak could be the junction between adjacent staple cartridges. This is why it is considered important to oversew these junctions.

Does oversewing the staple line prevent leaks? We all think it does, which is why practically all of us do so. However, as this Czech paper says, it may be unnecessary in most cases.

How do we detect leaks?

During the operation, we check the staple line by pushing in methylene blue dye into the stomach. A leak will be seen if present. Some people use an endoscopic verification of the staple line.

After the operation, a contrast (dye) study usually done just before liquid diet is started may be done, especially if intraoperative checks were not done, or a leak was detected and corrected at that time.

Does using staple line reinforcement reduce leaks? As this literature review says, no.

Which patients are more prone to leaks?

While the heaviest middle-aged male smokers are the stereotypical ‘bad’ patients, those who undergo revision surgery (for example, a sleeve with a band removal) are more liable to leaks.

How is a leak managed?

1. Ensure drainage of the peritoneal cavity (percutaneous, CT-guided drainage versus laparoscopic surgical placement of a drain)

2. Endoscopic stent to cover the leak, though a stent may migrate and be unsatisfactory in a given situation.

3. Suture closure of the leak after re-exploration of the abdomen.

4. Parenteral or enteral nutrition.

5. Mere observation in given patients

In most instances, the leak takes several weeks to dry out fully, and this results in prolonged hospitalisation and increased costs as well.

The important thing about leaks is to detect it early, as clinical examination in the severely obese is notoriously unreliable.

Useful references:

1. ASMBS position paper on Sleeve Gastrectomy 2009

2. Canadian overview on Sleeve Gastrectomy

3. World Journal of Gastroenterology 2008 Editorial

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