Endoscopy: Front and center in management of bariatric surgery complications
The number of bariatric surgeries performed in the United States has increased with about 252000 surgeries performed annually.
“Obesity has reached alarming rates posing significant threat to global health,” Barham K. Abu Dayyeh, MD, MPH, FASGE, professor of medicine, director of advanced endoscopy and director of bariatric and metabolic endoscopy at Mayo Clinic, Rochester, Minn., told Healio Gastroenterology. “In the United States about 42.4% of the adult population has obesity.”
Currently, the two most common bariatric surgeries are Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy.
“There are acute and chronic complications associated with bariatric surgery; the practice of endoscopy is front and central in managing these complications,” Abu Dayyeh said.
In an interview with Healio Gastroenterology, Andrew C. Storm, MD, assistant professor of medicine at Mayo Clinic, said in initial bariatric surgery there is a less than 1 in 1,000 risk for serious complication that may lead to death, with revision it is a 1 in 100 risk for having serious complications.
“One of the reasons I feel strongly about bariatric endoscopy is that the morbidity for surgical revision in patients is very high,” Storm said.
Initial bariatric surgery is helpful in many ways, Storm said. Further, bariatric surgery is considered safe and highly effective for weight loss. However, if surgeons need to revise or repair the same area twice the surgery may become significantly more dangerous.
“This is why the field of bariatric endoscopy has really grown over these last 10 years.”
Healio Gastroenterology spoke with experts and key leaders regarding various bariatric surgery complications and the advancements of endoscopic management of these post bariatric surgery complications.
Healing Marginal Ulcers
Storm said ulcerations can occur in up to 30% to 50% of patients following bariatric surgery. He recommends tobacco users to stop using because nicotine may play an important role in ulcerations. Tobacco may negatively affect marginal ulcers ability to heal.
He noted ulcer complications include bleeding and pain.
“Medical management is really the cornerstone therapy and one thing that many physicians and caretakers don’t know after gastric bypass is the portion of the stomach that makes acid is actually moved off to the side.”
Storm said many capsule medications are made to open in a liquid acidic environment of the stomach that is no longer there after gastric bypass.
“Proton pump inhibitors are excellent in achieving healing of most stomach ulcers; however, they don’t work as well for marginal ulcers because the capsules often don’t open. So in a patient with RYGB and marginal ulcers, if you do a colonoscopy you may actually see the PPI capsule in their colon unopened, as evidence that they are not absorbing the medication or not getting the full dose,” Storm said.
Storm tells his patients to open the PPI capsules and take with a spoon of applesauce or yogurt twice a day. This can help in healing the ulcers.
Gastrogastric fistula of the excluded stomach is a mechanical issue that can lead to marginal ulcerations after gastric bypass. Storm said this is much less common now as most patients undergo divided gastric bypass rather than just being sectioned off by surgical staples. A gastrogastric fistula allows gastric acid from the remnant stomach to crossover to the pouch and this acidic fluid is then exposed to the jejunum, without the protective buffering effects of bicarbonate from the pancreas, and this can lead to ulcer formation. Other issues leading to marginal ulceration includes sutures and staples, which may be extruded, causing friction injury of the small bowel mucosa, Storm said. Forceps, endoscopic scissors and cutters can be used to remove the suture or staple materials.
“For patients who are symptomatic from their ulcer and fail medical therapy we have the OverStitch [Apollo Endosurgery Inc.] device that allows us to suture a flap over the ulcer and result in the healing of the ulcer, all done endoscopically, or thought the mouth,” Storm said.
Apollo EndoSurgery has also released early information about a new device, the “X-Tack,” which uses a series of helix coils connected to a suture which may be used to close defects like ulcers in the GI tract.
“That device is going to be potentially disruptive technology for ulcer healing,” he said, “It will be very helpful to all endoscopists because the device will fit through a standard endoscope without needing any special scope or equipment. The very last line of management, if the ulcer can’t be healed despite all of the aforementioned treatments, is consideration of a revision surgery, which is fortunately becoming less often necessary.”
Abu Dayyeh said after laparoscopic sleeve gastrectomy (LSG), stenosis occurs in about 1-4% of patients. Diagnosing this problem endoscopically is not always straight forward as the mere passage of the endoscope through the sleeve does not mean that the patient does not have a stenosis or functional narrowing of the sleeve.
There are three anatomical subtypes based on findings from upper gastrointestinal (UGI) series and esophagogastroduodenoscopy (EGD). The first is gastric stricture caused by fibrosis after surgery. The other two include gastric angulation and gastric torsion along the gastric longitudinal axis. These are functional stenoses preventing the stomach from emptying properly, which hypothetically results from disruption of ligaments surrounding the stomach, thereby allowing the gastric sleeve to move freely with unbalanced traction on the stomach resulting from stapling during surgery.
An appropriate diagnosis must be made first to determine the stenosis subtype, Abu Dayyeh said. In addition to UGI and EGDs, newer diagnostic tools, such as ENDOFLIP (Medtronic) impedance planimetry, have aided in the appropriate diagnosis of the stenosis subtype to determine the best treatment algorithm.
When a fibrotic fixed stricture is the problem, EGD with simple hydrostatic balloon dilation is often sufficient to resolve the problem; however, pneumatic balloon dilation and or intraluminal stenting are likely more efficacious in the management of refractory fibrotic fixed stenosis and or gastric angulation.
“The challenge for endoscopic management has been the gastric torsion subtype or commonly referred to as twist,” Abu Dayyeh said. “Unfortunately, this subtype does not often respond to endoscopic treatment, and the patient ends up requiring revisional bariatric surgery.”
Newer emerging techniques, such endoscopic strictureplasty through a tunneling approach, are being investigated to manage fixed LSG stenosis.
Stenosis after Roux-en-Y gastric bypass usually occurs at the gastrojejunal anastomosis with a prevalence between 3-15% due to a variety of factors including ischemia, mechanical angulation of the roux limb, and marginal ulceration. Hydrostatic balloon dilation is usually effective in managing ischemic fibrotic strictures after RYBG; however, endoscopist should limit the dilation to 15mm or less to avoid complications, such as weight regain.
If patients continue to have symptoms and have three failed balloon dilations, then placement of a fully covered lumen-opposing metal stent (LAMS; AXIOIS, Boston Scientific) can be considered prior to surgical revision. LAMS are not meant to treat strictures but have been used off-label because of their ideal properties to manage short gastrojejunal stoma strictures and are well tolerated by patients.
Weight Regain After Bariatric Surgery
Pichamol Jirapinyo, MD, MPH, ABOM, director of bariatric endoscopy fellowship at Brigham and Women’s Hospital, said at around 10 years after bariatric surgery, patients regain about one-third of their weight that they had initially lost.
“Weight regain is not uncommon after bariatric surgery,” Jirapinyo told Healio Gastroenterology.
Jirapinyo said weight regain management includes lifestyle modifications with diet and exercise, medications, endoscopic management and revision surgery.
When patients fail diet and exercise, the next step used to be revision surgery. However, Jirapinyo noted that for the past decade or so, more and more patients with weight regain are being managed with medications or an endoscopic approach.
Physicians have been using weight loss medications off label to help patients lose weight after weight loss surgery and they work effectively.
“Furthermore, we as bariatric endoscopists can also provide a variety of endoscopic procedures to help treat weight regain. These procedures are done by mouth, no surgery,” she said.
Jirapinyo said there are three main endoscopic procedures for management of weight regain after Roux-en-Y gastric bypass and it depends on the size of the outlet and pouch. The procedures include argon plasma coagulation or laser treatment, transoral outlet reduction endoscopy with the Apollo OverStitch suturing device and restorative obesity surgery endoscopic with the USGI Pose (USGI Medical Inc.) plication device. These procedures are associated with approximately 10% weight loss at one year when the procedure is appropriately selected based on the sizes of the outlet and pouch. The amount of weight loss also appears to maintain at least 5 years.
Sleeve gastrectomy has become the most bariatric surgery for the past several years. Therefore, we also started seeing more patients who are referred for weight regain after sleeve gastrectomy. Similar to Roux-en-Y gastric bypass, we can also revise the sleeve endoscopically to tighten the sleeve.
“You can use either the Apollo Overstitch suturing device or the USGI plication device to revise the sleeves, and outcomes were good,” Jirapinyo. “We see about 10% of the total weight loss within 1 year.”
Fistulas and Leaks Managed Endoscopically
Manoel Galvao Neto, MD, MSC, FASBMS, FASGE, affiliate professor of surgery at Faculty of Medicine of ABC in Santo Andre, Sao Paulo, Brazil, told Healio Gastroenterology that bariatric surgery in recent years has changed from open surgery to laparoscopic surgery; open surgeries tend to have more leaks or fistulas after bariatric surgery.
“With bariatric endoscopy, we are able to treat locally by endoscopy and getting much better than when patents were reoperated on,” Galvao Neto said.
Leaks after gastric bypass tend to heal; however, with sleeve gastrectomy, the leaks tend to become chronic due to the hyper pressure system created. The leaks can be very drastic and can happen within the first 2 weeks after a sleeve gastrectomy, Galvao Neto said.
Galvao Neto further reported that surgeons use the endoscopic vacuum, or E-vac, when draining leaks after gastrectomy.
“The E-Vac have revolutionized the way we treated the most severe septic complications,” on the other leaks, the stents can also fix it, he said.
“Achalasia balloons were also used to help open up [the stomach] and to let the pressure goes down.
“We have all these tools where we can treat more than 80% of leaks by endoscopy and are able to give patients the stomach they want to have,” he said.
However, one downside, according to Galvao Neto, is that there has not been a comparative study done on the different techniques to treat leaks to see which one is better to drain and treat the leaks.
Bariatric Surgery Adds to Complexity of GERD
Gastroesophageal reflux disease alone can be a very complicated physiological process, Erik B. Wilson, MD, professor and vice chair of surgery at The University of Texas Health Science Center, McGovern Medical School in Houston, said in an interview with Healio Gastroenterology. He said the volume of the refluxate usually sits in the stomach and it regurgitates into the esophagus in an abnormal amount.
“When you add bariatric surgery, it just ramps up the complexity [of GERD] that much more,” he said.
Wilson also said there are bariatric surgeries that make reflux dramatically better and there is a procedure that can make it worse.
With sleeve gastrectomy, there may be potential changes to how the stomach functions because a portion of the stomach is cut out, Wilson said. Because of that, the shape of the stomach is altered and the incisura angularis can be narrowed if surgeons cut too close to it during a sleeve gastrectomy.
“After gastrectomy, reflux can also be due to surgeons potentially cutting some of the supporting structure or flap valve where the lower esophageal sphincter is,” he said.
In the long-term after a sleeve gastrectomy, between 20% to 50% of patients can experience some symptoms of reflux. Most of the time, the reflux is manageable with medications, but it can be severe and may require another form of surgery to manage, Wilson reported. One option is converting the sleeve gastrectomy to a gastric bypass.
“For patients who had great weight loss but developed bad reflux from their sleeve gastrectomy, they may have a more bile regurgitating into their stomach and then into the esophagus. You may need to eliminate the bile from the mix and a gastric bypass allows you to divert the bile from the esophagus,” he said.
A gastric bypass addresses the volume of acid well. Wilson said when patients are evaluated for bariatric surgery preoperatively, patients with significant reflux symptoms should consider a gastric bypass because the stomach is divided into two portions with a small upper pouch the produces very little acid.
“Gastric bypass patients have very little reflux symptoms in the vast majority of scenarios because they don’t have the volume of refluxate,” Wilson said. “It was eliminated by the anatomy that has been created with the gastric bypass and the intestinal roux.”
If patients develop reflux after a gastric bypass it is usually due to a volume of refluxate returning, he said. This may be due to the stomach pouch being larger, a distal blockage of the intestine or a fistulous connection between the small upper pouch and the lower stomach which increases the volume of refluxate.
Wilson noted, sleeve gastrectomy patients with reflux sometimes have strictures that need to be dilated with balloons as mentioned by Dr. Abu Dayyeh. In gastric bypass patients with reflux symptoms due to having a larger pouch that cannot drain effectively, reflux may be improved by making the pouch smaller with endoscopic suturing. This helps gastric bypass patients that do not have other issues from the gastric bypass.
There are two less common procedures that include gastric banding and the duodenal switch. The gastric banding is a good anti-reflux procedure when it is done properly, Wilson said.
“Bands do a good job of managing reflux unless they are mismanaged for over a period of years by leaving the band too tight,” he said. “Bands aren’t as commonly used because of the management issues that have come up.”
The duodenal switch is a more complicated procedure mimicking the combination of a gastric bypass and sleeve gastrectomy together. Duodenal switch patients usual have less reflux symptoms because of the biliary bypass.
“It is safe to say gastric bypass patients rarely have symptoms of reflux and commonly have much less GERD than sleeve gastrectomy patients,” Wilson said.
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