GASTROINTESTINAL COMPLICATIONS AFTER BARIATRIC SURGERY Stanley J. Rogers, MD, FACS Associate Clinical Professor of Surgery University of California San Francisco UCSF DEPARTMENT OF SURGERY Original Article Long-Term Mortality after Gastric Bypass Surgery Ted D. Adams, Ph.D., M.P.H., et al University of Utah School of Medicine Salt Lake City, UT N Engl J Med Volume 357(8):753-761 August 23, 2007 Original Article Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects Lars Sjöström, M.D., Ph.D., et al. Swedish Obese Subjects (SOS) Study Sahlgrenska University Hospital, Gothenburg, Sweden, N Engl J Med Volume 357(8):741-752 August 23, 2007 Overview The prospective, controlled Swedish Obese The prospective, controlled Swedish Obese Subjects study enrolled 4047 subjects who Subjects study enrolled 4047 subjects who either underwent bariatric surgery or either underwent bariatric surgery or received conventional treatment received conventional treatment The results of follow The results of follow-up for up to 15 years up for up to 15 years suggest that bariatric surgery for severe suggest that bariatric surgery for severe obesity is associated with long obesity is associated with long-term weight term weight loss and loss and decreased overall mortality decreased overall mortality Sjostrom L et al. N Engl J Med 2007;357:741-752
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GASTROINTESTINAL COMPLICATIONS AFTER BARIATRIC SURGERY
Stanley J. Rogers, MD, FACSAssociate Clinical Professor of SurgeryUniversity of California San Francisco
UCSF DEPARTMENT OF SURGERY
Original Article
Long-Term Mortality after Gastric Bypass SurgeryTed D. Adams, Ph.D., M.P.H., et al
University of Utah School of MedicineSalt Lake City, UT
N Engl J MedVolume 357(8):753-761
August 23, 2007
Original Article
Effects of Bariatric Surgery on Mortality in Swedis h Obese Subjects
Lars Sjöström, M.D., Ph.D., et al.Swedish Obese Subjects (SOS) Study
Sahlgrenska University Hospital, Gothenburg, Sweden,
N Engl J MedVolume 357(8):741-752
August 23, 2007
Overview�� The prospective, controlled Swedish Obese The prospective, controlled Swedish Obese
Subjects study enrolled 4047 subjects who Subjects study enrolled 4047 subjects who either underwent bariatric surgery or either underwent bariatric surgery or received conventional treatmentreceived conventional treatment
�� The results of followThe results of follow--up for up to 15 years up for up to 15 years suggest that bariatric surgery for severe suggest that bariatric surgery for severe obesity is associated with longobesity is associated with long--term weight term weight loss and loss and decreased overall mortalitydecreased overall mortality
Sjostrom L et al. N Engl J Med 2007;357:741-752
Unadjusted Cumulative Mortality
Sjostrom L et al. N Engl J Med 2007;357:741-752
0.76 (95% CI, 0.59 to 0.99; P = 0.04)
0
10
20
30
40
50
60
70
80
90
100
Diabetes Hyperlipidemia HTN Sleep apnea
BandGBP
% R
esol
utio
n C
omor
bidi
ty
Resolution of Comorbidities – 22,094 patientsBariatric Surgery – A Systematic Review and Meta-analysis
Buchwald H. et al.JAMA. 2004; 292(14):1724-37
0.4
1.7
00.6 0.8
6.6
0.30.9
2.1
8.6
0.70
2 1.7 1.9
0.4
3
0.1 0.2
3.1
0.5
4.7
0123456789
10
Splenec
tomy
Leak
Early
SBO
GI Ble
ed PEW
ound I
nfPneu
monia
Death
Late
SBO
Inc H
ernia
Stenos
is
OPEN GBP LAP GBP
% C
ompl
icat
ions
Laparoscopic vs. Open Gastric BypassComplications – Review of 3464 cases
Podnos YD et al. Arch Surg 2003;138: 957-961
Malabsorptive Procedures
� Duodenal Switch/Biliopancreatic Diversion
� Highest rate of longterm complications related to malnutrition / diarrhea
� Death rate highest of any bariatric procedure at 1.1 percent
Gastric Banding
Current Most-Used Bariatric Procedures
Roux-en-Y GB
0.4
1.7
00.6 0.8
6.6
0.30.9
2.1
8.6
0.70
2 1.7 1.9
0.4
3
0.1 0.2
3.1
0.5
4.7
0123456789
10
Splenec
tomy
Leak
Early
SBO
GI Ble
ed PEW
ound I
nfPneu
monia
Death
Late
SBO
Inc H
ernia
Stenos
is
OPEN GBP LAP GBP
% C
ompl
icat
ions
Laparoscopic vs. Open Gastric BypassComplications – Review of 3464 cases
Podnos YD et al. Arch Surg 2003;138: 957-961
No difference
0.4
1.7
00.6 0.8
6.6
0.30.9
2.1
8.6
0.70
2 1.7 1.9
0.4
3
0.1 0.2
3.1
0.5
4.7
0123456789
10
Splenec
tomy
Leak
Early
SBO
GI Ble
ed PEW
ound I
nfPneu
monia
Death
Late
SBO
Inc H
ernia
Stenos
is
OPEN GBP LAP GBP
% C
ompl
icat
ions
Laparoscopic vs. Open Gastric BypassComplications – Review of 3464 cases
Podnos YD et al. Arch Surg 2003;138: 957-961
No difference
Lap > Open
0.4
1.7
00.6 0.8
6.6
0.30.9
2.1
8.6
0.70
2 1.7 1.9
0.4
3
0.1 0.2
3.1
0.5
4.7
0123456789
10
Splenec
tomy
Leak
Early
SBO
GI Ble
ed PEW
ound I
nfPneu
monia
Death
Late
SBO
Inc H
ernia
Stenos
is
OPEN GBP LAP GBP
% C
ompl
icat
ions
Laparoscopic vs. Open Gastric BypassComplications – Review of 3464 cases
All Grades Grade I Grade IIa Grade IIb Grade III Grade I V
% C
ompl
icat
ions
Complication of Lap Gastric Bypass (n = 404)
Grade I - events carrying “minor risks”; requiring only bedside interventionsGrade IIa - events requiring use of drug therapy or blood transfusionsGrade IIb - events requiring therapeutic intervention and without lasting disability Grade III - complications resulting in organ resection or lasting disabilityGrade IV - death
Campos GM, Ciovica R, Rogers SJ, Posselt AM, Vittinghoff E, Takata M, Cello JP. Archives of Surgery 2007; 142(10):969-75.
Campos GM, Ciovica R, Rogers SJ, Posselt AM, Vittinghoff E, Takata M, Cello JP. Archives of Surgery 2007; 142(10):969-75.
13.7
3.91.5
6.9
0.9 0
44.3
19.4
12.58.3
0 1.40
10
20
30
40
50
All Grades Grade I Grade IIa Grade IIb Grade III Grade I V
LAP GBP
Open GBP
% C
ompl
icat
ions
Complications of Lap Gastric Bypass(n = 404) v. Open (n=74)
*
**
Campos GM, Ciovica R, Rogers SJ, Posselt AM, Vittinghoff E, Takata M, Cello JP. Archives of Surgery 2007; 142(10):969-75.
Results Results –– Band Versus Gastric BypassBand Versus Gastric Bypass
Rabl C, Palazzo F, Rogers S, Posselt A, Cello J, Campos GMLaparoscopic Gastric Bypass is as Safe as Laparoscopic Gastric Banding and Provides Superior Weight Loss Outcomes.
Wound infectionTrocar site bleedingUrinary Retention
Wound infection (n=3)G-J Bleed
LUQ abscessPneumonia
Late Complications 5%�Port Malfunction�Port Erosion�Severe dysphagia�Band Erosion
�Conversion to Bypass
5%G-J Ulcer
G-J Strictures (n=2)G-J Bleed
�Small Bowel Obstruction
Re-operation 7 1
P =0.63
P =0.06
No Mortality
P =0.49
Rabl C, Palazzo F, Rogers S, Posselt A, Cello J, Campos GMLaparoscopic Gastric Bypass is as Safe as Laparoscopic Gastric Banding and Provides Superior Weight Loss Outcomes.
Obesity Surgery. 18 (4): 459, 2008.
Laparoscopic Conversion Band to BypassLaparoscopic Conversion Band to Bypass
1 2
3 4
�� Lap Gastric Bypass has similar rates of Lap Gastric Bypass has similar rates of
early and late complications compared to early and late complications compared to
Lap BandLap Band
�� There was a strong trend to more reThere was a strong trend to more re--
operations in the Lap Band groupoperations in the Lap Band group
ConclusionsConclusions
Rabl C, Palazzo F, Rogers S, Posselt A, Cello J, Campos GMLaparoscopic Gastric Bypass is as Safe as Laparoscopic Gastric Banding and Provides Superior Weight Loss Outcomes.
Obesity Surgery. 18 (4): 459, 2008.
ConclusionsConclusionsWith the benefit of superior weight loss , greater resolution of type 2 DM , and similar rate of complications (and possibly lower rate of re-operations) , Lap Gastric Bypass may have a similar or lower risk-benefit ratio compared to Lap Band.
This information should be available when informing patients about surgical options available to treat morbid obesity.
Rabl C, Palazzo F, Rogers S, Posselt A, Cello J, Campos GMLaparoscopic Gastric Bypass is as Safe as Laparoscopic Gastric Banding and Provides Superior Weight Loss Outcomes.