Endoscopy in Benign Ampullary Neoplasms: Not Just for Diagnosis Anymore

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Endoscopic Management of ObesityNot just for
surgical complications anymore

• AGA Institute Fellows Nutrition Course 2007
• Rosemont/Chicago, Illinois November 9, 2007
• John A. Martin, M.D.
• Associate Professor of Medicine and Surgery
• Director of Endoscopy
• Northwestern University Feinberg School of
  Medicine Chicago, Illinois

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Role of Endoscopy in the Management of Obesity

• Management of bariatric surgical complications
• Endoscopically-delivered bariatric interventions
  (investigational)
• NOTES (investigational)

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Endoscopic Management of Bariatric Surgical
Complications
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Case PresentationRYGB

• 37 y/o F (WV)
• S/P laparoscopic RYGB surgery for morbid obesity
• Lost 35 lbs in 4 wks
• 5 wks postop
• Vomiting
• Epigastric pain
• Whats going on? What do you do?

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Why is this important?
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Obesity Trends Among U.S. AdultsBRFSS, 1990,
1998, 2006
(BMI ?30, or about 30 lbs. overweight for 54
person)
1998
1990
2006
No Data lt10 1014
1519 2024 2529
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Obesity Burden of Disease

• 300,000 deaths annually
• 100 billion per year in direct and indirect
  costs (17 of total health care costs)

• Comorbidities are protean
• Hypertension
• Diabetes
• Cardiomyopathy
• Sleep Apnea
• DJD
• Psychosocial
• etc

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Obesity Treatment

• Why surgery for obesity?
• Conservative treatments dont work (i.e., largely
  unsuccessful in maintaining long-term weight loss
  in morbid obesity)
• Diets
• Behavioral modification
• Exercise
• No medications that are highly-effective but safe
• Bariatric surgery is effective durable
• 50 reduction in excess body weight within 18
  to 24 months
• Operations
• Vertical-banded gastroplasty (VBG)
• Lap Band
• Gastric Bypass
• BPD

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Estimated Number of Bariatric Operations in the
US 1992-2003
120
gt 100,000
100
80
Thousands of Operations per Year
60
40
20
0
1992
1994
1996
1998
2000
2002
Year
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Restrictive Procedures
Gastric pouch
Subcutaneous port
Adjustable Lap band
Silastic ring/band
Illustration John Pandolfino, MD
VBG
Lap Band
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Malabsorptive Procedures
Gastric pouch
Subcutaneous port
Adjustable Lap band
Silastic ring/band
BPD
BPD Duodenal Switch
Illustration John Pandolfino, MD
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Roux-en-Y Gastric Bypass
Gastric Pouch
Anastomosis
Remnant Stomach
Jejunojejunostomy
Illustration John Pandolfino, MD
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Post-operative Complications
Perioperative mortality of bariatric surgery is
less than 1 but morbidity can be substantial
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Anastomotic Complications

• Marginal Ulcer- 5-15
• On jejunal side--probably acid- related
• Stomal Ulcer- 5-15
• On gastric pouch side--probably ischemia-related
• Stomal Stricture- 12
• Stoma size usually greater than 1cm when created
• Stricture defined arbitrarily as inability to
  pass 27 Fr (9mm) scope
• May be associated with marginal/stomal ulceration

Endoscopic view of stomal stricture with
ulceration
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Anastomotic Complications RYGB

• Pouch
• Stomal ulcer
• Anastomosis
• Marginal ulcer
• Anastomotic stricture
• Remnant stomach
• PUD
• Duodenum
• PUD
• Roux anastomosis
• Bleeding
• Stricture
• Ulceration

Illustrator John Pandolfino, MD
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ENDOSCOPY POST-RYGB
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Endoscopy Post-Bariatric Surgery

• Symptomatic indications
• Vomiting /- nausea
• Abdominal pain (usually epigatric)
• Weight gain/decelerated weight loss
• GI bleeding
• Hematemesis
• Melena
• Jaundice (possibly)

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Endoscopic Appearance of Common Anastomotic
Complications

• Anastomotic ulcer
• Anastomotic stricture

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EGD Forward-viewing endoscopy
Images Pentax Medical, Inc.
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Endoscopic Stricture DilationTTS (Mylar
Gruntzig) Balloons
Images Boston Scientific, Inc.
Wilson-Cook Medical, Inc.
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Treatment Options Ulcer

• Treat medically
• PPI
• Sucralfate
• Avoid NSAIDS ASA
• Eradicate H. pylori
• Schirmer, et al., 2002 marginal ulcers with
  without preop HP screening
• screen 2.4
• -screen 6.8
• Plt0.05

Anastomotic Ulcer (Marginal)
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Treatment Options Stricture
Treat Endoscopically
Dilation with a through-the-scope balloon
dilator
Gastrograffin swallow
From Martin and Pandolfino, Curr Gastroenterol
Rep 2005.
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• Details
• 14 patients
• 23 dilations
• 15-25 Fr balloons
• 1-3 total dilations

• Results
• At µ18 mos
• r7-30 mos
• All responded
• No complications

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Case Presentation 1 RYGB

• 37 y/o F (WV)
• S/P RYGB surgery
• Lost 35 lbs in 4 wks
• 5 wks postop
• Vomiting
• Epigastric pain
• Whats going on? What do you do?

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Case Presentation 1 RYGB

• EGD is performed

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Case Presentation 2 RYGB

• 57 y/o F
• S/P RYGB surgery 9 mos prior to transfer to
  Northwestern Memorial Hospital
• Complication 1 gastropleural fistula requiring
  thoracotomy drainage
• Complication 2 chronic gastrocutaneous fistula
  requiring operative drainage debridement, now
  with persistent output
• Unable to tolerate oral intake now on TPN

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Pre UGS 1
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Pre UGS 2
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Gastric pouch
Fistula tract
Anastomosis
Jejunum
Pre UGS 3
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Pre UGS 4
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Pre UGS 5
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Pre UGS 6
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Pre UGS 7
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EGD 1
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EGD 1
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EGD 1
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EGD 1
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EGD 1
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EGD 1
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EGD 1
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EGD 1
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EGD 1
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EGD 1
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EGD 1
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EGD 1
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3 weeks later
EGD 2
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EGD 2
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EGD 2
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serial, graduated dilation
EGD 2
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EGD 2
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In another 3 weeks, give it another go
EGD 3
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EGD 3
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EGD 3
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EGD 3
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Post UGIS
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Post UGIS
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Fistula closed
Anastomosis widely patent
Post UGIS
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Case Resolution

• At 3 months follow up
• Her fistula had closed
• Her skin wound had healed
• She was tolerating solid oral intake without
  difficulty
• and she remains well today

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DO WE REALLY KNOW WHAT WERE DOINGYET?
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How about a bit of data
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Endoscopic Balloon Dilation in RYGB
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Do we know what were doing?Our recent
retrospective data

• 540 pts with RYGB at NMH
• 112 underwent EGD (21) for nausea, vomiting,
  inability to take po, dysphagia, hematemesis
• 80 had abnormal findings
• 39 have anastomotic ulcers
• 19 have stricture
• 22 have ulcer and stricture
• Only 20 have neither ulcers nor strictures
• All strictures were treated successfully with TTS
  balloon dilation without complication
• No ulcers or strictures have required reoperation

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Do we know what were doing?Our recent
prospective data from

• 24 RYGB patients had EGD in recent 4-month period
  for N/V and / or epigastric pain
• 79 have ulcers or strictures
• 71 have anastomotic ulcers
• 8 have stricture
• Only 21 have neither ulcers nor strictures
• All were treated with PPI or EGD dilation
• None have required reoperation
• So far, no predictive value for pain vs N/V in
  differentiating ulcer from stricture

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Opportunities to change the paradigm

• Prophylactic PPIs for all RYGB patients post-op?
  If so, for how long?
• Empiric PPI therapy instead of for all RYGB
  patients with N/V epig pain ?
• What is the optimum dilation diameter?
• What is the degree of acidity in the gastric
  pouch?
• Should patients routinely undergo concomitant
  cholecystectomy?
• What can be done endoscopically to treat
  recurrent weight gain post RYGB?
• What can be done endoscopically to treat suture
  line fistulas and leaks?

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Future Directions

• Anastomotic enlargement, gastric pouch stretching
• Bulking agents polymer injectables
• Ligation plication
• Fistulas suture line leaks
• Endoscopic clipping
• Ligation devices
• Bulking agents polymer injectables

Images Microvasive, Inc.
Wilson-Cook Medical, Inc. Olympus
America, Inc.
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More Future Directions

• Anastomotic ulcers
• Postop prophylactic acid suppression
• Postop sucralfate
• Suture material / staple material / technique
• Prevention of gallstone complications
• Concomitant cholecystectomy
• Postop prophylactic ursodiol
• Combined management of non-anastomotic strictures
  (e.g., restriction band stenosis)
• Endoscopic management in complications of the
  afferent Roux limb
• Expanded endoscopic role in Lap-Band
  complications?

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Endoscopic Management of Obesity
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Endoscopically-delivered BariatricInterventions

• All are investigational
• Gastric space-occupying devices
• GEGB
• BIB
• Non balloon-based space-occupying devices
• Gastric anatomical modification
• Endoluminal gastric plication techniques
• Endoscopic gastrojejunostomy
• Luminal sleeves

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NOTES in Bariatrics
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NOTES in Bariatrics

• All investigational in animal models
• NOTES correlates to existing bariatric surgery
• Roux-en-Y gastric bypass
• Gastrojejunostomy
• Gastroplasty

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Wrapping it up

• Change is opportunity
• New operations create new
• anatomy and new complications
• Minimally invasive surgery interfaces
• constantly with interventional endoscopy
• Both create opportunities for high-impact
  endoscopy
• New technology novel concepts are spawning new
  endoscopic techniques to manage bariatric
  surgical complications and to deliver definitive
  endoscopic bariatric solutions
• Medical surgical colleagues are already at
  work, together, seamlessly, in a team-approach to
  advance anatomical solutions to treat obesity

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Fighting disease in chicago
THANK YOU FOR YOUR INTEREST!
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INTERVENTIONAL ENDOSCOPY NORTHWESTERN UNIVERSITY
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