Endoscopic therapy for obesity and complications of bariatric surgery

Endoscopic therapy for
obesity and complications of
bariatric surgery
Jacques Devière, MD, PhD
Erasme University Hospital
Brussels Belgium
[email protected]
Obesity
• Affects 300 millions people worldwide (WHO)
• Is linked to 500000 deaths/year in western
countries
• 100 billions dollars direct healthcare
expenditures/year in USA (where 22 millions
adults are MORBIDLY obese)
• Incidence (and indications for treatment)
increased by 800% over the last 15 years
Lancet 2005;366:1197, NEJM 2007;356:21
Complications of bariatric
surgery
•
•
•
•
•
•
•
Cardiopulmonary insufficiency.
Anastomotic fistula.
Wound infections.
Digestive occlusions.
Bleeding.
Incisional hernias.
Migration of implanted material.
Having an effective procedure which does not require
transabdominal access would be appealing
Balloon implantation
Bioenterics BIB
• 10 series, 900 patients, mainly
retrospective, rare controlled series
• Major indications
– Before surgery for superobese
– Non morbid obesity (BMI < 40)
• 6 months treatment
• Results : Median Excess Weight Loss
around 30%, Median BMI loss 5 kg/m2
Transoral vertical gastroplasty in
64 patients
Fogel et al, GIE 2008 ; 68 : 51-59
Endocinch suture.
Transoral vertical gastroplasty in
64 patients
Fogel et al, GIE 2008 ; 68 : 51-59
% EWL 12 months = 58%
Too beautiful to be true ?
Bessler, GIE 2008 ; 68 : 59-60
Transoral gastroplasty (TOGa)
Deviere et al Surg Endosc 2008, Moreno et al Endoscopy 2008 Video Forum – Nishi GK et al, 1016
Main results of the first human pilot trial
• Average BMI decreased from 43.3 pretreatment to 38.6 at 6 months (p<0.0001)
• Absolute mean weight loss was 8 kgs, 11.1
kgs and 13 kgs at 1, 3 and 6 months,
respectively
• Mean excess weight loss was 16%, 22% and
24.4% at 1, 3 and 6 months, respectively
• Mid stomas were observed between the 2
staple lines in 9/21 patients
Deviere et al, Surg Endosc 2008; 22: 589
Adjustable septum
TOGA Pilot Trial Phase II – 1 and 2 sleeves
TOGA Pilot Trial Phase II : Weight Loss
TOGA
N Engl J Med 2007;357:741-52
Poids (Kg)
TOGa, Balloon and 3 Surgical techniques in a single
bariatric center :
Absolute Weight loss
60
55
50
45
40
35
30
25
20
15
10
5
0
1 mois
3 mois
Banding
6 mois
Bypass
9 mois 12 mois 18 mois 24 mois
SRVG
BIG
TOGa1
TOGa2
Prospective randomized study
•
•
•
•
11 centers, 10 US , 1 Europe
Sham-controlled, 2:1
303 patients, inclusion completed
1 perforation due to wire looping
RYGBP after TOGa
• 4 patients, after 1 year follow up
• Stapling visible in 3/4
• Mean operative time 112 minutes vs 110
min for the last 10 primary RYGBP and 142
min for the last 10 RYGBP after restrictive
surgery by the same operator
Closset et al, Obes Surg, ip
Implantable Devices
• EndoBarrier
(GIDynamics)
• Pilot clinical results:
weight loss and
improvement of
diabetes
Others: Barosense, ValenTx
Endoscopic treatment of GI
complications after bariatric surgery
• Dilatation of anastomotic/ post
gastroplasty stenoses
• Removal of partially migrated Rings and
Lapbands
• Treatment of leakages/ fistulae
Strictures
• Etiology: Ischemia, Ulceration (RYGBP),
Band related (LapBand, Gastroplasty)
• Treatment: Dilatation, starting 12-15 mm .
.
in RYGBP
.
.
Band Removal
..
.
Surgical Revision
Various cases…..
Ring or band dysfunction
type
Symptoms
I. Slipping
Weight gain, reflux
or obstruction
Contrast RX
II. Stenosis with pouch
dilation
Nausea, vomiting,
weight loss
Contrast RX/
Endoscopy
Weight gain,
abdominal pain
(port-site infection)
UGI
Endoscopy
Weight gain,
abdominal pain
UGI
Endoscopy
IIIa. Minor Erosion
IIIb. Major Erosion or
intragastric migration
Diagnosis
Technique , success and complications
Case n°
Dysfunction
type
SEPS placement
Band or ring
cutting
Endoscopic
Complication
success
1
II
+
+
Yes
No
2
II
+
-
Yes
No
3
II
+
-
Yes
No
4
II
+
-
Yes
No
5
IIIa
+
+
Yes
No
6
IIIa
+
+
Yes
No
7
IIIa
+
-
Yes
No
8
II
+
-
Yes
No
9
IIIb
-
+
Yes
No
10
IIIa
+
+
Yes
No
11
IIIb
-
+
No
Failure
12
II
-
+
Yes
No
13
II
+
-
Yes
No
Blero et al, GIE, submitted
Leakages/fistulae: Surgical principles
1. Control of leakage
2. Clearance of mediastinal or peritoneal
contamination/collections by lavage &
drainage
3. Antibiotics
4. Nutritional support
TO BE FOLLOWED WHEN
ENDOSCOPIC TREATMENT IS FORESEEN !
Clips/Sutures do not work
Early
diagnosis
(hours)
Leak/Fistula
+
Abcess /
Collection
Primary
repair
Delayed
diagnosis
(days)
+
Chronic
situation
(weeks)
+
-
+
+/-
+
-
-
GIE 1996;44:477
Treatment of post operative fistulae
after bariatric surgery : 21 pts
Type of fistula
Gastro-Cutaneous/Per
18
Duodeno-Cutaneous
2
Gastro-Bronchial
1
Revision laparoscopies
None
5
One
11
Two
5
Median delay between
laparoscopic bariatric surgery
and endotherapy (days)
30 (21-199)
Endoscopy 2007; 39:625
Sequencial Endotherapy
1.
SEMS (Ultraflex) in order to cover the fistula ( 2-3 months)
Sequencial Endotherapy
•
SEPS (Polyflex) to remove both stents
(pressure induced necrosis, 10-15 days)
PROXIMAL
HYPERPLASIA
DISTAL
HYPERPLASIA
AFTER
POLYFLEX
RETRIEVAL
(15
days
in
place)
PLASTIC
STENT
TO INDUCE
NECROSIS
OF HYPERPLASIA
AFTER
POLYFLEX
RETRIEVAL
(15
days
in
place)
AFTER
ULTRAFLEX
RETRIEVAL
months
after
placement
Major
ofproximal
distal hyperplasia
by after
radial
forces
22disappearence
months
placement
Major
disappearence
of
hyperplasia
Proximal part
Success (Complete fistula healing
after stent removal with > 2mo f-up)
• Primary (1 stenting period: 13/21pts)
• Complementary stenting plus sealant
(4/8 residual pts)
• Success with endoscopic treatment:
17/21 pts (81 %)
Endoscopy 2007; 39:625
For refractory fistulae
Fistula Plug™
• Surgisis
• Submucosal intestinal preparation (pig)
• Allows fibroblastic migration and
enhance healing of anal fistulae
Fistula Plug™ implantation
Results of Fistula Plug™ use in
chronic fistulae
• 10 patients with cutaneous fistulae
refractory to previous
surgical/endoscopic treatments
• 1 to 3 Plugs inserted according to fistula
diameter
• Covered by a stent
• 60 % of patients healed with a median
follow-up of 7 months
Toussaint et al, Endoscopy, 2009
Collections / Abcesses after
gastric bypass
Voermans, GIE 2007; 66: 1013
Conclusions
• Endoscopic techniques may offer alternative
approaches to obesity (Morbid, grade 1?,
bridge to RYGBP)
• Endoscopy plays a growing role in managing
complications of bariatric surgery
• A multidisciplinary approach and case
volume are the cornerstone of an optimal
management of these patients