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• W2023130109 abstract "The surgically altered GI tract provides the GI endoscopist with a challenging array of problems. Few operations are as creative and problematic as those encountered in the patient who has undergone bariatric surgery. Although the overwhelming majority of patients subjected to present-day bariatric procedures achieve dramatic success in terms of both weight reduction and improvement or correction of comorbidities, a minority of patients experience diverse GI symptoms, inadequate weight loss, or a combination of both. These adverse outcomes frequently eventuate a GI consultation. With this is mind, the present review addresses the current epidemic of obesity, its surgical management, and the implications for the GI endoscopist. Current-day references to obesity in the United States continually evoke the emotionally charged terms “epidemic” and “crisis.” “Obesity in the United States is a national health-care crisis…,”1Balsiger BM Luque-De Leon E Sarr MG. Surgical treatment of obesity: who is an appropriate candidate?.Mayo Clin Proc. 1997; 72: 551-558Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar “…overweight and obesity have reached nationwide epidemic proportions….”2Deitel M The surgeon-general's call to action to prevent an increase in overweight and obesity.Obes Surg. 2002; 12: 3-4Crossref PubMed Scopus (16) Google Scholar “Epidemic Increase in Childhood Overweight, 1986-1998”3Strauss RS Pollack HA. Epidemic increase in childhood overweight, 1986-1998.JAMA. 2001; 286: 2845-2848Crossref PubMed Scopus (946) Google Scholar and “The Continuing Epidemics of Obesity and Diabetes in the United States”4Mokdad AH Bowman BA Ford ES Vinicor F Marks JS Koplan JP. The continuing epidemics of obesity and diabetes in the United States.JAMA. 2001; 286: 1195-1200Crossref PubMed Scopus (2236) Google Scholar are singular examples from a myriad of publications not isolated to the medical literature. Although there is adequate justification for using the descriptors “crisis” and “epidemic,” this association between ill health and excess body weight has been recognized only of late. Two conferences sponsored by the National Institutes of Health (NIH) in the 1970s attempted to address the issue of obesity as a public health problem; consensus regarding a cause and effect relationship between obesity and illness was lacking.5Bray GA. Obesity in perspective: a conference. John E Fogarty International Center for advanced study in the health sciences. : Govt Print Office, Washington, DC1975Google Scholar, 6Bray GA. Obesity in America. An overview of the Second Fogarty International Center conference on obesity.Int J Obes. 1979; 3: 363-375PubMed Google Scholar In 1985, an NIH Consensus Conference did recognize the health implications of obesity, identified it as a health risk, and acknowledged the importance of both the prevention and treatment of obesity.7Health implications of obesity. National Institutes of Health Consensus Development Conference Statement.Ann Intern Med. 1985; 103: 1073-1077Crossref PubMed Scopus (597) Google Scholar The Consensus Conference Panel also recommended using the body mass index (BMI) to evaluate patients for obesity. Subsequently, a qualitative assessment of this health risk has been developed that reflects the magnitude of obesity (Table 1).8Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. The Evidence Report. Sept. 1998Google ScholarTable 1Classification of overweight and obesity by BMI and associated disease riskObesity classBMI (kg/m2)RiskUnderweight—<18.5Increased9Kuczmarski RJ Carrol MD Flegal KM Troiano RP. Varying body mass index cutoff points to describe overweight prevalence among US adults: NHANES III(1988-1994).Obes Res. 1997; 5: 542-548Crossref PubMed Scopus (410) Google ScholarNormal—18.5-24.9NormalOverweight—25.0-29.9IncreasedObesityI30.0-34.9HighII35.0-39.9Very highExtreme obesityIII≥40Extremely high Open table in a new tab The BMI is correlated with body fat in most individuals and allows not only a projection of health risk but also a comparison of obesity between individuals. Consider two obese individuals: one 6 feet tall and 500 pounds, a second individual weighing 400 pounds standing 5 feet tall. It is obvious which individual is heavier, but the BMI provides a quantification of who is actually “bigger.” Although heavier by 100 pounds, the 6-foot-tall individual has a BMI of 67.8 whereas the “lighter” 5-foot-tall individual has a BMI of 78.1. The non-metric conversion formula for BMI is as follows: [weight (pounds)/height (inches)2] × 703 By using the precise quantitative values of BMI and corresponding qualitative descriptors (overweight, obese, and extreme obesity also referred to as morbid obesity), it is easier to appreciate the progression of this health condition over the last several decades. The National Health and Nutrition Examination Surveys (NHANES) examined weight and height of sample populations during 3 periods: NHANES I (1971-74), NHANES II (1976-80), and NHANES III (1988-94). The prevalence of obesity (BMI ≥30) during the time from the first to the third period increased from 11.8% to 19.9% in men and from 16.1% to 24.9% in women.8Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. The Evidence Report. Sept. 1998Google Scholar, 9Kuczmarski RJ Carrol MD Flegal KM Troiano RP. Varying body mass index cutoff points to describe overweight prevalence among US adults: NHANES III(1988-1994).Obes Res. 1997; 5: 542-548Crossref PubMed Scopus (410) Google Scholar In 1999, 61% of adults in the United States were overweight or obese.2Deitel M The surgeon-general's call to action to prevent an increase in overweight and obesity.Obes Surg. 2002; 12: 3-4Crossref PubMed Scopus (16) Google Scholar In 2000, the prevalence of obesity among adults in the United States ranged from a low of 13.8% for Colorado to a high of 24.3% in Mississippi.4Mokdad AH Bowman BA Ford ES Vinicor F Marks JS Koplan JP. The continuing epidemics of obesity and diabetes in the United States.JAMA. 2001; 286: 1195-1200Crossref PubMed Scopus (2236) Google Scholar This same study found that most adults (> 56%) in the United States were overweight and about 1 in 5 were obese. It has been estimated that at least 6 million Americans have a BMI of 40 or greater and thus qualify for the diagnosis of morbid obesity (Class III obesity). Although the association between obesity and comorbidities such as type 2 diabetes, osteoarthritis, obstructive sleep apnea, and coronary artery disease, to name just a few, is well established, the relation between body weight and mortality remained uncertain until recently. The Cancer Prevention Study II, a prospective study of more than 1 million men and women in the United States resolved this uncertainty.10Calle EE Thun MJ Petrelli JM Rodriguez C Heath CW. Body-mass index and mortality in a prospective cohort of U.S. adults.N Engl J Med. 1999; 341: 1097-1105Crossref PubMed Scopus (3047) Google Scholar Heavier men and women in all age groups had an increased risk of death; significantly increased risks of death from cardiovascular disease were found at all BMIs of more than 25.0 in women and 26.5 in men. The lowest rates of death from all causes were found at BMIs between 23.5 and 24.9 in men and 22.0 and 23.4 in women; relative risks were not significantly elevated for the range of BMIs between 22.0 and 26.4 in men and 20.5 and 24.9 in women. Similar to adults, major problems with obesity are manifest in children and adolescents. Dramatic increases in childhood obesity have been documented.11Gortmaker SL Dietz WH Sobol AM Wehler CA. Increasing pediatric obesity in the United States.Am J Dis Child. 1987; 141: 535-540PubMed Google Scholar The National Longitudinal Survey of Youth (NLSY) observed over 8000 children, aged 4 to 12 years, from 1986 to 1998.3Strauss RS Pollack HA. Epidemic increase in childhood overweight, 1986-1998.JAMA. 2001; 286: 2845-2848Crossref PubMed Scopus (946) Google Scholar The NLSY found that the prevalence of children classified as overweight increased by 21.5% among African Americans, 21.8% among Hispanic, and 12.3% among non-Hispanic whites. The prevalence of obesity in 18- to 29-year-olds increased from 12% in 1991 to 18.9% in 1999.12Mokdad AH Serdula MK Deitz WH Bowman BA Marks JS Koplan JP. The spread of the obesity epidemic in the United States, 1991-1998.JAMA. 1999; 282: 1519-1522Crossref PubMed Scopus (1912) Google Scholar A report from the Surgeon-General (Dec. 13, 2001)2Deitel M The surgeon-general's call to action to prevent an increase in overweight and obesity.Obes Surg. 2002; 12: 3-4Crossref PubMed Scopus (16) Google Scholar calculated 300,000 deaths per year attributable to overweight and obesity. In 2000, the health care costs related to obesity in the United States were estimated to be $117 billion (an $18 billion increase from 5 years earlier). The consequences of obesity are not only premature death, disability (from obesity directly and through the associated co-morbidities), and an increased health care financial burden but also loss of productivity and social stigmatization. The relentless growth of this health care problem warrants its designation as both a crisis and epidemic. When called upon to evaluate the postoperative bariatric patient, the GI endoscopist will be confronted not only with diseases foreign to the nonbariatric patient but also new anatomy. One of the most comprehensive ways for the gastroenterologist to understand the altered anatomy found in the bariatric surgical patient is through an understanding of the evolution of surgical procedures for the treatment of obesity. This history now spans 5 decades. Although bariatric surgical procedures have been simplified into two types, restrictive and malabsorptive, this oversimplification fails to capture the complexity of operations currently performed. A modification of the classification provided by the physicians from the Mayo Clinic is much more instructive1Balsiger BM Luque-De Leon E Sarr MG. Surgical treatment of obesity: who is an appropriate candidate?.Mayo Clin Proc. 1997; 72: 551-558Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar (Table 2). Table 2Operative strategy for the bariatric patientConceptPrototypical operationsGlobal malabsorptionJI bypassPure restrictionVBGLASGBCombined restriction and “minimal” malabsorptionRGBSelective maldigestion and malabsorptionBPD Open table in a new tab The earliest attempts to treat obesity reflect the approach of creating global malabsorption. This concept was enticing, both in theory and technical simplicity. In theory, an altered GI anatomy would be created such that the obese patient did not have to change eating behavior; oral intake did not need to be limited because there would simply be no opportunity for energy sources to be absorbed. The technical simplicity corresponded to the operative technique; dissection occurred in the central abdomen, avoided the difficult recesses of the upper abdomen inasmuch as there was no gastric component, and finally necessitated only a small-bowel anastomosis, a technique familiar to all general surgeons. A prototypical jejunoileal bypass is presented in Figure 1. The important component of this operation is as follows. The overwhelming extent of jejunum and ileum is excluded from receiving any consumed nutrients; in the illustration the “blind” defunctionalized segment is drained into the sigmoid colon. Other modifications include a more proximal anastomosis that drains this segment into the transverse colon or the terminal ileum. In the latter situation, nutrients may reflux back into the defunctionalized segment and thus undermine the attempts at malabsorption. The first jejunoileal bypass for obesity was reported in 1954 by Kremen et al.13Kremen AN Linner JH Nelson CH. Experimental evaluation of the nutritional importance of proximal and distal small intestine.Ann Surg. 1954; 140: 439-448Crossref PubMed Scopus (316) Google Scholar This represented a single patient; it was nearly a decade later that Payne et al.14Payne JH DeWind LT Commons RR. Metabolic observations in patients with jejunocolic shunts.Am J Surg. 1963; 106: 273-289Abstract Full Text PDF PubMed Scopus (206) Google Scholar popularized the procedure, first performing a jejunocolic bypass. The bypass was planned to be temporary. However restoration of intestinal continuity led to regains in weight. Thus, Payne and DeWind subsequently performed jejunoileal (JI) bypass15Payne JH DeWind LT. Surgical treatment of obesity.Am J Surg. 1969; 118: 141-147Abstract Full Text PDF PubMed Scopus (324) Google Scholar, 16DeWind LT Payne JH. Intestinal bypass surgery for morbid obesity.JAMA. 1976; 236: 2298-2301Crossref PubMed Scopus (128) Google Scholar; this operation and its modifications became the mainstay for the surgical treatment of obesity for nearly 2 decades. Despite the minimal length of available intestine for absorption of nutrients, weight regain after initial weight loss is relatively common. In our experience, when this occurs, the terminal ileum has become a markedly enlarged and thickened segment suggesting adaptation by hypertrophy. The JI bypass is no longer performed for management of obesity. Takedown and conversion of this operation is indicated to correct the complications associated with the operation, weight regain, or both. One complication associated with JI bypass is liver cirrhosis and hepatic failure.17Kaminski DL Hermann VM Martin S. Late effects of jejunoileal bypass operation on hepatic inflammation, fibrosis and lipid content.Hepatogastroenterology. 1985; 32: 159-162PubMed Google Scholar Recognition of this entity is important if takedown and conversion is contemplated because operative mortality in this situation is significant. It may be appropriate in patients with an intact JI bypass to obtain liver biopsy specimens periodically. Because chronic diarrhea accompanies the JI bypass, colonoscopic evaluation of the colon would be appropriate for patients who are candidates for reversal or conversion of the bypass to avoid missing occult colonic pathology masked by the effects of the JI bypass. Gastric bypass was introduced by Mason and Ito18Mason EE Ito C. Gastric bypass in obesity.Surg Clin North Am. 1967; 47: 1345-1351Crossref PubMed Scopus (630) Google Scholar in 1966 as a way of limiting food intake while maintaining normal digestion and absorption. Thus, this operation represented the antithesis to the JI bypass. Mason subsequently abandoned this procedure in favor of a purely restrictive procedure, the gastroplasty.19Printen KJ Mason EE. Gastric surgery for relief of morbid obesity.Arch Surg. 1973; 106: 428-431Crossref PubMed Scopus (109) Google Scholar While eliminating the side effects and risks of the JI bypass, gastroplasty, as initially performed, proved inadequate in terms of weight loss. This failure was attributed to the sizes of the pouch and outlet.20Grace DM. The demise of horizontal Gastroplasty.Prob Gen Surg. 1992; 9: 260-265Google Scholar Mason eventually refined this operation into the vertical banded gastroplasty (VBG), a procedure still performed today (Fig. 2A).21Mason EE. Vertical banded gastroplasty for obesity.Arch Surg. 1982; 117: 701-706Crossref PubMed Scopus (593) Google Scholar, 22Doherty C. Vertical banded gastroplasty.Surg Clin North Am. 2001; 81: 1097-1112Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar The essential components of this operation include a vertically oriented gastric pouch that is calibrated to a volume of 15 mL or less and an outlet from this pouch into the remainder of the stomach, which is reinforced by a polypropylene mesh collar. The VBG, like all other bariatric procedures, has been performed with a laparoscopic approach.23Schauer PR Ikramuddin S. Laparoscopic surgery for morbid obesity.Surg Clin North Am. 2001; 81: 1145-1179Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar VBG construction might be feasible with an endoscopic sewing machine.24Awan AN Swain CP. Endoscopic vertical band Gastroplasty with an endoscopic sewing machine.Gastrointest Endosc. 2002; 55: 254-256Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Laparoscopic adjustable silicone gastric banding (LASGB) (Fig. 2B) represents the newest attempt to create a purely restrictive gastric procedure.25DeMaria EJ. Laparoscopic adjustable silicone gastric banding.Surg Clin North Am. 2001; 81: 1129-1144Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar The appeal of the LASGB lies in the minimally invasive approach, the silicone collar, which theoretically prevents erosion, and the ability to adjust the gastric pouch outflow tract. A survey by the American Society of Bariatric Surgery (ASBS) in 1999 identified the Roux-en-Y gastric bypass (RGB) (Fig. 3) as the most frequently performed procedure in the United States and Canada for the treatment of morbid obesity. Although modifications abound, the RGB is the prototypical operation for combining gastric restriction and minimal malabsorption. The essential components to this operation are a small-volume (less than 30 mL) gastric pouch, which does not include any gastric fundus that will stretch, a small opening between the pouch and the jejunum, and a variable length Roux limb. The pouch may remain in continuity with the rest of the stomach26Flickinger EG Pories WJ Meelheim D Sinar DR Blose IL Thomas FT. The Greenville gastric bypass. Progress report at 3 years.Ann Surg. 1984; 199: 555-562Crossref PubMed Scopus (49) Google Scholar or be detached.27MacLean LD Rhode BM Sampalis J Forse RA. Results of the surgical treatment of obesity.Am J Surg. 1993; 165: 155-162Abstract Full Text PDF PubMed Scopus (262) Google Scholar The outlet from the pouch may be reinforced with some type of ring or band.28Fobi M Lee H Igwe D Felahy B James E Stanczyk M et al.Band erosion: incidence, etiology, management and outcome after banded vertical gastric bypass.Obes Surg. 2001; 11: 699-707Crossref PubMed Scopus (103) Google Scholar Most commonly, the Roux limb is 75 cm in length. Doubling the length to 150 cm, termed long-limb Roux-en-Y gastric bypass, has been performed in revisional bariatric surgery when inadequate weight loss has been achieved despite a normal pouch or as a primary procedure for those patients who are super obese (BMI ≥50).29Torres J Oca C. Gastric bypass lesser curvature with distal Roux-en-Y.Bariatric Surg. 1987; 5: 10-15Google Scholar, 30Brolin RE Kenler HA Gorman JH Cody RP. Long-limb gastric bypass in the superobese. A prospective randomized study.Ann Surg. 1992; 215: 387-395Crossref PubMed Scopus (381) Google Scholar, 31Murr MM Balsiger BM Kennedy FP Mai JL Sarr MG. Malabsorptive procedures for severe obesity: comparison of pancreaticobiliary bypass and very very long limb Roux-en-Y gastric bypass.J Gastrointest Surg. 1999; 3: 607-612Crossref PubMed Scopus (112) Google Scholar The gastric pouch limits oral intake by simple volume restriction, the small anastomosis limits pouch emptying, and the Roux limb probably creates clinically occult and undetectable malabsorption. The Roux limb also frequently causes dumping syndrome when large concentrations of simple sugars are ingested. Thus, many patients find they are unable to tolerate foods that have previously been instrumental in their obesity, such as desserts and carbonated beverages. Patients with RGB usually describe a sense of satiety and lack of hunger which, until recently, has been difficult to explain. Because the pouch in RGB is so small, the sense of fullness with eating is understandable as is the discomfort with overeating. The lack of hunger at some time after eating a fraction of what the patient ate before having undergone bypass may be explained by the effects of ghrelin.32Cummings DE Weigle DS Frayo RS Breen PA Ma MK Dellinger EP et al.Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery.N Engl J Med. 2002; 346: 1623-1630Crossref PubMed Scopus (1949) Google Scholar Ghrelin is secreted by the stomach and duodenum and rises shortly before eating and falls shortly afterward. It has been referred to as the hunger hormone. Cummings et al.32Cummings DE Weigle DS Frayo RS Breen PA Ma MK Dellinger EP et al.Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery.N Engl J Med. 2002; 346: 1623-1630Crossref PubMed Scopus (1949) Google Scholar have demonstrated that plasma ghrelin levels increase with diet-induced weight loss (perhaps explaining the difficulty of maintaining weight loss after dieting); somewhat surprisingly Roux-en-Y gastric bypass patients have markedly suppressed ghrelin levels. This finding in patients who have undergone RGB may explain the paradoxical lack of appetite despite minuscule food portions. The last concept in the operative strategy for managing the morbidly obese patient is represented by the biliopancreatic diversion (BPD) (Fig. 4). This is also known as the Scopinaro procedure since Nicola Scopinaro and colleagues developed the operation and first reported their results in 1979.33Scopinaro N Gianetta E Civalerri D. Biliopancreatic bypass for obesity: II. Initial experiences in man.Br J Surg. 1976; 66: 618-620Crossref Scopus (414) Google Scholar It differs from the JI bypass in that there is no blind segment, thus avoiding the consequences of bacterial overgrowth, and a distal gastrectomy is performed. The goal of the operation is to create selective malabsorption for fat and starch by means of the bypassed segment and reduce oral intake by the limited gastrectomy. Biliary and pancreatic secretions are managed with a long Roux limb that enters the ileum 50 cm proximal to the ileocecal valve. Thus, the common channel is only 50-cm long. All of these components are thought to benefit the super-obese patient. A modification of the BPD is the duodenal switch procedure. The most significant changes made in moving from BPD to the duodenal switch procedure are utilization of a sleeve gastrectomy rather than distal gastrectomy and anastomosis of the enteric limb end-to-end with the postpyloric duodenum.34Marceau P Hould FS Lebel S Marceau S Biron S. Malabsorptive obesity surgery.Surg Clin North Am. 2001; 81: 1113-1127Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar, 35Hess DW Hess DS. Biliopancreatic diversion with a duodenal switch.Obes Surg. 1998; 8: 267-282Crossref PubMed Scopus (652) Google Scholar Given the apparent variety of surgical approaches to the morbidly obese patient, the nonsurgeon might question the efficacy of a potentially harmful operation. Strict guidelines have been developed by the NIH for the appropriate application of surgery to manage obesity.36NIH Consensus Development Conference Panel Gastrointestinal surgery for severe obesity.Ann Intern Med. 1991; : 956-961Google Scholar These state that weight loss surgery (at the time of the Consensus Conference this referred to VBG and RGB) is an option in carefully selected patients with clinically severe obesity (BMI ≥40 or ≥35 with comorbid conditions) when less invasive methods of weight loss have failed and the patient is at high risk for obesity-associated morbidity or mortality.8Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. The Evidence Report. Sept. 1998Google Scholar Not only is surgery the most effective long-term treatment for well selected morbidly obese patients, it is more cost effective at producing and maintaining weight loss.37Martin LF Tan TL Horn JR Bixler EO Kauffman GL Becker DA et al.Comparison of the cost associated with medical and surgical treatment of obesity.Surgery. 1995; 118: 599-607Abstract Full Text PDF PubMed Scopus (88) Google Scholar The endoscopist must observe certain basic principles before initiating an endoscopic procedure in the bariatric surgical patient. These are similar to those outlined by Feitoza and Baron38Feitoza AB Baron TH Endoscopy and ERCP in the setting of previous upper GI tract surgery. Part I: Reconstruction without alteration of pancreaticobiliary anatomy [review article].Gastrointest Endosc. 2001; 54: 743-749Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar in guiding the endoscopist in the setting of previous upper GI tract surgery, although with some important modifications. The following steps will be helpful to ensure success as well as minimize morbidity. 1.Whenever possible, discuss the bariatric operation with the patient's surgeon. Modifications of standardized bariatric procedures are commonplace and this communication may provide the best possible knowledge of the new anatomy.2.If direct dialogue is not possible, review not only the formal operative report, but any perioperative records. It is unusual for the operative note to include a diagram because it is a transcribed text; drawings and diagrams may be found in the perioperative record.3.Feitoza and Baron suggest discussing the case with a surgical colleague before attempting the procedure. Unfortunately, many general surgeons may not have an adequate knowledge of these bariatric procedures. If the patient's surgeon is not available, discussion with another bariatric surgeon including joint review of the operative note may be helpful.4.Review all available postoperative abdominal imaging studies.5.Based on the above and the indications for the procedure, select the most appropriate type of endoscope and accessories needed to complete the procedure.6.Recognize that specially designed accessories may be necessary and if so, obtain these beforehand. The common indications for endoscopy in the postoperative bariatric patient include the evaluation of symptoms, the management of complications, and the evaluation of failure of weight loss. Some symptoms such as nausea are extremely common after bariatric surgery. Vomiting is most commonly associated with persistence in inappropriate eating habits; for example, rapid eating of large volumes of food with inadequate chewing. The gastric pouches of RGB and VBG will not accommodate large boluses of food (Fig. 5). Occasionally it may be necessary to perform contrast studies or upper endoscopy to verify the adequacy of the pouch and anastomosis (Fig. 6). Fig. 6Endoscopic view of normal, Roux-en-Y anastomosis.View Large Image Figure ViewerDownload (PPT) When an obvious cause for nausea and vomiting with or without epigastric pain is not evident, or when intolerance develops to foods that were tolerated postoperatively, stomal stenosis should be considered. Stomal stenosis is easily identified endoscopically (Fig. 7) and endoscopic balloon dilatation can be curative (Fig. 8). Fig. 8Endoscopic view of dilation of stomal stenosis seen in Figure 7 with through-the-scope balloon dilator.View Large Image Figure ViewerDownload (PPT)In our experience the need for more than one dilatation does not indicate that permanent correction cannot be attained. Although nausea is commonplace and vomiting can be caused by the patient's inappropriate eating habits, persistence of vomiting in the postoperative bariatric patient may lead to protein calorie malnutrition and resultant Wernicke's encephalopathy.39Kramer LD Locke GE Wernicke's encephalopathy: complication of gastric plication.J Clin Gastroenterol. 1987; 9: 549-552Crossref PubMed Scopus (25) Google Scholar, 40Gould J Elbanna M Neddleman B Cook C Muscarella P Kissel J et al.Severe acute neuropathy after gastric bypass [abstract].Obes Surg. 2002; 12: 213Google Scholar This symptom must be recognized as one of the more serious in this group of patients. If unrecognized or inadequately treated, irreversible neurologic damage may result. The management of the bariatric patient with intractable vomiting is administration of thiamine before administration of glucose or nutrients. It has been suggested that in addition to the above, intravenous administration of immunoglobulin may be helpful.40Gould J Elbanna M Neddleman B Cook C Muscarella P Kissel J et al.Severe acute neuropathy after gastric bypass [abstract].Obes Surg. 2002; 12: 213Google Scholar Abdominal or retrosternal pain with or without vomiting may be caused by stomal ulceration. If a prosthetic device was used to restrict the outlet, erosion of the band may be responsible for the ulceration. Diagnosis is by endoscopy and management may be expectant if the patient is asymptomatic; spontaneous extrusion of the band may occur. Treatment with a proton pump inhibitor and treatment for Helicobacter pylori, if present, should be instituted when expectant treatment is undertaken. Band removal can be performed endoscopically if the patient is symptomatic28Fobi M Lee H Igwe D Felahy B James E Stanczyk M et al.Band erosion: incidence, etiology, management and outcome after banded vertical gastric bypass.Obes Surg. 2001; 11: 699-707Crossref PubMed Scopus (103) Google Scholar or to prevent band migration.41Biagini J. Intragastric band erosion.Obes Surg. 2001; 11: 100Crossref PubMed Scopus (12) Google Scholar, 42Weiss H Nehoda H Labeck B Peer R Aigner F. Gastroscopic band removal after intragastric migration of adjustable gastric band: a new minimal invasive technique.Obes Surg. 2000; 10: 167-170Crossref PubMed Scopus (76) Google Scholar, 43Taskin M Zengin K Unal E. Intraluminal duodenal obstruction by a gastric band following erosion.Obes Surg. 2001; 11: 90-92Crossref PubMed Scopus (25) Google Scholar This problem has been" @default.
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