Bariatric Therapy: Alliance between Gastroenterologists and Surgeons

542 Pages·2018·20.004 MB·English

by  Elisabeth M.H. Mathus-Vliegen, Jérôme Dargent

Bariatric Therapy
Alliance between
Gastroenterologists 
and Surgeons
Elisabeth M. H. Mathus-Vliegen
Jérôme Dargent
123
Bariatric Therapy
Elisabeth M. H. Mathus-Vliegen
Jérôme Dargent
Bariatric Therapy
Alliance between Gastroenterologists
and Surgeons
Elisabeth M. H. Mathus-Vliegen Jérôme Dargent
Amsterdam UMC Polyclinique Lyon Nord
(University Medical Centres) Lyon
Amsterdam France
The Netherlands
ISBN 978-3-319-90073-5 ISBN 978-3-319-90074-2 (eBook)
https://doi.org/10.1007/978-3-319-90074-2
Library of Congress Control Number: 2018945544
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Preface
Overweight and obesity are a global epidemic associated with many health conse-
quences and an impressive psychosocial and economic burden. As yet, preventive
measures to reverse the global trend have been unproductive and overweight has
surpassed the incidence of undernutrition. Therapeutic options are limited. Intensive
lifestyle interventions have been able to reduce the cumulative incidence of diabetes
over a period of 4–6 years in obese patients with impaired glucose tolerance, but
such interventions are difficult to sustain lifelong and thus are usually short-lived.
Medical drug treatment is moderately effective and also hampered by a limited
duration of prescription. Moreover, the Gaussian curve of the distribution of over-
weight shifts to the right, signifying that in the category of obesity patients move
towards the category of morbid obesity and thus become eligible for bariatric
surgery.
Many obesity-associated comorbidities relate to the gastrointestinal tract, and
formerly this was the only place where surgeons and gastroenterologist met.
Nowadays they should form an alliance, as not only the complications of obesity
itself but also the treatment of obesity by endoscopic and surgical bariatric means
and possible complications thereof require a close cooperation and mutual under-
standing. This alliance between the two specialisms is the topic of this book.
Although this book was written in close cooperation, the signature of the gastro-
enterologist will be visible in Chaps. 1, 2, 4–6 and the signature of the surgeon in
Chaps. 3 and 7. These chapters deal with the comorbidities related to the gastroin-
testinal tract, the endoscopic bariatric treatment, the preoperative screening and
perioperative and postoperative guidance and the whole spectrum of surgical
options. When postbariatric complications occur, the endoscopic modalities in the
early and late postoperative period are discussed at length.
The remaining Chaps. 7–11 were a true challenge and as such cannot be retrieved
from the literature: they are the result of weighing the pros and cons. They discuss
matters such as when the endoscopist needs the surgeon, when gastroenterologist
and surgeons should act as one, and when they are possible opponents. Also, a com-
pletely new way of looking at weight loss trajectories is offered.
The detailed discussions should enable gastroenterologists and surgeons to better
delineate the options, the responsibilities and knowledge and possibilities of each
specialty. The profound conviction that a lot can be gained from a close cooperation
v
vi Preface
lays the foundation of this book and both authors wish the reader as much as p leasure
with reading as the authors had with writing. They do hope that it provides the tools
for adequate management of the obese patient.
Amsterdam, The Netherlands Elisabeth M. H. Mathus-Vliegen
Lyon, France Jérôme Dargent
Contents
1 Epidemiology and Comorbidities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Introduction and Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2 Definition and Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.3 Pathogenesis of Comorbidities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.3.1 Hormone-Like Adipokines . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.3.2 Inflammatory Cytokines and Anti-inflammatory Factors . . . 11
1.4 Decreased Life Expectancy and Mortality . . . . . . . . . . . . . . . . . . . . . 11
1.4.1 Mortality: All-Cause and Disease-Specific Causes . . . . . . . . 14
1.4.2 Population Attributable Fraction . . . . . . . . . . . . . . . . . . . . . . 15
1.4.3 Current Developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1.5 Comorbidities in General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.6 Symptoms and Comorbidities More Specifically Related
to the Gastrointestinal Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.7 Symptoms Related to the Gastrointestinal Tract . . . . . . . . . . . . . . . . 18
1.8 Comorbid Diseases Related to the Gastrointestinal Tract . . . . . . . . . 21
1.8.1 Oesophagus and Stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
1.8.2 Gallbladder and Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
1.8.3 Rectocolon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
1.8.4 Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
1.8.5 Gastrointestinal Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
2 Current Endoscopic/Laparoscopic Bariatric Procedures . . . . . . . . . . 85
2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
2.2 Endoscopic Bariatric and Metabolic Therapies . . . . . . . . . . . . . . . . . 92
2.3 Gastric Endoscopic Bariatric and Metabolic Therapies . . . . . . . . . . . 96
2.3.1 Non-invasive Endoscopic Bariatric
and Metabolic Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
2.3.2 Invasive Endoscopic Bariatric
and Metabolic Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
2.4 Intestinal Endoscopic Bariatric and Metabolic Therapies . . . . . . . . . 147
2.4.1 Non-invasive Endoscopic Bariatric
and Metabolic Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
2.4.2 Invasive Endoscopic Bariatric and Metabolic Therapies . . . . 153
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2.5 Perspective of Endoscopic Bariatric and Metabolic Therapies . . . . . 156
2.6 Laparoscopic Minimally Invasive Techniques . . . . . . . . . . . . . . . . . . 158
2.6.1 Gastric Pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
2.6.2 Vagal Blockade (Enteromedics Inc., St-Paul, MN, USA) . . . 162
2.7 Perspectives of Laparoscopic Minimally Invasive Techniques . . . . . 163
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
3 Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
3.2 Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
3.2.1 A Brief History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
3.2.2 Discussion of Bariatric Techniques with the
Most Current Operations More in Detail . . . . . . . . . . . . . . . . 181
3.2.3 Adjuncts to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
3.2.4 Reoperations in Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . 197
3.2.5 Indications and Contraindications
for Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
3.3 Effect of Bariatric Surgery Through Weight Loss
and Metabolic Changes on Obesity-Associated Comorbidities . . . . . 203
3.3.1 Mechanisms of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
3.3.2 Beneficial Effects on Diseases . . . . . . . . . . . . . . . . . . . . . . . . 206
3.3.3 Adverse Effects on Diseases . . . . . . . . . . . . . . . . . . . . . . . . . 209
3.4 Economical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
4 Endoscopists and Surgeons Playing in the Same Team:
The Multidisciplinary Approach in Screening
and Preoperative Workup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
4.2 Preoperative Workup and the Role of Endoscopy . . . . . . . . . . . . . . . 223
4.2.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
4.2.2 Arguments of Proponents and Opponents . . . . . . . . . . . . . . . 225
4.2.3 Skills and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
4.2.4 Meta-Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
4.2.5 Preoperative Endoscopy and Fear of Missing
Cancers and Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
4.2.6 Predictors of Significant Endoscopic Findings
in the Preoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
4.3 Preoperative Workup and the Role of Manometry and pH
Measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
4.4 Role of the Gastroenterologist in Preoperative Workup . . . . . . . . . . 237
4.4.1 Role of Helicobacter pylori . . . . . . . . . . . . . . . . . . . . . . . . . . 237
4.4.2 Impact of Abnormal Manometry and 24-h pH
Measurements on Post-bariatric Outcomes . . . . . . . . . . . . . . 239
4.4.3 Gastrointestinal Conditions that May Interfere
in the Decision- Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
4.4.4 Sense and Nonsense of Preoperative Weight Loss . . . . . . . . . 247
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Contents ix
5 When the Surgeon Needs the Endoscopist
in Rescuing Bariatric Surgery: Intraoperative and Early
Post- operative Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
5.2 Intraoperative Endoscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
5.2.1 Detection of Leaks After Roux–En–Y Gastric
Bypass (RYGB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
5.2.2 Detection of Leaks After Sleeve Gastrectomy (SG) . . . . . . . 266
5.3 Post-operative Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
5.3.1 Routine Post-operative Investigation by Radiology
and Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
5.3.2 Endoscopy for the Evaluation of Symptoms
Post-operatively . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
5.4 Frequency and Predictors of Complaints and Complications
in the Post–operative Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
5.4.1 Mortality and Morbidity Risk Calculators . . . . . . . . . . . . . . . 277
5.4.2 Frequency and Predictors of Complaints and Complications
in the Post–operative Period According to the Type
of Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
5.5 Description of Surgical Procedure and Herewith Associated
Normal Endoscopic Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
5.5.1 Choice of the Endoscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
5.5.2 Endoscopic Armamentarium . . . . . . . . . . . . . . . . . . . . . . . . . 285
5.5.3 Endoscopy and Surgically Induced Altered Anatomy . . . . . . 286
5.6 Emergencies and Endoscopic Findings and Therapy
in the Early (<6 Weeks) Post-operative Period . . . . . . . . . . . . . . . . . 291
5.7 Gastrointestinal Perforations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
5.8 Leaks and Fistulas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
5.8.1 Pathophysiology of Leaks and Predisposing Factors
for a Leak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
5.8.2 Symptoms and General Treatment . . . . . . . . . . . . . . . . . . . . . 295
5.8.3 Non-operative Endoscopic Treatment . . . . . . . . . . . . . . . . . . 296
5.8.4 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
5.9 Gastrointestinal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
5.9.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
5.10 Acute Gastrointestinal Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . 319
5.10.1 Gastric Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
5.10.2 Small-Bowel Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
5.10.3 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
6 When the Surgeon Needs the Endoscopist
in Rescuing Bariatric Surgery: Intermediate and Late
Post- operative Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
6.2 Symptomatology and Differential Diagnosis . . . . . . . . . . . . . . . . . . . 340
6.2.1 Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
6.2.2 Heartburn, Reflux, Epigastric or Retrosternal Pain . . . . . . . . 343
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6.2.3 Diarrhoea and Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . 343
6.2.4 Abdominal Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
6.2.5 Haematemesis and Melaena . . . . . . . . . . . . . . . . . . . . . . . . . . 344
6.2.6 Inadequate Weight Loss or Weight Gain . . . . . . . . . . . . . . . . 344
6.3 Bariatric Surgery-Specific Endoscopic Findings
and Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
6.4 (Laparoscopic) Roux-En-Y Gastric Bypass (RYGB) . . . . . . . . . . . . 345
6.4.1 Marginal Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
6.4.2 Gastrojejunal/Stomal Stenosis . . . . . . . . . . . . . . . . . . . . . . . . 349
6.4.3 Internal Hernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
6.4.4 Gastrointestinal Haemorrhage . . . . . . . . . . . . . . . . . . . . . . . . 357
6.4.5 Dilation of the Gastrojejunal Anastomosis
and the Gastric Pouch and Weight Regain . . . . . . . . . . . . . . . 358
6.4.6 Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
6.4.7 Banded Gastric Bypass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
6.4.8 Phytobezoar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
6.4.9 Dumping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
6.4.10 Postprandial Hyperinsulinaemic Hypoglycaemia . . . . . . . . . 380
6.4.11 Problems Related to the Bypassed Stomach
and Duodenum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
6.4.12 Gastro-Oesophageal Reflux Disease . . . . . . . . . . . . . . . . . . . 401
6.5 Sleeve Gastrectomy (SG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402
6.5.1 Stenosis and Stricture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
6.5.2 Sleeve Dilation and Weight Regain . . . . . . . . . . . . . . . . . . . . 405
6.5.3 Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408
6.5.4 Post-bariatric Hypoglycaemia . . . . . . . . . . . . . . . . . . . . . . . . 410
6.5.5 Gastro-Oesophageal Reflux Disease . . . . . . . . . . . . . . . . . . . 410
6.6 Biliopancreatic Diversion (BPD) with (BPD-DS) or
Without Duodenal Switch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
6.6.1 Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
6.6.2 Postprandial Hyperinsulinaemic Hypoglycaemia . . . . . . . . . 415
6.7 Laparoscopic Adjustable Gastric Banding (LAGB) . . . . . . . . . . . . . 415
6.7.1 Band Slippage or Pouch Slippage . . . . . . . . . . . . . . . . . . . . . 417
6.7.2 Stoma Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
6.7.3 Pouch Dilation and Oesophageal Dilation . . . . . . . . . . . . . . . 420
6.7.4 Band Erosion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
6.7.5 Weight Regain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
6.7.6 Phytobezoar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
6.7.7 Gastro-Oesophageal Reflux Disease . . . . . . . . . . . . . . . . . . . 428
6.8 Vertical Banded Gastroplasty (VBG) . . . . . . . . . . . . . . . . . . . . . . . . . 430
6.8.1 Stoma Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430
6.8.2 Band Erosion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
6.8.3 Vertical Staple-Line Disruption . . . . . . . . . . . . . . . . . . . . . . . 435