Bariatric Times - January 2009 - (Page 10)

10 Surgical Perspective Bariatric Times • January 2009 used to cut it. Rat tooth forceps are used to grasp the ring, which usually slides out of the tract easily. Free perforation into the abdomen after the endoscopic removal of a silastic ring that has chronically been eroded is a potential concern, but has not been reported. No other intervention is usually done to the erosion site. Suture material is another frequently encountered foreign body FIGURE 2. An endoscopic view FIGURE 1. Fluoroscopic view of often leading to ulcerations or through a balloon of a stricture dilation balloon. Waist on balloon gastritis at the pouch, anastomosis, being dilated. The clear balloon corresponds to the site of stricture. and/or jejunum.25, 26 These are easily allows for endoscopic managed with a dual working Fluoroscopy allows continued visualization of the stricture being channel upper endoscope to allow monitoring of balloon dilation until the dilated as the balloon is inflated. one channel to grasp and place waist on balloon is ablated. tension on the suture and the other working channel to have endoscopic scissors to cut and remove the sutures. Using a single-channel endoscope makes it more difficult as the endoscopic scissors do not cut very well and need the traction on the suture to cut (Figure 10). A gastric bezoar is another foreign body encountered after bariatric surgery, especially if a band FIGURE 4. Self-expanding plastic stent with is too tight, an anastomotic stricture is present, or a patient is not FDA approval for benign disease. Proximal FIGURE 3. Dilating balloon compliant with his or her diet. These flare designed for improved stent fixation. catheter that is able to be bezoars can be managed safely and Three radiopaque markers to assist with introduced through the easily via endoscopic interventions.27 fluoroscopic positioning. Silicone coating is working channel of the The use of a net allows sweeping of designed to enhance patency, resist tumor the bezoar and collection into the endoscope. ingrowth and seal concurrent enteral net to assist in removal. If the foreign body is large or sharp, then a fistulae. foreign body retrieval hood and rat tooth forceps are recommended for a firm grasp and minimizing injury of the esophagus upon removal of the foreign body (Figure 11). Decreasing the pouch and/or stoma size demonstrates another concept of endoscopic treatment of bariatric surgery complications. However, which technologies result in the most durable and consistent methods of pouch and/or stoma reduction and subsequent weight loss has yet to be determined. Presently, we perform endoscopic sclerotherapy and StomaPhyx. CONCLUSION Bariatric surgery has experienced continual evolution. From its early days of open surgery to the current standard of laparoscopic surgery, the field is ever-changing and physicians involved in bariatric surgery must continue to be knowledgeable of WEIGHT REGAIN/INSUFFICIENT WEIGHT LOSS We have previously discussed endoscopic revisional bariatric surgery for inappropriate weight loss and/or weight regain.28 Briefly, there are various options that are available to the patient and surgeon when encountering weight loss issues after Roux-en-Y gastric bypass. Most of these options are based on reducing either the stomach or stoma size. This reduction occurs via endoscopic suturing, endoscopic injection of sclerosing agents, or utilized specialized endoscopic devices. Sclerotherapy, as first mentioned by Spaulding,29 utilizes sodium morrhuate for its complication of causing stricture with deep injection. We find that about half of the patients have a satisfactory response to this treatment. Other potential modalities have included the Flexible Endoscopic Suture Device (Wilson-Cook; Winston-Salem, NC),30 the EndoCinch System,31 the USGI Endosurgical Operating System (USGI Medical, Inc., San Clemente, CA),32 and StomaPhyx (EndoGastric Solutions, Inc., Redmond, WA). FIGURE 5. Endoscopic view of stricturotomy performed on a refractory stricture with a needle knife sphincterotome used traditionally in biliary endoscopy. A longitudinal cut along the stricture is demonstrated. FIGURE 6. Endoscopic clips visualized to close a gastric fistulae. Just as the surgery itself is becoming less and less invasive, so is the MANAGEMENT of its associated complications. FIGURE 7. View of fibrin glue injected into a fistula tract. A required dual lumen channel catheter to prevent premature mixing of glue components is demonstrated. FIGURE 8. Eroded silastic band noted on inferior lumen corresponding to a gastro-gastric fistulae after a Roux-en-Y gastric bypass. emerging technologies. Just as the surgery itself is becoming less and less invasive, so is the management of its associated complications. The standard to proceed with surgery for any identified postoperative complication has evolved to much less aggressive interventions.

Table of Contents Feed for the Digital Edition of Bariatric Times - January 2009

Bariatric Times - January 2009 Surgical Perspective Psychological Perspective Metabolic Perspective Editorial Message Table of Contents Editorial Board Anesthesiology Perspective Body Contouring Perspective Journal Watch Advertiser Index News & Trends

Bariatric Times - January 2009

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.