ENDOSCOPY IN BARIATRICS

Shankar Zanwar

Headings Preoperative endoscopy

Post procedure – endoscopic management of surgical complications

Endoscopic treatment of obesity

Pre-operative Indications of bariatric

surgery NIH -1991 criteria

BMI>40 or >35 with co-morbidties*

1. DM2. HT3. Hyperlipidemia4. GERD5. Arthritis6. IBS7. OSA8. 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

Management of postop complications

Ulcers

Post operative bleeding

Stenosis

Foreign body complications

Leaks and fistulae

Pancreatico-biliary disease

Weight regain

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

…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

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

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.

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

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

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 RYGB

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

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%)

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

Fistulae highest with divided RYGB.

Gastro-gastric fistula between the excluded stomach and pouch

Course indolent Heart burn Acid reflux Abdominal discomfort Weight regain

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

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

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

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

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

Incisionless operating platform

Apollo OverStich – sleeve gastroplasty

TransOral Gastroplasty(TOGA)

Comparisons

Restrictive procedures

Weight loss BMI reduction

Incisionless operating platform (n=45, 6mon)

16.3kg ± 7.1 5.8 ± 2.5

Apollo OverStich (n=23)

- 5

Transoral gastroplasty (n=21, 6mon)

12 Kg 7

Nitin Kumar, WJGE, 2015

EndoBarrier

Used mainly for metabolic benefits 60 cm polymeric sleeve n=42, 1 year, weight loss 22kg, BMI ↓ 9 and

significant ↓ in HbA1c Nitin Kumar, WJGE, 2015

Obrera and Heliosphere balloons

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

Aspiration devices

RCT – n=29 Duration 1 year Weight loss –

18.6% Vs control 5%

Sulivan, gastroenterology

2013

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!!

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

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.

Thank You