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“Complicaties na bariatrische ingrepen”
Refereeravond: Sedatie bij de obese patiënt Dr WL Curvers, MDL-arts
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Content Bariatric surgery: why, who and how?
Bariatric complications and Endoscopy Bariatric endoscopy
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Bariatric surgery: why?
Obesity and DM type 2 are a worldwide epidemic
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Bariatric surgery: why?
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Bariatric surgery: why?
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Bariatric surgery: who?
Adults with BMI ≥ 40 kg/m2 Adults with BMI ≥ 35 kg/m2 with obesity-related comorbiditeis (e.g. Hypertension, DM type 2, OSAS) difficult controlled with life-style of drugs Elibilge pts must have tried and failed non-surgical weight loss measurements
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Bariatric surgery: how?
Restrictive / metabolic / both
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Bariatric surgery: how?
Restrictive / metabolic / both
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Bariatric surgery: how?
Restrictive / metabolic / both Sleeve Gastrectomy
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Bariatric surgery: how?
Restrictive / metabolic / both Duodenunal-jejunal bypass
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Bariatric surgery: how?
Restrictive / metabolic / both Biliary pancreatic division combined with gastrectomy
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Bariatric surgery: how?
Restrictive / metabolic / both Roux en-Y Gastric Bypass
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Complications Local Systemic Intra-operative Splenectomy (0,4%)
Peri-operative Anasomotic leakage (1,1%) GI hemorrage (2,5%) Trocar injury (0,1%) DVT (1%) PE (0,5%) Bowel obstruction (1,7%) Wound infection Pneumonia (0,2%) Carida event Mortality (2%) Late Anastomotic strictures (3-12%) Marginal ulcer (0,5%-20%) “Candy Cane” syndrome GERD Bowel obstruction (2,5%) Incisional hernia (0,5-8%) Internal hernia (1-3%) Cholecystitis/gallstones Dumping syndrome (up to 30%) Anemia Vitamine deficienies
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Complications Local Systemic Intra-operative Splenectomy (0,4%)
Peri-operative Anasomotic leakage (1,1%) GI hemorrage (2,5%) Trocar injury (0,1%) DVT (1%) PE (0,5%) Bowel obstruction (1,7%) Wound infection Pneumonia (0,2%) Carida event Mortality (2%) Late Anastomotic strictures (3-12%) Marginal ulcer (0,5%-20%) “Candy Cane” syndrome GERD Bowel obstruction (2,5%) Incisional hernia (0,5-8%) Internal hernia (1-3%) Cholecystitis/gallstones Dumping syndrome (up to 30%) Anemia Vitamine deficienies
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Endoscopic managment Local Systemic Intra-operative Splenectomy (0,4%)
Peri-operative Anasomotic leakage (1,1%) GI hemorrage (2,5%) Trocar injury (0,1%) DVT (1%) PE (0,5%) Bowel obstruction (1,7%) Wound infection Pneumonia (0,2%) Carida event Mortality (2%) Late Anastomotic strictures (3-12%) Marginal ulcer (0,5%-20%) GERD Bowel obstruction (2,5%) Incisional hernia (0,5-8%) Internal hernia (1-3%) Cholecystitis/gallstones Dumping syndrome (up to 30%) Anemia Vitamine deficienies
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Anastomotic leaks Early leaks (< 14 days postoperative)
Generaly surgical emergency Intermediate leaks (2-6 weeks) Surgical mangement has high mortality 10%, morbidity (50%) and conversion rate. Conservative supportive care Medical treament of sepsis/antibiotics, nil per mounth, tube feeding or TPV Radiological or endoscopic drainge of collections Endoscopic treatment
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Endoscopic intervention
EUS-guided drainage of collections
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Endoscopic intervention
Endoscopic closure of leaks/fistula Clips
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Endoscopic intervention
Endoscopic closure of leaks/fistula Clips
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Endoscopic intervention
Endoscopic closure of leaks/fistula Clips
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Endoscopic intervention
Endoscopic closure of leaks/fistula Over-the-Scope-Clip (OTSC)
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Endoscopic intervention
Endoscopic closure of leaks/fistula Over-the-Scope-Clip (OTSC)
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Endoscopic intervention
Endoscopic closure of leaks/fistula Stents
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GI BLeeding Early bleeding Late bleeding Intrabdominal bleeding
Surgical of radiological intervention Intraluminal bleeding Endoscopic treatment Late bleeding Mariginal ulcers (RYGB) Ulcers in remant stomach
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Endoscopic intervention
GI bleeding Dual therapy with epinephrine and clips
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Endoscopic intervention
GI bleeding Dual therapy with epinephrine and Goldprobe
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Endoscopic intervention
GI bleeding Hemospray
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Anastomotic strictures
Multifactorial Technical factors (stapler>hand-sewn), local ischemia, inflammatory reponse No passage of diagnostic endoscope Most strictures occur in first 2-3 months
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Endoscopic intervention
Anastomotic stricture Dilatation
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Endoscopic intervention
Anastomotic stricture Dilatation
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Marginal ulceration Multifactorial Most common in first 2-4 months
Gastric acidity, pouch size, fistel, ischemia, NSAIDs, Helicobacter Pylori, smoking, alcohol Most common in first 2-4 months Management Exclude fistel Treat Helicobacter Pylori Cessation of smoking and NSIAD use PPI treatment (addition of ulcogant)
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Marginal ulceration Multifactorial Most common in first 2-4 months
Gastric acidity, pouch size, fistel, ischemia, NSAIDs, Helicobacter Pylori, smoking, alcohol Most common in first 2-4 months Management Exclude fistel Treat Helicobacter Pylori Cessation of smoking and NSIAD use PPI treatment (addition of ulcogant)
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Gastro-esophgeal reflux disease
Obesity is major riskfactor GERD RYGB shows improvement of GERD symtpoms Sleeve Gastrectomy may increase GERD Especialy in patients with pre-existing GERD Hiatal hernia without repair is a contraindication for SG Pathogensis: inefeccteive persitalsis, increased (non-acid) reflux
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Bariatric Endoscopy Early intervention in obese patients (BMI ≥ 30kg/m2) Primary intervention in subjects eligible for surgery but refuse surgery or have no access to surgery Secondary intervention as bridge to elective surgery (BMI ≥ 40kg/m2) or as bridge to bariatric surgery (BMI ≥ 50kg/m2)
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Bariatric Endoscopy Intragastric balloon treatment
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Bariatric Endoscopy Intragastric balloon treatment
Early ballon 1980s many complications Maximum duration of 6 – 12 months Most weight loss supposed by gastric adaptation After 30 years still not covered by existing evidence based guidelines
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Bariatric Endoscopy Duodenojejunal bypass liner
Mimics effects of gastric bypass bycreating a physical barrier that allows bypass of the duodenum an jejunum
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Bariatric Endoscopy Satisphere
Desgined to delay transit time through duodenum
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Bariatric Endoscopy Aspiration therapy
Aspirate gastric content 20 min after meal
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Bariatric Endoscopy Gastric suturing/stapeling
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