Stomach: Bariatric Surgery

Laparoscopic Adjustable Gastric Banding (LAGB)

Procedure

  • Expose Left Crus at the Angle of His
  • Dissect the Gastrohepatic Ligament to Enter the Lesser Sac
  • Place Band Around Proximal Stomach
    • Medial-to-Lateral Direction (45-Degree Angle to Left Shoulder)
    • Inferior-to-Superior Slant
  • Pull Tubing Externally & Secure to the Subcutaneous Port

Complications

  • Band Slippage
    • Herniation of Stomach Above the Band
    • UGI: Fundus Above Band
      • Band on XR Should Be at 45-Degree Angle (90-Degree or More is Indicative of Slippage)
    • Tx: Deflate Band (Remove Saline) & Surgically Remove
  • Gastric Erosion
    • Erosion of the Band into the Stomach
    • Presentation: Erythema & Tenderness at Port Site
    • UGI: Contrast Outside of Lumen
    • Tx: Remove Band & Repair Defect
  • Tube Kinking
    • Presentation: Difficulty Adding/Removing Fluid from Port
    • Tx: Explore Under Local Anesthesia
  • Band Too Tight
    • UGI: Esophageal Dilation
    • Tx: Deflate Band or Surgically Remove

Vertical Banded Gastroplasty (VBG)

  • A Vertical Staple Line Through the Proximal Stomach with a Band Placed Around the Middle of the Stomach at the End of the Staple-Line to Create a Small Pouch
  • Fallen Out of Favor
  • Only 10% Maintain Weight Loss After 10 Years
    • Restrictive Nature Causes Difficulty Tolerating High Fiber/Protein Diet
    • Many Result to Liquid Carbs and Junk Food Causing Weight Regain

LAGB 1

VBG 2

Laparoscopic Vertical Sleeve Gastrectomy (LVSG)

Procedure

  • Divide the Short Gastric Vessels Along the Greater Curvature
  • Pass Bougie Orally and Direct Along the Lesser Curvature
  • Divide Stomach Along the Greater Curvature
    • Start 5-6 cm from Pylorus (Obstructs if Too Close)
    • Extend to Angle of His

LVSG 1

Roux-en-Y Gastric Bypass (RYGB)

Procedure

  • Divide Jejunum 30-50 cm (Biliopancreatic Limb) Distal to Ligament of Treitz
  • Anastomose Proximal End 75-150 cm (Roux Limb) Down Distal Jejunum
  • Expose Left Crus at the Angle of His
  • Dissect the Gastrohepatic Ligament to Enter the Lesser Sac
  • Transect Stomach to Create a 20 cc Proximal Gastric Pouch
  • Anastomose Roux Limb to Gastric Pouch
  • Close Mesenteric Defects

Mesenteric Defects

  • Jenjuno-Jejunostomy Defect
  • Petersen’s Space
    • Between Roux Limb Mesentery & Transverse Mesocolon
  • Transverse Mesocolon Defect
    • Only Present After Retrocolic Procedures

Roux Limb Variations

  • Antecolic – Roux Limb Passed Anterior to Transverse Colon
    • Faster to Preform
  • Retrocolic – Roux Limb Passed Posterior to Transverse Colon
    • Shorter Route (Less Ischemia Risk)
    • Higher Risk for Internal Hernia

Complications

  • Failure & Weight Regain (15%, Long Term 35%)
    • Definition: BMI > 35 or Failure to Achieve/Maintain ≥ 50% of Excess Weight Loss
    • Most Often Due to Maladaptive & Noncompliant Eating Habits
      • Pouch Can Stretch/Dilate from Repeated Overdistention
      • Unlikely to Benefit from Revisional Surgery
    • Can Be Caused by a Gastrogastric Fistula
  • Anastomotic Leak (0-5%)
    • Consider Barium Swallow on Postoperative Day #2
    • Most Common Cause: Ischemia
    • Sx: Tachycardia (First), Tachypnea, Fever & Often Have No Pain
      • Any Evidence of New Onset Tachycardia Could Suggest a Leak
    • Tx:
      • Unstable or Early (Not Contained): Surgery
      • Stable & Late (Contained): IR Drain & ABX
  • Stomal/Anastomotic Stenosis (6-17%)
    • Manifests When Anastomosis Diameter Narrow < 10 mm
    • Presentation: Unable to Swallow Liquids
    • Tx: Endoscopic Dilation
  • Marginal Ulcers (0.6-16%)
  • Gastrogastric Fistula (1-2%)
    • Fistula Between Stomach Pouch & Stomach Remnant
    • Presentation: Marginal Ulcers, Pain, Bleeding or Weight Gain
    • Tx: Endoscopy vs Surgery
  • Internal Hernia (3-5%)
    • *See Small Intestine: Internal Hernia
    • Most Common Cause of SBO after RNY (Not Adhesions)
    • Herniated Bowel Through Internal Mesenteric Defect
    • See Mesenteric Swirl on CT
    • Cause: Poor Closure of Defects
      • Increased Risk in Laparoscopic Surgery (Less Adhesions > More Mobility)
      • Most Common Defect: Transverse Mesocolon (Less With Antecolic Limb)
    • Tx: Surgery
  • Gallstones
    • Cause: Stasis & Increased Calcium/Mucin Secretion
      • Rapid Weight Loss Increases Lithogenicity of Bile
    • Asymptomatic Gallstones are Common but Symptoms are Rare
    • Difficult to Preform ERCP for Choledocholithiasis After RYGB Due to Altered Anatomy
      • May Require Surgical Gastrostomy into Remnant to Pass the Endoscope
    • Some Recommend Prophylactic Cholecystectomy at Time of Original Surgery (Controversial)
  • Dumping Syndrome
  • Candy Cane Roux Syndrome
    • Excessively Long Blind Afferent Roux Limb at the Gastrojejunostomy
    • Presentation: Postprandial Pain Relieved by Vomiting
    • Dx: UGI or Endoscopy
    • Tx: Surgical Revision
  • Gastric Remnant Distention
    • Risk for Rupture
    • Tx: Emergent Gastrostomy Tube for Decompression
  • B12 Deficiency & Iron-Deficiency Anemia
  • Medication Absorption Changes:
    • Increased Absorption:
      • Digoxin
      • Lithium
      • Penicillin
      • Atorvastatin
    • Decreased Absorption:
      • Phenytoin
      • Erythromycin
      • Coumadin
      • Ampicillin
      • Tamoxifen
      • Cyclosporine
      • Levonorgestrel
      • Imatinib
      • Tacrolimus

RYGB 1

Mesenteric Defects; (a) Petersen’s Space, (b) Transverse Mesocolon Defect, (c) Jejuno-Jejunostomy Defect 3

Jejunoileal Bypass

Procedure

  • Divide Proximal Jejunum at 35 cm
  • Anastomose to Proximal End to Ileum, 10 cm From Ileocecal Valve

Basics

  • No Longer Preformed
  • High Complication Rate – Liver Cirrhosis, Kidney Stones, Osteopenia & Malnutrition
    • Reoperate if Found

Jejunoileal Bypass 4

Biliopancreatic Diversion with Duodenal Switch (BPD-DS)

Procedure

  • Preform a Sleeve Gastrectomy
  • Divide Ileum 250 cm From Ileocecal Valve
  • Anastomose Proximal End (Ileoileostomy) 100 cm from Ileocecal Valve
  • Divide Duodenum 3-4 cm Distal to Pylorus
  • Anastomose Roux Limb to Duodenum (Duodenoileostomy)
  • Close Mesenteric Defect

Considerations

  • May Require Two-Stage Procedure if Extremely High BMI > 70
    • Stage 1: Sleeve Gastrectomy
    • Stage 2: Diversion & Switch After 1 Year of Weight Loss
  • Duodenal Switch Leaves the Pylorus Intact
    • Biliopancreatic Diversion Alone Has Roux Limb Anastomose to Stomach

BPD-DS 1

References

  1. Neff KJ, Olbers T, le Roux CW. Bariatric surgery: the challenges with candidate selection, individualizing treatment and clinical outcomes. BMC Med. 2013 Jan 10;11:8. (License: CC BY-2.0)
  2. Friberg J, Fruitsmaak S. Wikimedia Commons. Public Domain.
  3. Izadpanah A, Izadpanah A, Karunanayake M, Petropolis C, Deckelbaum DL, Luc M. Abdominal compartment syndrome following abdominoplasty: A case report and review. Indian J Plast Surg. 2014 May;47(2):263-6. (License: CC BY-NC-SA-3.0)
  4. Sylvan A. Wikimedia Commons. (License: CC BY-SA-4.0)