Bariatric Times - Supplement A - Covidien - (Page 20)

THE 2007 INTERNATIONAL CONSENSUS SUMMIT ON SLEEVE GASTRECTOMY is present and not repaired, the patient will be left with a small, proximal mediastinal pouch that will lead to progressively worse reflux over the early postoperative years. The pouch must be stapled in a way that avoids segmental narrowing or a relatively capacious area proximally. We have had two patients with a proximal segment of pouch that was stenotic and responded well to dilation; one required a removable stent. Segmental narrowing further down can lead to a hourglass-shaped pouch that can yield significant pouch stay in position. Applying these concepts should yield an excellent anatomical pouch. beyond the first two postoperative months. EVALUATION CARDIOSPASM Cardiospasm may be another reason for postoperative reflux, vomiting, and dysphagia. This is usually most severe in the first few weeks after surgery and is the main reason these patients must be limited to liquids for the first three weeks. It is unlikely that any solid food can be consumed safely and may produce vomiting to the point of requiring readmission for The evaluation process for early obstructive symptoms must include careful review of the patient’s diet and medication intake. If a patient is attempting a liquid diet (not a regular diet) and not getting a good response to the medications listed above, they will most likely become dehydrated in less than one week. Possible tests that can be done include an upper gastrointestinal (UGI) series, endoscopy, and The clinical manifestations of [spasms, gastritis, and anatomical points of narrowing] will present with a progressive inability to tolerate liquids, progressive dysphagia, vomiting, reflux, and regurgitation in the early weeks after surgery the surgeon cannot assume that the patient [with these symptoms] is not compliant and that an anatomical problem does not exist. reflux symptoms and ultimately proximal pouch dilation over several years. Failure to exclude the posterior proximal stomach can lead to a large proximal pouch, which will dilate and lead to weight regain. This can be avoided by proper mobilization proximally and viewing the stomach both anterior and posterior prior to stapling each segment. Angulation or tortuosity of the angularis can occur if the pouch diameter is smaller (<40Fr) and the stapler is too tight on the bougie at the level of the angularis. We also try to avoid this by positioning the pouch laterally over the pancreas so that it has a gradual curvature from LES to pylorus. Fibrin sealant may help the dehydration or staple-line disruption. Hyosamine is an anticholinergic drug that can help reduce cardiospasm and improve liquid intake in the first few weeks. Approximately 30 percent of our patients use this in the early postoperative period. It is rare to require it beyond three weeks after surgery. We prescribe metoclopramide for nausea, which is usually quite mild. It does not seem to improve oral intake as well as hyosamine and may compete with it. We prescribe proton pump inhibitors for the first two months postoperatively to prevent the development of gastritis. Some patients will require proton pump inhibitors for reflux symptoms computed tomography (CT) scan. The UGI is useful as a diagnostic test but has no therapeutic value and may delay treatment. We usually prefer to have the patients undergo an urgent endoscopy with simultaneous rehydration. The endoscopy can be therapeutic as the act of blowing air into the pouch helps to expand it. In addition, it can diagnose gastritis, ulcers, stenosis, and other anatomic abnormalities as previously discussed. Rarely, an endoscopic balloon dilation or even a stent may be required. Most often, we find that rehydration and endoscopy resolves the obstructive type symptoms and patients subsequently improve. 20 Bariatric Times [ J U N E 2008, SUPPLEMENT A]

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Bariatric Times - Supplement A - Covidien Contents Laparoscopic Sleeve Gastrectomy: From Magenstrasse And Mill To Sleeve Sleeve Gastrectomy Provides Resoultion of Type-2 Diabetes Without Duodenal Exclusion The Relationship Bewtween The Resected Remnant And Weight Loss Laparoscopic Sleeve Gastrectomy: Results After Two And Five Years Laparoscopic Sleeve Gastrectomy As An Initial Weight Loss Procedure For High-Risk Patients With Morbid Obesity Three-Year Results Of Laparoscopic Sleeve Gastrectomy In The Treatment Of Morbid Obesity In Korea Laparoscopic Sleeve Gastrectomy: Nutritional Concerns And PostOperative Dietary Care Laparoscopic Sleeve Gastrectomy: Prevention And Treatment Of Bleeding Prevention And Treatment Of Gerd/Hiatal Hernia And Stenosis Associated With Sleeve Gastrectomy Laparoscopic Revisions Of Sleeve Gastrectomy Survey Results

Bariatric Times - Supplement A - Covidien

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