Dr. Abdelrahman Nimeri

Total Alimentary Limb Length and Marginal Ulcer on RYGB and OAGB

Data Collection: Becoming a MBSAQIP Center of Excellence

The treatment of morbid obesity is eminently multidisciplinary. Interaction between surgeons, obesity physicians, dietitians and psychologists has led to improved clinical care. One of the main factors influencing outcome improvement has been centralization in high-volume centers. Currently, the designation of a center of excellence is based on its accreditation. In North America, in 2006 the National Coverage Decision Insurance Medicare was approved, and one of the statutes regarding bariatric surgery was that the costs were only covered in accredited hospitals. This type of decision was based on several studies that concluded that the results in accredited centers were significantly better in terms of mortality, reoperations, complications, readmissions, and costs. The Metabolic and bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), based on the records of the American College of Surgeons (ACS) and the American Society for Metabolic and Bariatric Surgery (ASMBS), has more than 850 centers across the United States, Canada, Abu Dhabi, Jordan, Lebanon, Saudi Arabia, and Puerto Rico. The MBSAQIP program has proven to be a robust method for data recording and center auditing, both at the perioperative level and in the follow-up years. In this talk, Dr. Abdelrahman A. Nimeri explains the history of ACS NSQIP and MBSAQIP registries, as well as some of the main studies on the effect of accredited bariatric surgery centers on postoperative outcomes. He also explains the process to become a center of excellence, the applications that must be completed, and the type of training that must be carried out. Finally, he talks about some of the annual evaluations specified in the MBSAQIP report about quality improvement. Endorsed by: [Image]

IFSO Journal Club XVII

CASE 1: Transjejunal laparoscopic-assisted ERCP a technique to deal with choledocholitiasis after a Roux-en-Y reconstruction. The patient is a female of 31 years old that undergone a Roux-en-Y Gastric Bypass two years earlier and presented periodic abdominal pain. MRCP showed stones on the biliary common duct. In the preoperative CT scan no internal hernias were found. TREATMENT: It was decided to perform a laparoscopic-assisted ERCP. The first thing to do was to identify the gastro-jejunal anastomosis and the jejunal-jejunal anastomosis. An internal hernia in the Petersen space was found but immediately reduced and closed. Then the cholecystectomy was performed. Once the limb near the Treitz ligament was identified and pulled through a mini-laparotomy, a colonoscope was introduced and a plastic stent was placed in the papilla, which was the reference for the sphincterotomy. After doing that, a 5mm stone came out. Then the bile duct was checked with a fogarty balloon catheter and a cholangiogram. Then enterotomy was closed and it was checked for any biliary lesions. OUTCOME: After the surgery the patient started liquid diet the first day and was dismissed after 4 days. Questions were about the use of colonoscope rather than duodenoscope, absorbable suture, mini-laparotomy and transgastric and totally endoscopic approach for similar cases. CASE 2: Endoscopic tunneled stricturotomy with full-thickness dissection in the management of a sleeve gastrectomy stenosis. The patient was a 28 years old women with a history of a sleeve gastrectomy in 06/2018. (BMI: 35.3) who was presenting dysphagia to solid food. During the progression to solid food she developed food regurgitation and vomiting and that is why upper-GI series were performed (stenosis was identified). To treat this stenosis she underwent 3 endoscopic pneumatic balloon dilatations. Those were not effective and she lost 30kg in 5 months so it was decided to perform an endoscopic tunneled stricturotomy with full-thickness dissection. TREATMENT: To start the procedure, once the stenosis was identified a submucosal injections is performed 3-5 cm before the stenotic area. Then, an incision was performed to tunnel submucosally. In this part of the surgery is important to stay on the submucosal layer and not go full-thickness. Then a myotomy was performed and in the area marked with both yellow arrows (stapled line) we dissect out performing the full-thickness stricturotomy. After that, we close using clips. We can see a comparison before and after performing the procedure showing a much larger lumen. OUTCOME: The patient had no post-procedure symptoms and during follow-up the patient tolerated diet and no recurrence of the symptoms appeared. At 2 months, we can see the differences in the upper-GI series and in the endoscopy. As a conclusion endoscopic tunneled stricturotomy with full-thickness dissection appears to be safe and effective in the management of stenosis after sleeve gastrectomy. This procedure can be used after conventional techniques such as pneumatic balloon dilatation or stents fail, or may be considered as an initial therapy for sleeve stenosis. Discussion was based on patient selection, indications, myotomy technique and leak rates. CASE 3: From Nissen Fundoplication to RYGB to treat both GERD and morbid obesity Patient was a 31 year-old woman that had an open Nissen fundoplication on 2010 and a surgical revision with a redo of it on 2012. She complained with dysphagia and morbid obesity so an extensive preoperative workout was done. In the Barium swallow, an esophageal dilatation with a cardial stenosis was presented, and also, an additive image on the left side of the esophagus suggestive of an ulceration. The Upper-GI endoscopy revealed an esophagitis grade C and the manometry showed incomplete waves at lower 3rd and inappropriate release of LES. In the pH-metry acid reflux and positive DeMeester score were evidenced. TREATMENT: The procedure starts dissecting the perigastric tissue, that is challenging as it presented high fibrotic component. Then the dissection of the gastric valve and the hiatal region from the right to the left was completed. Once that was performed an small gastric pouch of 20cc was created to reduce the acid production. Then as in a normal RYGB the biliopancreatic is done at 50cm and the alimentary at 150cm. Jejuno-jejunal and gastro-jejunal were handsewn. OUTCOME: No events were presented in the postoperative, patient at two years follow-up has a BMI of 27, No GERD and no IPP. As a conclusion RYGB is a great option to treat GERD in obese patients. We cannot forget dysphagia as a complication of Nissen fundoplication and conversion from Nissen to RYGD allows us to treat dysphagia, GERD and obesity. Different topics were discussed after the presentation of this case as: short gastric pouch, differences with regular bypass, situations where you cannot undo the Nissen fundoplication, mesh indications above others. CASE 4: From RYGB to SADS Patient was a 49 year-old woman with an initial BMI of 57 and it was decided to convert to SADS for weight regain. TREATMENT: The first thing to do was remove all adhesions from previous surgeries and then dissect the Hiss angle. Once this has been done, he identifies the Roux limb and dissects it 25cm after the gastric pouch. The next thing to do was to connect the greater curve with the Hiss angle. He disconnects the previous anastomosis and performs a gastro-gastrostomy. It is important to do it near the lesser curve as after that a Sleeve gastrectomy will be performed using a Bougie of 42 frames as a reference. The transection of the duodenum is performed conserving as much vascularization as it is possible in order to maintain sleeve well irrigated. After that duodenum-ileal anastomosis handsewn was performed. Anastomosis were checked with methylene blue. OUTCOME: The outcome was good and the patient was discharged 2 days after the procedure with no complications. Questions were about rate of complications, length of limbs, roux limb, conversion after RYGB and weight loss after conversion. CASE 5: PETERSEN’S HERNIA AFTER OAGB Patient was a 48 years-old woman with a BMI of 52, she was referring bile reflux with no response to medical treatment. So it was decided to convert mini-gastric bypass to RYGB. TREATMENT: As the surgery started, an internal hernia was identified on the Petersen’s defect, in this case the hernia was protruded from medial to lateral something that is rare as normally it is the other way around. To start the procedure we need to identify the proximal and distal limb of gastrojejunal anastomosis. On the proximal limb of this anastomosis an enterotomy was performed and 75cm of the alimentary limb were measured to perform the jejunojejunal anastomosis. After that the jejunojejunal and Petersen’s defect were closed. After doing that, the transection of biliopancreatic limb from alimentary limb was performed. OUTCOME: The outcome was good and the patient was discharged 1 day after the procedure with no complications. A short term follow-up at 3 months was symptoms free. In this last case, discussion was based on rate bile reflux, biliopancreatic limb length, indications for conversion, causes for bile reflux and hernia defect closures.

A longer biliopancreatic limb in Roux-en-YGB improves weight loss in the first years after surgery: results of a randomized controlled trial

Abdelrahman Nimeri, Chairman of the IFSO Communication Committee, presents the Journal Club with Frits Berends, Bariatric and Metabolic surgeon at Erasmus MC (The Netherlands). Dr. Berends talks about the Elegance Trial, a RCT intended to answer the question: does longer biliopancreatic (BP) limb improve weight loss in Roux-en-Y Gastric Bypass (RYGB) surgery? The trial started in 2011 following the hindgut theory, according to which a series of mechanisms (anorectic, incretin effect, ileal brake) are triggered when food and bile acids land more distally in the gut. RYGB design is the same as in 1977. Dr. Berend wonders whether there might be something we can change in the technique to improve the results. BP length has been studied but nowadays there is not much scientific evidence on its more appropriate length. According to this background Dr. Berends and his team decided to randomize patients into two groups comparing short BP limb (75 cm, 74 patients) versus long BP limb (150 cm, 67 patients). The excess weight loss (EWL) difference in 2 years’ time was then registered. Patients were blinded to the treatment. Results were favorable to long BP initially: 48 months after surgery 72% EWL was found in long BP limb and 64% in short BP limb. The significance in total body weight loss disappeared 4 years after surgery. Glycemic control was excellent in both groups. The authors concluded that BP limb of 150 cm has a significantly better weight loss, with no other differences regarding the associated comorbidities. Berends suggests considering a long limb for RYGB, and even points to a major lengthening up to 200 cm in the future, although further research is needed. After the speech Dr. Nimeri and Dr. Berends discuss the main points and communicate with the audience through the following quick poll questions: - Do you prefer SG or RYGB? - When would you perform a RYGB? - If you perform RYGB how long do you usually make your BP-limb? - Do you feel that a a longer BP-limb improves weight loss and maybe other outcomes as well?

Defining weight recidivism and success: When to operate and when to wait

Abdelrahman A. Nimeri (President of IFSO Middle East - North Africa Chapter, President of the PanArab Society for Metabolic and Bariatric Surgery, Abu Dhabi) explains, in this lecture from IFSO 2018, the main concerns about weight regain and the treatment of superobese patients. He remarks that there is no clear consensus on how much weight loss is significant or how to measure success after primary bariatric surgery. Although most authors agree that success should be measured as > 50% of Excess Weight Loss, this is not a good indicator, as it will be different depending on the initial BMI, with patients regaining weight afterwards. In medical literature, a 10% weight loss is considered significant as it reduces comorbidities, and Dr. Nimeri suggests this 10% as a marker of success. He also explains the difficulties of treating superobese patients and, making comparisons with oncologic surgery, he suggests that the treatment of this group of patients may start with medical treatment - or even a balloon - and when the patient has lost some weight, then surgery is indicated. He also discusses the importance of choosing the right procedure for each patient, especially now that sleeve gastrectomy is being increasingly performed. A thorough evaluation of the patient is mandatory. The presence of reflux is also important to decide which procedure is indicated.

VII IFSO Online Symposium “What You Have Missed at IFSO 2018”

IFSO 2018 in Dubai brought together world leaders in metabolic and bariatric surgery. More than 1200 abstracts from more than 90 countries were presented. Several communications on obesity and metabolic surgery were given, focusing on the different techniques and the best indications for each of them. Type 2 Diabetes Mellitus control, postoperative complications reduction and comparison of weight loss in different procedures were some of the main topics discussed during the congress. This webinar summarises the highlights of the 23rd IFSO World Congress in Dubai. Asim Shabbir, Ali AMiniam, Ahmad Bashir, Alex Escalona and Bart van Wagensveld present and discuss about 30 of the best abstracts. They also present 9 Randomized Clinical Trials, 10 Registry studies, 3 Matched case control studies, 4 Non matched controlled studies, and 3 other studies. In the first abstract, R. Gadiot found that after a 1-year follow-up, there was no significant difference in weight loss between the Very long Roux limb -RYGB and the standard limb -RYGB groupds. There were no differences regarding deficiencies either. Similar results were found in other abstracts in 2016. The experts agree that with longer follow-ups, the differences between the two groups should be significant in terms of weight loss and nutritional deficiencies. The study by Ruiz de Gordezuela compares SADI-S vs Duodenal Switch. In this comparison there were no significant differences, except as regards surgical time. However, the Duodenal Switch shows better weight loss results after 3 years (BMI reduction of 46.95% vs 36.61%). J.Ruiz-Tovar’s group showed the Impact of implementation of ERAS on Large Roux in Y Gastric Bypass (LRYGB). It associates lower postoperative pain, lower incidence of postoperative nausea and vomiting, and earlier hospital discharge. Another group shows that weight loss 3 months after the primary bariatric surgery is predictive for weight loss up to 60 months, giving us the opportunity to select low responder patients. In this video you will see the entire discussion on these abstracts and the opinion of the experts in the 23rd IFSO World Congress.