Gastrointestinal (GI) Bleed following weight loss surgery is rare but does require knowledge of the particular bariatric surgical procedure the patients has and how to proceed with diagnostics to fully evaluate the situation. Acute or chronic gastrointestinal bleeding can cause anemia in patients. However, Anemia may also be caused by nutritional deficiencies (iron, vitamin , minerals), Kidney disease, bone marrow disease and others. The work-up for anemia following weight loss surgery follows a routine protocol. If there is an evidence of bleeding from intestine (bloody emesis, bloody bowel movement, “tar” like black bowel movements) then the diagnostic work up would include an upper and lower endoscopy.
Upper endoscopy Esophagogastroduodenoscopy (EGD): evaluates the esophagus, stomach and a limited area of the duodenum past pyloric valve.
Lower endoscopy Colonoscopy or coloscopy: evaluates the rectus and the entire colon.
Between these two tests, there is still a considerable amount of the small bowel that is not accessible or visualized with endoscopic procedures. For the small bowel, examination Capsule endoscopy is an option in an intact GI tract. Patients who have had Gastric bypass RNY or the Duodenal Switch, the large segments of the small bowel can not be visualized or examined with capsule endoscopy.
Patients who have had Duodenal Switch, Gastric Bypass and SADI – S would need a tagged red cell scan or CT angiography if GI bleed is suspected in areas of the small intestine that are inaccessible by endoscopic procedures.
There are differing opinions, based on a broad set of scientific publication, wether or not gallbladder should be removed at the time of weight loss surgery. Obviously, Cholecystectomy is a stand alone general surgical procedure that is often performed due to gallstones and/or gallbladder disease with a variety of symptoms. However, the focus of this blog will deal with Bariatric Surgery and Cholecystectomy.
Rapid weight loss can increase a patients chance of forming gallstones. This rapid weight loss can be as little as 3-5 pounds per week. Weight loss surgery can increase your risk for gallstone formation. Several of the common thought processes the mechanism of this is, obesity may be linked to higher cholesterol in the bile, larger gallbladders, high fat diet and larger abdominal girth.
When a patient is having the Duodenal Switch (DS) Bariatric operation, or having a revision of a failed gastric bypass to the DS, I always remove the gallbladder. This is because there isn’t an anatomical route to utilize endoscopic procedure for an ERCP should the need rise.
In the case of a patient undergoing Vertical Sleeve Gastrectomy, if there are any indications or complaints of abdominal pain then an ultrasound is done. If there are findings of gallstones or other disease of the gallbladder, then a cholecystectomy is performed at the same time as the Sleeve Gastrectomy.
In my opinion, every patient having the Gastric Bypass (RNY) should also have the gallbladder removed because of the anatomical limitations after surgery that prevents the use of ERCP if needed. Some clinicians will place the patient on a long term medications to reduce the chance of gladstone formation after surgery, which themselves have side effects limiting the compliance in most patients.
Further information on Common Bile Duct Dilatation and ERCP
PolyCystic Ovarian Syndrome PCOS is a complex condition. The exact cause of PCOS is unknown however, it involves hormones imbalance and multiple ovarian cysts, irregular menses, and infertility. In some cases, PCOS can be compounded by diabetes, hypertension and other metabolic conditions. PCOS has been shown to effect approximately 10% of women of childbearing age with symptoms of menstrual abnormalities, poly cystic ovaries, and excess androgen (male sex hormone). PCOS should be diagnosed by ensuring there are no other underlying endocrine issues. There are several associated disease processes that seem to be related to PCOS. These related disease processes are Type 2 Diabetes, higher depression and anxiety, increased cardiovascular risks, stroke, hyperlipidemia, sleep apnea, overall inflammation, and endometrial cancer.
Anatomically, numerous cysts are found on the ovaries. These are usually diagnosed by ultrasound, blood levels of hormones, and symptoms described above.
Bariatric Surgery and PolyCystic Ovarian Syndrome PCOS
Bariatric Surgery can improve PCOS in those individuals with Type 2 Diabetes Mellitus. Further information on weight loss surgery and its effect on PCOS here.
Stéfane Lebel, M.D.*, Geneviève Dion, M.D., Simon Marceau, M.D., Simon Biron, M.D., M.Sc., Maud Robert, M.D., Laurent Biertho, M.D. earlier this year released a research article comparing patients undergoing standard common channel of 100cm and standard common channel 200cm. The conclusion of this article was: “In this population, BPD-DS with a 200-cm common channel offered similar remission rate of co-morbidities compared with standard BPD-DS. It was associated with similar weight loss at nadir, followed by a more significant weight regain. It might yield a lower rate of nutritional complications. Long-term randomized data are needed to detect other potential advantages.”
One of the most dreaded outcomes of any weight loss surgical procedure is weight regain. This is assuming that initial adequate weight was lost to result in resolution of the co-morbidities in the first place. As the weight loss surgical field has changed over the years so has been the cases of regain that we have seen.
There was a time when Lap bands were being revised for inadequate weight loss and weight regain. Not to mention the complications of reflux, difficulty swallowing and persistent Nausea and vomiting. Then as more Gastric bypass procedures “aged” the number of patients that started looking for revision for weight regain increased. The latest fad is the Vertical Sleeve Gastrectomy that are done with false sense of expectation and results. The long term outcome of Vertical Sleeve Gastrectomy is no where close to that of the Duodenal Switch, independent of the size of the sleeve. In fact, more surgeons are trying to get a little more weight loss by making the sleeve too tight. All they are doing is creating a significant and debilitating set of problems such as reflux, nausea, and solid intolerance.
The ideal revisional procedure for these patients should be the Duodenal Switch. Some surgeons, however, have started advocating “single anastomosis” knock off the duodenal switch. Others do “standard length common channel” rather than a Hess method Duodenal Switch. I have always performed a traditional Hess method Duodenal Switch. The Hess method Duodenal Switch has held the largest and longest excess weight loss maintenance for 28 years, going into 29 years. Here is a past blog regarding small bowel length.
The predetermined standard common channel results in weight regain. Study
Buyer Beware ! There are a lot of look alike and counterfeit “Duodenal Switch” procedure being performed. A recent online chat discussion clearly demonstrates the point that just because a patient is told that they had the duodenal switch operation this is not necessarily the case.
In our practice, we always warn our patients of not comparing notes and their outcome to others. I perform the Duodenal Switch procedure the way it was described by Dr. Hess, making the common and alimentary lengths as a percentage of the total length of small bowel. This is why our patient population has very little nutritional, and gastrointestinal issues compared to others. Unfortunately when a patient is given a disproportionately long Common channel and/or Alimentary channel the patient will have inadequate weight loss. Alternatively, when patients are given a shorter alimentary channel in proportion to the total bowel length, significant nutritional deficiencies can arise. In a shorter alimentary channel situation patients have to consume higher doses of vitamins and nutrients to keep their laboratory values normal.
I have repeatedly raised the issues to clearly distinguish the single anastomosis procedures from Duodenal Switch operation.
One of the unfortunate problems is the lack of clear guidance given to the patients. It is not uncommon, when I do second opinion consultation with patient who were given generic gastric bypass post op protocol and instructions after their duodenal switch operation. This clearly shows lack of fundamental understanding of the practice performing these procedures and it is carried onto the patient.
Minimally Invasive does not mean better, easier, proven outcomes or good excess weight loss. Weight loss surgical patients should be careful of catch phrases such as “less invasive”, “simpler”, “shorter recovery”, “outpatient” and many others that had been used to described procedures with less than optimal outcome. We should not forget the lessons learned from adjustable gastric banding which was also promoted as ” less invasive, simpler to perform, and be done as an outpatient with a short recovery “. We all know how that story has panned out. The overwhelming majority of patients who had an adjustable gastric banding have undergone revision, had it removed or had additional surgeries following the complications which were associated with this simple procedure.
When evaluating outcome data for weight loss surgical procedures, it is important to bear in mind that the long-term success of these procedures will take years to document. More often than not the early weight loss is significantly better than the long-term stable weight loss. This has been clearly documented in the case of the adjustable gastric banding and the gastric bypass and laparoscopic sleeve gastrectomy operation. Duodenal switch , as described by Dr. Hess using the percentage based technique, has the best long-term documented success of all of the weight loss surgical procedures. The scientific data reports 20+ years of successful excess weight loss with a Hess Duodenal Switch procedure. There has been an alternative proposed to Duodenal Switch recently, the SIPS and SADI procedures. As I have already stated in the past, these are not the same as the duodenal switch operation. Any suggestion or innuendos that SIPS/SADI is the same as the Duodenal Switch is deceptive and misleading. We have also seen attempts to use the same catch phrases as described above to promote these unproven procedures. The published data that’s been reported with SIPS/SADI is mostly short-term in small population studies. There are no long-term studies that have documented the efficacy of the SIPS/SADI procedure and “simpler” or minimally invasive does not mean better.
The 2015 ASMBS meeting was held November 2-6, 2015. It was combined with TOS (The Obesity Society) and had more than 5,600 attendees from all over the world in every aspect of obesity treatment. There were some interesting additions and deletions from this meeting compared to the past.
The one sentence that comes to my mind is “I told you so”.
One important addition was a DS course for Surgeons and Allied Health. This was very exciting, except the content and questions seemed to gravitate to SADI/SIPS/Loop rather than DS. Dr. Cottam was one of the moderators of the course. It seems that they have found the value in preserving the pyloric valve. It was clear that the discussion was driven by the need to come legitimize the single anastomosis procedures at this early stage with almost no data to prove long term outcome. With many of the Vertical Sleeve Gastrectomies having re-gain and the they are looking for a surgery that the “masses” can perform. This was actually the term used by one of the presenters, implying that the duodenal switch needed to be simplified so that all surgeons, those who have pushed all other procedures can not offer Duodenal Switch to their patients with less than desirable outcome. Several surgeons also voiced their concern and dissatisfaction with the issues and complication of the RNY and want an alternative. There was much discussion regarding SADI/SIPS/Loop being investigational and that it shouldn’t be as it is a Sleeve Gastrectomy with a Billroth II. Dr. Roslin and Dr. Cottam discussed their SIPS nomenclature saying they wanted to stay away from something that had Ileostomy, suggesting bowel issues, or the word “SAD”i due to negative connotations. The point to be made is that the SADI and SIPS and the loop are all the same. I have also noticed other surgeons using SADS (Single Anastomosis Duodenal Switch). There is a great deal of industry behind these procedures and many surgeons being trained in courses funded by industry. One surgeon stood up and informed the entire course that they need to be clear with their patients about the surgery they are performing, as he had been in Bariatric chat rooms and there is upset within the community about SADI/SIPS/Loop being toted as “the same or similar to Duodenal Switch”.
There was also presenter who said “We are doing something new about every five years.” No, “we” are not. Some of us have stood by the surgery and techniques with the best long term outcomes and not gone with every “new” thing out there. The process of Duodenal Switch may have changes, open Vs. Lap, drains, location of incisions, post operative care and stay, but the tested procedure with the best outcome has been the duodenal switch operation and not the shortcut versions. Although, those of us that are standing by long term results seems to be in the minority. Why do I stand by Duodenal Switch? Because it works, when done correctly by making the length of the bowel proportional to the patient total bowel length, and height, and not just cookie cutter length for all patients, with the right follow-up, patient education, vitamin and mineral regime and eating habits.
A new addition was the Gastric Balloon, which in the research presented had a 60-70% re-gain rate and a no more than 10-15% weight loss one year only. This data represents more than 70% weight regain when the balloon is taken out. The Gastric Balloons can be left in between 4-6 months depending on the brand or type of balloon. The Gastric Balloon is not new to the Bariatrics and was first introduced in 1985. After 20 years and 3,608 patients the results were and average of 17.6% excess weight loss. It seems that we are re-gurgiating old procedures. There are many new medications that were front and center in this meeting.
The Adjustable Gastric Bands were missing from the exhibit hall this year. It is my hope and feeling from the other attendees that we may be seeing the era of the Adjustable Gastric Band being placed in patients come to an end. Although there are some still holding out that there are some patients that can do well with the Band.
Attending the 2015 ASMBS meeting this year, as it has every year, only reemphasized the importance of avoiding what has become the norm of chasing a simple solution that is fashionable and easy now. We stay convinced that the duodenal switch operation with the common channel and the alimentary length measured as a percentage of the total length is by far the best procedure with the proven track record. The patient should avoid the temptation of settling for an unproven procedure or device, because if history holds true, there will be a need for revision surgeries in the future.
There is no substitute for the Duodenal Switch (DS) operation. The other easier procedures that are being presented as DS equivalent are untested, and unproven operations that in my opinion will fall short of the outcome patients expect. The coding definition of BPD/DS is as follows: A Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) Please not that there are two anastomosis within the definition.
As a patient advocate and a surgeon who has seen a number of recent complications (significant bile reflux gastritis, inadequate weight loss, etc..) of these “Duodenal Switch” substitute procedures, (SADI/SIPS/Loop) I would recommend that any patient considering anything other than the anatomically accurate and proven standard DS procedure realize that they are being subjected to a procedure with an unknown long-term outcome other than what is published in a few studies with a very short-term follow-up. The weight loss of SADI/SIPS/Loop studies have only been measured in terms of months versus years. I would predict that for the majority of those patients, the long-term weight loss will be inadequate and further corrective surgery will be needed, either for inadequate weight loss or other complications such as bile reflux.
In 1881, Dr. Theodore Billroth performed the first successful gastrectomy for pyloric tumor. He removed the distal part of the stomach and tumor of the pyloric region and reconnected the distal end of the transected stomach directly to the segment of the duodenum. This was later renamed as Billroth I procedure. In Billroth I the anastomosis allows the food pathway to stay in the same directional flow with the exception of pyloric valve having been removed. There is, however, increased incidence of bile reflux with the pyloric value removal.
There are incidences where the resected segment is so large that the proximal stomach and the distal duodenal can not be mobilized and brought close to each other to be able to create the Billroth-I anastomosis. Larger resection, where the Billroth I could not be completed Dr. Billroth in 1885 created a procedure call the Billroth II. The Billroth II was performed when the tumor was very large and the continuity of the GI track was created by a loop gastrojejunostomy. This procedure was named Billroth II.
In the Billroth II the bile flow from the small bowel flows toward the stomach, and this results in a much higher incidence of Bile reflux and its associated complication.
The lesson learned from Billroth I and Billroth II was that bile reflux can be a significant problem when creating the continuity of the proximal GI track with exclusion of the pyloric valve. In Bilroth II, there is the additional burden of the bile flowing toward the stomach unlike the Billroth I.
The SADI or SIPS, Loop procedures that are incorrectly promoted as “duodenal switch” employ a loop anastomosis, which results in a biliary flow toward the post pyloric duodenum significantly increasing the chance and the possible incidence of Bile reflux.
All these unknowns about the SIPS, SADI Loop are yet to be investigated.