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119
Primary GIST
Easily resectable?
No Yes
Neoadjuvant
imatinib
Surveillance
Gold JS, Gönen M, Gutiérrez A, etal. Development and validation of a prog-
nostic nomogram for recurrence-free survival after complete surgical
resection of localised primary gastrointestinal stromal tumour: a retrospective analysis. Lancet Oncol. 2009;10:1045–1052.
Joensuu H, Eriksson M, Sundby Hall K, etal. One vs three years of adjuvant
imatinib for operable gastrointestinal stromal tumor: a randomized trial.
JAMA. 2012;307:1265–1272.
Keung EZ, Raut CP. Management of gastrointestinal stromal tumors. Surg
Clin North Am. 2017;97(2):437–452.
Marcella C, Shi RH, Sarwar S. Clinical overview of GIST and its latest
management by endoscopic resection in upper GI: a literature review.
Gastroenterol Res Pract. 2018;2018(1):1–9.
Surgical
resection
Adjuvant
imatinib*
Recurrent or metastatic GIST
Imatinib
Partial response,
stable disease, or
focal resistance
• Surgery
• Ablation
• Hepatic artery
embolization
Chronic imatinib
FIG. 9 Schematic approach to patients with
gastrointestinal stromal tumor (GIST). For locally
advanced primary tumors treated with adjuvant
Progression
• Sunitinib
• Regorafenib
• Other TKIs
• Clinical trials
Miettinen M, Lasota J. Gastrointestinal stromal tumor: pathology and prog-
nosis at different sites. Semin Diagn Pathol. 2006;23(2):70–83.
Rutkowski P, Gronchi A, Hohenberger P, etal. Neoadjuvant imatinib in local-
ly advanced gastrointestinal stromal tumors (GIST): the EORTC STBSG
experience. Ann Surg Oncol. 2013;20:2937–2943.
Schmieder M, Henne-Bruns D, Mayer B, etal. Comparison of different risk
classification systems in 558 patients with GISTs after R0 resection. Front
Pharmacol. 2016;7:504–510.
Solaini L, Cavaliere D, Fico V, etal. Open versus laparoscopic versus robotic
gastric gastrointestinal stromal tumour resections: A multicentre cohort
study. Int J Med Robot. 2021;17(2):e2198.
imatinib, tumor density should be assessed by
CT at 4 weeks to document response to therapy.
If GIST nomogram predicts a high or intermediate risk of recurrence, adjuvant imatinib (*)
should be continued for at least 3 years, possibly
chronically. Surveillance after resection of GIST
should include a CT of abdomen and pelvis
every 3 to 6 months for 3 to 5 years and then
annually. TKI, Tyrosine kinase inhibitor. (Modified
from Gold JS, DeMatteo RP. Combined surgical and
molecular therapy: the gastrointestinal stromal tumor
model. Ann Surg. 2006;244:176.)
Gastrointestinal
Tubes for Feeding and
Decompression
Lawrence B. Brown, MD, MPH, MHS, and
Susan L. Gearhart, MD
INTRODUCTION
The primary purposes for placement of upper gastrointestinal access
tubes are gastric decompression, prevention of aspiration, and administration of medications or nutrition. Over the past decade, the importance of gastrointestinal access in the management of several conditions
has been redefined. This chapter highlights the current indications and
contraindications to the use of gastrointestinal access and outlines current knowledge regarding their safe placement and usage.
NASOGASTRIC TUBE
A nasogastric (NG) tube is a flexible tube with a single or double
lumen that is passed through the nose, down the nasopharynx, and
into the stomach. NG tubes are made of polyurethane, polyvinyl
chloride (PVC), or silicone. They come in several sizes and vary
based on patient size (pediatric or adult). The most common type
of NG tube is the Salem-sump, and its primary function is gastrointestinal decompression (Fig. 1). This tube has two lumens; the
larger lumen connects to wall suction to provide aspiration of gastric
contents. When not connected to suction, this port can be used for
medication delivery or enteral feeding. The smaller lumen is used
to vent to the atmosphere to prevent the distal tip of the tube from
adhering to the stomach wall. This equalization takes place in the
stomach once the gastric contents have been emptied.
Unlike the Salem-sump tube, the Levin tube (Fig. 2) has a single
lumen with multiple distal holes. Its advantage lies in its relatively
large single internal diameter. However, because of its inability to
vent, there is a high likelihood that without venting, the suction
would cause the mucosa of the stomach to adhere to the tube, leading not only to poor decompression but also to potential mucosal
ischemia. Because of this likelihood, the Levin tube is uncommonly
used in practice. Finally, a tri-lumen long tube with the ability to
intubate into the mid-jejunum has been described and found to
have a reduced failure rate for conservative management of an
acute small bowel obstruction (ASBO) in one study. However, the
long tube can only be placed endoscopically and for this reason is
rarely used.
120 GASTROINTESTINAL TUBES FOR FEEDING AND DECOMPRESSION
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TABLE 1 Indications and Types of Commonly Used
Gastrointestinal Tubes
Indications Type of Tube
Acute intestinal obstruction NG tube, long enteric tube
Prolonged ileus with vomiting NG tube
Decompression during minimally
invasive surgery
Long-term nutritional
supplementation, medication
delivery, decompression using
gastric access
Long-term nutritional supplemen-
tation without gastric access
DPEJ, Direct percutaneous endoscopic jejunostomy; NG, nasogastric
PEG, percutaneous endoscopic gastrostomy.
NG tube, Levin tube
PEG
DPEJ
FIG. 1 Salem-sump tube. In addition to a suction lumen for decompres-
sion, this tube has a second lumen that allows venting during continuous
suction. Insertion depth markers are placed on the tube (black dots).
NG tube decompression is effective for up to 72 hours, after which the
risks outweigh the benefits. Routine use of an NG tube for prevention
of postoperative ileus in no longer recommended in adult or pediatric
patients. In addition, a recent Cochrane review suggests that NG tube
placement for postoperative ileus is associated with a slower return to
bowel function and higher likelihood of pulmonary complications.
The review found that use of an NG tube was only beneficial in
patients who were experiencing vomiting.
During both minimally invasive and open abdominal surgery, an
NG tube is often placed postintubation to decompress the stomach
for safe port placement and to prevent emesis/aspiration caused by
increased gastric distention following positive pressure/bag-mask-valve
ventilation. The risk of gastric injury during port placement for minimally invasive surgery is reportedly 7%, although these data are from
a study performed before the development of newer access ports with
more safety features. Esophageal and gastric trauma is managed with
NG tube decompression until healing of the injury is confirmed. For
patients unable to swallow, an NG tube may be placed to administer
medications or oral contrast for a computed tomography (CT) scan.
Contraindications
NG tube placement is contraindicated in patients with basilar skull
fracture or facial fractures because of the risk of intracranial penetration and misplacement. Additionally, their blind placement should
be avoided in patients with esophageal stricture or a history of alkali
ingestion because of the risk of esophageal perforation. Because of
the increased risk of bleeding, esophageal varices and coagulation
abnormalities are relative contraindications to NG tube placement.
FIG. 2 The Levin tube has a single lumen and multiple distal holes.
Indications for Nasogastric Tube Placement
Indications for NG tube decompression include management of
acute gastrointestinal obstruction, management of prolonged ileus
with vomiting, and prevention or treatment of intestinal perforation
(Table 1). The successful removal of gastrointestinal contents decreases
emesis and the chance of possible aspiration pneumonia. The NG
tube is essential in the nonoperative management of an ASBO and is
generally placed early in the treatment algorithm. In consensus statements regarding the management of ASBO, most societies agree that
Placement of Nasogastric Tubes
NG tubes are often placed at the bedside in an awake patient, and the
benefits and risks should be discussed. The head of the bed is raised
so the patient is upright. An absorbent pad or emesis basin is placed
on the patient’s lap in case vomiting is induced by the procedure. The
insertion distance should be estimated by measuring the distance
between the tip of the nose to the earlobe and then to the xiphoid;
15 cm should be added to this number and noted on the tubing. One
should visualize the nares for obstruction and ask the patient to sniff
while occluding one nostril to determine the most patent nostril
for placement. To reduce gagging and discomfort with insertion,
the nares, nasopharynx, and oropharynx are anesthetized before
NG tube placement. Typically, this is performed with lidocaine gels,
Cetacaine (a combination of tetracaine, butyl aminobenzoate, and
benzocaine), or nebulized or atomized lidocaine. Additionally, some
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121
have administered antinausea medications before NG placement
to reduce nausea and gagging. Gentle pressure should be applied if
mild resistance is encountered in the posterior nasopharynx. Asking
the patient to sip water through a straw will take advantage of the
swallowing mechanism to facilitate the passage of the tube into the
stomach. Additionally, flexing the patient’s neck once the tube is in
the nasopharynx aids in allowing it to traverse into the esophagus
rather than the trachea. If too much resistance or bleeding is met
upon initial passage into the nasopharynx, then one should attempt
passage down the other naris. Gagging is a common occurrence
during NG tube placement and should not be an indication to halt
the procedure. However, excessive choking, coughing, voice changes,
or condensation within the NG tube indicates tracheal placement,
and the tube should be removed.
NG tube placement in patients who are incapacitated as a result of
cognitive disorders or sedation and in patients on a ventilator can be
challenging and is reportedly only successful 50% of the time. Airway
protection is of primary importance, and securing the airway before
NG tube placement may be required. Once secured, NG tube passage
can be assisted with the use of a laryngoscope or a nasopharyngeal
airway. One randomized study demonstrated that placement of a right
nasopharyngeal airway in intubated patients increased first-time success rates to 80%. Furthermore, icing a PVC or silicone tube increases
its stiffness, which may prevent coiling and assist in placement.
The NG tube should be secured with a commercial adhesive
holder applied to the nose. Guidelines exist for proper securing and
repeat assessment of the NG tube fixation method. For long-term
insertion, bridling of the NG tube is a method that has been shown
to significantly decrease inadvertent removal and pressure injury. NG
tube bridle kits are available and assist in the safe passage of a bridle
loop through the posterior nasopharynx from one nostril to the other.
Confirmation of Nasogastric Tube Placement
Before using an NG tube, one should confirm placement. Bedside
confirmation can be accomplished by auscultation over the stomach for a rushing noise while one insufflates the stomach with air
through the NG tube. Unfortunately, this method is unreliable.
Literature also describes confirmation with ultrasound, litmus paper
testing, pH paper testing, capnography/colorimetric capnometry,
manometric techniques, and electromagnetic tracing; however, these
tests are impractical. The goal standard method for confirming NG
tube placement is performing a lower-chest/upper-abdominal x-ray.
Based on imaging, the NG tube should be advanced or retracted so it
is properly positioned in the middle of the stomach for best function.
NG tube placement should be reassessed every 4 hours and before
using for administration of medications or feeding.
Complications
The most common complication from NG tube placement is
aspiration pneumonia. This may result from insertion of the NG
tube directly into the airway during insertion or from occlusion
of the tube during use, allowing for reflux and aspiration of gastric
contents. Pressure injuries to the nares from prolonged NG tube
insertion are most common among ICU patients, and the reported
incidence is 0.13/1000 patient days. Gastric mucosa trauma has been
shown to be reduced if continuous low-pressure wall suction is utilized compared with intermittent suction.
FEEDING TUBES
Current literature demonstrates that enteral nutrition is superior
to parenteral nutrition. Indications for nutritional support are as
follows: critical illness, poor caloric intake, oropharyngeal dysfunction, neurologic disorders, acute and chronic pancreatitis, short
bowel syndrome, serious trauma and burns, and malnutrition before
elective major surgery. Enteral feeding tubes are classified by the
location of the tip of the tube, with termination in the stomach,
proximal intestine, or both. Post-pyloric feeding has been shown to
prevent aspiration of feeds and is largely recommended. Patients with
diseases or who have had procedures associated with gastric atony
(Box 1) may require enteral feeds that are beyond the ligament of
Treitz. ICU patients have been found to have abnormal small bowel
motility leading to retroperistalsis and increasing the risk of aspiration when fed directly into the stomach.
Nasoenteric Tubes
Nasoenteric tubes (NETs) are best suited for short-term (<6 weeks)
use for nutritional assistance. NETs can be placed unassisted at the
bedside or with endoscopic or fluoroscopic guidance. NETs are
made of silicone or polyurethane and are commonly 12 or 14F in
diameter (Fig. 3). If performed at the bedside, informed consent
should be obtained before insertion. Like NG tube placement, the
NET should be measured from the patient’s nose to the xiphoid
process. After lubrication, the NET should be inserted to the distance previously measured to the xiphoid process. Once secured,
one should obtain a chest x-ray to confirm placement in the esophagus. If confirmed, the tube should be advanced slowly to 75 cm.
Placing the patient and right lateral decubitus and insufflating the
stomach can assist with tube advancement. If the stylet moves freely
(slides back and forth by 5–10 cm), the tube is likely not coiled in
the stomach, and the NET can be advanced to its furthest point
(approximately 110 cm). NETs may also be placed via endoscopic
means into the small intestine. Once an endoscope has traversed
through the stomach into the small bowel, a guidewire is advanced
through the accessory channel. The endoscope is then removed
while the guidewire remains in place. The NET is placed over this
guidewire. One should obtain an abdominal x-ray while the patient
is lying in the supine position to confirm placement. Once post-pyloric placement is confirmed, the stylet or guidewire is removed,
and the tube is used for enteral feeding.
Percutaneous Endoscopic Gastrostomy
or Jejunostomy Tubes
Percutaneous endoscopic gastrostomy or jejunostomy (PEG or PEG/J)
tubes are widely used for enteral nutrition. Common indications for
PEG placement include disease processes that interfere with normal
oral intake and swallowing, such as severe neurologic impairment,
facial trauma, and oropharyngeal tumors. Jejunostomy tubes are
required if the stomach is absent or nonfunctioning as a result of
gastroparesis or tumor. Patients who are unable to maintain sufficient
nutritional intake for more than 1 month, despite a functioning gastrointestinal tract, are candidates for a feeding tube placement.
Placement of PEG, PEG/J, or direct percutaneous endoscopic jejunostomy (DPEJ) tubes can be performed endoscopically (PEG, PEG/J,
DPEJ), radiographically (PEG), and surgically (PEG, jejunostomy). For
BOX 1 Patient Groups, Diseases, and Procedures
Associated with Gastric Atony
Diabetes with neuropathy
Gastrointestinal neuromuscular disorders
Abdominal surgery
Intraabdominal sepsis
Cerebrovascular accident
Hypothyroidism
Polytrauma, including head trauma
Acute pancreatitis
ICU patients on ventilators
Neuromotor deglutition disorders
122 GASTROINTESTINAL TUBES FOR FEEDING AND DECOMPRESSION
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been grasped. For PEG tube insertion using the pull technique, the
endoscope is removed over the guidewire. The wire is then attached
to the gastrostomy tube, and a small skin incision is made around
the wire in the abdominal wall. The gastrostomy tube is then pulled
through the mouth, into the stomach, and out of the incision created
in the abdominal wall. The dilation technique and push technique
are used for jejunostomy placement. A smaller jejunal tube can also
be passed through one port of the PEG tube and endoscopically
placed in the jejunum. However, one randomized trial suggested
that the DPEJ tube as compared to the PEG/J clogged less due to
the larger caliber.
It is important to note that the internal bolster of the feeding tube
should contact the mucosa, and the external bolster (or crossbar)
should be placed snugly against the abdominal wall. Endoscopic
and radiologically placed tubes have a soft cupped bolster internally
and a second bolster that is placed over the tube near the abdominal
wall. This design allows for the internal bolster to deform and the
tube to be removed by applying traction on the tube when necessary.
It also avoids common issues such as inadvertent deflation of the
balloon, which can happen with balloon-tipped gastrostomy tubes
(Fig. 4). Immediately after placement, the tube can be placed to grav-
ity drainage. After 4 to 6 hours, the tube can be used for medication
delivery. Historically, enteral feeds start 12 to 24 hours following the
FIG. 3 Nasoenteric tube with stylet.
procedure.
Routine Care
Routine care involves three considerations: positioning of the external
bolster to avoid compression of the abdominal wall between the bol-
the purpose of this chapter, the endoscopic technique will be discussed
as surgical placement usually occurs when the patient is going to the
operating room for a separate procedure. On occasion, laparoscopy is
used to guide placement when endoscopic placement alone is challenging; however, the technique does not differ greatly as endoscopic insertion techniques are used while laparoscopy is performed. Laparoscopic
or endoscopic jejunostomy is rarely performed as there is a significant
risk for tube leakage and failure. There are three main techniques: (1)
Sachs-Vine push technique, (2) Ponsky pull technique, and (3) Russell
external dilation. Antibiotics should be given before the procedure.
Contraindications to feeding tube placement are esophageal or
oropharyngeal obstruction (i.e., unable to perform endoscopy),
aspiration risk, gastric varices, severe coagulopathy, massive ascites,
gastroparesis, gastric outlet obstruction, gastric resection, and hemodynamic instability.
sters, flushing the tube to prevent clogging, and maintaining a clean
feeding tube site. Compression of the tissues between the internal and
external bolsters of a feeding tube can lead to pressure necrosis, breakdown of the gastrostomy tract, and buried bumper syndrome (where
the internal bumper migrates alongside the tract of the stoma and
lodges between the intestinal wall and the skin). The external bolster
should be situated in such a manner as to allow 1 to 2 cm of in-and-out
movement of the tube in the abdominal wall. Additionally, gauze pads
Endoscopic Placement Technique
Once sedated, the left upper quadrant and mid-abdomen are
prepped and draped in a sterile fashion. An endoscope is passed into
the patient’s mouth, down the esophagus, and into the stomach. For
a jejunostomy, the endoscope must be passed to the jejunum. After
inspection of the gastrointestinal tract, the antrum of the stomach
or a dilated loop of proximal jejunum will be viewed through the
endoscope. A double-balloon endoscopic technique may assist in
performing DPEJ. An antiperistaltic medication can be given to
reduce peristalsis of the small bowel. Transillumination must occur.
The surgeon will use a finger to indent the external abdominal wall
to determine the optimal puncture site where the abdominal wall
and the stomach or jejunum are closest; this should be noted via the
endoscope. If transillumination is possible, an introducer or seeker
needle with a syringe attached is passed through the abdominal
wall. This syringe is advanced until the needle tip is seen entering
the gastric or jejunal lumen on endoscopic views. Upon aspiration,
if air is seen and the needle tip is not visualized, then the needle is
likely in another section of the gastrointestinal tract and not the
stomach. Once correct intraluminal location has been confirmed,
a guidewire is placed into the lumen and grasped by a snare via the
endoscope. The needle is removed from the skin once the wire has
FIG. 4 Gastrostomy tube with balloon.
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should not be placed underneath the feeding tube as this may allow
for pressure on the tract. During daily care, the feeding tube should be
pushed forward into the wound slightly and rotated to ensure that the
internal bumper does not become buried in the mucosa.
Feeding tubes tend to clog as a result of the interaction of protein-based formulas with an acidic environment and medications.
Tubes with a smaller diameter clog more frequently, and all feeding
tubes should be flushed with 20 mL of water every 4 to 6 hours and
after administration of medications or enteral feeds. If the tube becomes
clogged, and water flushing does not open the tube, the installation of
pancreatic enzymes is efficacious in relieving more than 50% of occluded
tubes. Mechanical devices, such as a Fogarty balloon, biopsy brush, or
commercially available tube decloggers, may be used if prior measures
fail. Tube replacement is reserved as a last resort to tube clogging. Bulking agents (e.g., psyllium) and resins (e.g., cholestyramine) should not be
placed through feeding tubes as they are prone to clogging.
Complications
Immediate complications of enteral access include aspiration, hemorrhage, perforation, and the risk of sedation/anesthesia. Aspiration
risks can be minimized by avoiding excessive sedation, aspiration of
gastric contents preprocedure, suctioning insufflated air from the
stomach postprocedure, and reducing the procedure time. A particularly morbid complication is inadvertent perforation of the stomach,
small bowel, or colon during percutaneous insertion leading to peritonitis. This harm may be reduced by maximizing endoscopic transillumination and using discrete finger palpation on the abdominal
wall to identify a safe entry site. In addition, laparoscopic assistance
can be used. Delayed complications of feeding tube insertion include
peristomal leakage or irritation, site infection, intraabdominal leakage, herniation of omentum, jejunal volvulus, gastric ulceration or
hemorrhage, fistulous tracts, inadvertent tube removal, fungal tube
infection, “buried bumper syndrome,” and tumor tract seeding.
Tube Deterioration and Replacement
Deterioration of the feeding tube is a common problem that is recognized by the presence of discoloration, irregular beading of the
tube, and foul odor. Though deterioration presents no direct risk to
the patient, a leak or break in the tube would disallow tube feeding.
Replacement tubes have a balloon at the distal tip. These should
only be placed in the tract once the site has matured (approximately
4 weeks). A Foley catheter may serve as a temporary replacement
tube, particularly in situations in which a tube has been inadvertently
removed and a replacement tube is unavailable.
Gastrostomy or Jejunostomy Tube Removal
Methods for removing a feeding tube vary by the type of tube (i.e.,
removal with traction on the tube, removal after deflating a balloon at
the distal tip, and tubes that required endoscopic visualization before
removal). One should know the type of tube and how it was placed
before an attempt to remove a tube. Endoscopic and radiologically
placed tubes have a soft cupped bolster within the lumen. This design
allows for the tube’s internal bolster to deform and the tube to be
removed by applying traction on the tube when necessary. Endoscopic
visualization should be performed if the type of tube cannot be confirmed with the patient’s medical record. Once removed, the feeding
tube site should be covered with a dressing until the tract closes. Generally, the tract closes within 24 to 72 hours following removal.
S u g g e S t e d R e a d i n g S
Bishoff J, Allaf M, Kirkels W, Moore R, Kavoussi L, Schroder F. Laparoscopic
bowel injury: incidence and clinical presentation. J Urol. 1999;101:887–
890.
Chuslip S, Yamoto M, Vejchapipat Ganji N, Pierro A. Nasograstic decom-
pression after intestinal surgery in children: a systematic review and
meta-analysis. Pediatr Surg Int. 2021;37:377–388.
Cyrany J, Rejchrt S, Kopacova M, Bures J. Buried bumper syndrome: A com-
plication of percutaneous endoscopic gastrostomy. World J Gastroenterol.
2016;22(2):618–627.
Dong X, Huang S, Jiang Z, Song Y, Zhang X. Nasointestinal tubes versus naso-
gastric tubes in the management of small-bowel obstruction. Medicine.
2018;97(36):e12175.
Fan AC, Baron TH, Rumalla A, et al. Comparison of direct percutaneous
endoscopic jejunostomy and PEG with jejunal extension. Gastrointest
Endosc. 2002;56:890–894.
Gauderer MS. Percutaneous endoscopic gastrostomy—20 years later: a histor-
ical perspective. J Pediatr Surg. 2001;36:217–219.
Greene Jr JF, Kovatch RM. Iatrogenic gastric ulceration in the dog: a compar-
ison between continuous suction, intermittent suction, and continuous
suction with hourly irrigation, using a double lumen nasogastric tube. Mil
Med. 1976;141(4):252–254.
Huang T, LIn J, Chung Y. A preinstalled nasopharyngeal airway in the right nasal
passageway to facilitate nasogastric intubation in anesthetized and intubated
patients: a prospective randomized trial. BMC Gastroenterol. 2020;20:365.
Keenan JE, Turley RS, McCoy CC, Migaly J, Shapiro ML, Scarborough JE. Trials
of nonoperative management exceeding 3 days are associated with increased
morbidity in patients undergoing surgery for uncomplicated adhesive small
bowel obstruction. J Trauma Acute Care Surg. 2014;76(6):1367–1372.
Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after
abdominal surgery. Cochrane Database Syst Rev. 2007(3):CD004929.
Samuels L. Nasogastric and feeding tube placementRoberts and Hedges’
Clinical Procedures in Emergency Medicine and Acute Care. 2nd ed. St.
Louis: Elsevier; 2019:828–851.
Schroeder J, Sitzer V. Nursing care guidelines for reducing hospital-acquired
nasogastric tube-related pressure injuries. Crit Care Nurse. 2019;39(6):54–63.
Speer E, Chow S, Dunst C, Shada A, Halpin V, Reavis K, Cassera M,
Swanstrom L. Clinical burden of laparoscopic feeding jejunostomy tubes.
J Gastrointestinal Surg. 2016;20:970–975.
Ten Broek RPG, Krielen P, Di Saverio S, etal. Bologna guidelines for diagno-
sis and management of adhesive small bowel obstruction (ASBO): 2017
update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg. 2018;13(1):24.
Management of Morbid
Obesity
Michael A. Schweitzer, MD, and Vivek Kumbhari, MD
he prevalence of morbid obesity has continued to increase in
the United States and throughout the world. The Centers for
T
Disease Control and Prevention (CDC) estimates that 42.4% of US
adults are classified as obese with a body mass index (BMI) greater
than 30 kg/m
kg/m
2
2
, with more than 9.2% being severely obese (BMI >40
). Bariatric surgery continues to be the only durable method
to obtain sustained weight loss and improvement of obesity-related
medical disease for most patients. New flexible endoscopic (intragastric balloon [IGB], endoscopic sleeve gastroplasty [ESG]) and
pharmaceutical therapies (e.g., GLP-1 analogs) have recently shown
better weight loss than any previous medical therapy; however, there
is a lack of long-term follow-up studies.
124 MANAGEMENT OF MORBID OBESITY
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Weight loss surgery first came into prominence in the 1970s, but
early procedures were abandoned largely because of unacceptable
complications and poor long-term results. In the late 1990s, weight
loss surgery saw a resurgence, largely because of the development of
improved bariatric procedures and application of minimally invasive
surgical techniques. Currently, more than 250,000 bariatric procedures are performed in the United States annually. Over the last
decade, numerous well-designed clinical trials have demonstrated
the safety, efficacy, and durability of weight loss surgery. The most
common bariatric operations performed in the United States include
vertical sleeve gastrectomy, Roux-en-Y gastric bypass, and duodenal
switch with biliopancreatic diversion. The American Society of Metabolic and Bariatric Surgery (ASMBS) estimates that laparoscopic
adjustable gastric band represents less than 1% of bariatric surgeries in the United States in 2019. Weight loss surgery also has been
demonstrated to have significant metabolic and neurohormonal
effects (independent of restriction and malabsorption), which play
an important role in the long-term success of these procedures.
PATIENT SELECTION
The National Institutes of Health issued a consensus statement in
1991 regarding the effectiveness of bariatric surgery and outlined
patient selection criteria that are still being used today by most
insurers. Patients are considered candidates for bariatric surgery if
they have a BMI of 40 kg/m
2
40 kg/m
if an obesity-related comorbidity such as diabetes or hypertension is present. The ASMBS position statement on class one
obesity (30–35 kg/m
2
or greater or a BMI between 35 and
2
) patients with obesity-related comorbidities
states, “bariatric surgery should be considered after a patient fails
nonsurgical treatment methods and should be strongly considered
for patients with type 2 diabetes.” An alternative to bariatric surgery
for patients with a BMI of 30 to 40 kg/m
2
could be IGB or ESG. These
flexible endoscopic therapies are especially worthy of consideration
in patients who have a contraindication to bariatric surgery (e.g.,
hostile abdomen, large incisional ventral hernia, etc.) or are simply
unwilling to undergo bariatric surgery despite being aware of its
effectiveness. In general, appropriate candidates for surgery should
demonstrate prior attempts at nonsurgical weight loss options that
may include dietary intervention, pharmacologic therapy, or behavioral modification. Patients should also have realistic expectations
regarding the long-term outcomes achieved with surgery (Box 1).
Relative contraindications include inability to comply with postoperative requirements, active alcohol or substance abuse, and uncontrolled psychiatric disease.
The evaluation of potential patients for bariatric surgery should
involve a multidisciplinary team approach. This team should include
a dietician and a mental health professional familiar with bariatric
surgery. Their purpose is to obtain a complete past dietary and
behavioral eating history, educate the patient on postoperative
dietary expectations, examine social support structure, and ensure
that any psychiatric or behavioral disorders are optimally controlled.
At the Johns Hopkins Center for Bariatric Surgery, all patients are
asked to attend an online preoperative education seminar. Participation in postoperative support group meetings also is encouraged.
The age limits for surgery have expanded considerably over the
last two decades. Select centers now offer surgery to adolescent
patients and to patients over the age of 70 years, with overall good
results.
OPERATIVE PROCEDURES
Most bariatric surgical procedures are performed laparoscopically, or
robot-assisted, with a hospital length of stay of 1 day or less. Staged
operations may be used in select cases for high BMI patients where
a laparoscopic sleeve gastrectomy is performed first followed by a
Roux-en-Y gastric bypass or duodenal switch with biliopancreatic
diversion at a later time, usually over a year out, if further weight loss
BOX 1 Indications for Bariatric Surgery for Morbid
Obesity
1. BMI of 40 kg/m2 or greater
2. BMI 35 to 39 kg/m2 with significant obesity-related comorbidities (diabetes, hypertension)
3. BMI 30 to 35 kg/m2 and obesity-related comorbidities who
have failed nonsurgical treatments
4. Clearance by a dietitian and mental health professional
5. No medical contraindications to surgery
is desired. An alternative approach for patients with a relatively lower
BMI could be to commence with a flexible endoscopic approach and
then proceed to bariatric surgery, though data on this are limited.
On the morning of surgery, all patients should receive appropriate antibiotics as well as subcutaneous unfractionated or low-molecular-weight heparin to help minimize venous thromboembolic
complications. Laparoscopic surgery involves the use of reverse
Trendelenburg position, and the patient must be placed appropriately
on the operating room table with use of a footboard and arms and
legs secured. Initial laparoscopic entry in a morbidly obese patient
can be difficult. We have found that the safest way to enter the peritoneal cavity is in the left upper quadrant with direct vision, while
using a device that allows visualization of the abdominal wall layers
during entry with a zero-degree laparoscope. Alternatively, we may
use a Veress needle, placed in the left upper quadrant, to insufflate
the peritoneal cavity and then place our midline optical trocar first,
followed by the remaining trocars under direct view with the laparoscope inside the peritoneal cavity.
Laparoscopic Roux-en-Y Gastric Bypass
Roux-en-Y gastric bypass (Fig. 1) is the second most common bariatric procedure performed in the United States (∼20% of all bariatric
surgery cases). Numerous articles have shown that gastric bypass
results in durable long-term weight loss and remission of metabolic
disease with a reasonably low complication rate.
A 45-degree angled laparoscope is inserted into the peritoneal
cavity through the midline trocar, and the operation is performed
using a total of five laparoscopic trocars. The omentum and transverse colon are retracted cephalad until the ligament of Treitz is
visualized. The jejunum is then transected approximately 40 to 75
cm distal to the ligament of Treitz with a 60-mm white stapler cartridge. The mesentery is then divided with a gray stapler cartridge
or ultrasonic shears. The proximal biliopancreatic limb of jejunum
is then anastomosed to the distal segment of jejunum 75 to 100
cm distal from the point of division. We perform this anastomosis
in a side-to-side fashion using a white 60-mm-length laparoscopic
stapler cartridge. The common enterotomy is then closed with a
white 60-mm-length laparoscopic stapler cartridge. The resulting
mesenteric defect is closed with a running suture to help minimize
the risk of internal hernia.
Next the patient is placed in reverse Trendelenburg position, and
the gastric pouch is created. The left lateral segment of the liver is
retracted using a Nathanson retractor (Cook Medical, Bloomington,
IN) through a subxiphoid 4-mm puncture and is held in position
with a movable arm that attaches to the bed. We next dissect the
peritoneal attachments at the angle of His to expose the left crus,
which is then followed by opening the bare area of the gastrohepatic
ligament with the ultrasonic shears to enter the lesser sac. Division of
the neurovascular bundle on the lesser-curve side of the stomach just
distal to the left gastric artery and vein is accomplished using a gray
vascular cartridge or ultrasonic shears. Multiple 60-mm blue staple
cartridges are then used to transect the stomach up to the angle of
His, creating a vertically oriented, 20-mL proximal gastric pouch. A
40 French bougie can be placed down into the stomach along the
Roux
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limb
(antecolic)
Gastric
pouch
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125
opening that was formed after the stapler was removed. This stay
suture and the stay suture on the left (angle of His side) are used to
elevate the tissue so that the 60-mm length blue load cartridge can be
used to close the opening. The stapler is brought down on top of the
bougie while the tissue to be transected is retracted and then fired.
The gastrojejunostomy is completed by running a 2-0 absorbable
suture as a second layer. The resultant anastomosis is approximately
12 mm in diameter. A leak test may be performed if the surgeon
desires by clamping the Roux limb just distal to the anastomosis
and insufflating air (via endoscope or orogastric tube), whereas the
gastric pouch and anastomosis are submerged in saline. The mesenteric defect then is closed between the Roux limb mesentery and the
transverse mesocolon, up to the transverse colon.
Laparoscopic Vertical Sleeve Gastrectomy
Laparoscopic vertical sleeve gastrectomy (LVSG) (Fig. 2) is currently
the most performed weight loss operation in the United States
(∼60% of all bariatric surgery cases).
The LVSG is primarily restrictive, as the lateral aspect of the
stomach is removed to create a sleevelike tube or reservoir. The gastric resection also may assist with weight loss by causing hormonally
assisted satiety. The fundus produces the proappetite hormone
ghrelin, and because the fundus is removed, these hormone levels
are reduced after LVSG. Although this bariatric procedure is not
reversible, it can be converted into a Roux-en-Y gastric bypass or
duodenal switch if greater weight loss is desired. It may also need
to be revised to a Roux-en-Y gastric bypass if postop complications
were to occur, for example, gastric stricture or severe gastroesophageal reflux disease.
The VSG typically is performed with one 5-mm, two 12-mm,
and one 15-mm trocar. With the liver retracted with the Nathanson, the short gastric vessels are divided along the greater curve of
the stomach. A LigaSure device (Covidien, Norwalk, CT) typically
is used to accomplish this. A 40F blunt-tip bougie is placed in the
FIG. 1 Antecolic-antegastric Roux-en-Y gastric bypass. (Courtesy Corinne
Sandone, Johns Hopkins University.)
lesser curve after the first firing of the stapler to assist in transecting
the stomach where the bougie is used as a guide to the angle of His.
The 40 French bougie is then removed. Any bleeding from the staple
lines is controlled with clips or suture ligation.
We routinely bring the Roux limb up to the gastric pouch in an
antecolic-antegastric orientation. This seems to reduce the incidence
of internal hernias, gives excellent exposure, and is simpler to perform than a retrocolic retrogastric approach. The side of the Roux
limb is sutured to the gastric pouch staple line. A small enterotomy is
made just proximal to the end of the Roux limb, and a similarly sized
gastrotomy is made in the gastric pouch for the placement of the stapler. The stapler is loaded with a 60-mm blue cartridge to create the
gastrojejunostomy, using only the first 40 mm of the staple cartridge.
After the stapler is fired, a stay suture is placed on the lesser curve
(right) side of the opening. A 32F, blunt, round-end bougie then is
passed from the mouth and through the gastrojejunal anastomosis
and into the Roux limb. The bougie can then be seen through the
Jejunojejunostomy
FIG. 2 Creation of the gastric sleeve. (Courtesy Corinne Sandone, Johns
Hopkins University.)
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stomach and directed along the lesser curve. The stomach is divided
at the greater curvature, beginning 4 to 6 cm proximal to the pylorus.
Green and blue staple loads are used adjacent to the 40Fr bougie and
extending to the angle of His. When stapling, it is important to avoid
stapling too close to the incisura angularis of the stomach since this
may lead to a gastric stricture. The staple line can be oversewn or an
absorbable buttress material can be used with the clips to assist with
hemostasis of the gastric staple line.
The partial gastrectomy specimen is removed through the 15-mm
trocar site. Care should be taken to suture close the fascial opening of
this enlarged trocar site to prevent postoperative herniation. As with
Roux-en-Y gastric bypass, a limited upper gastrointestinal study is
performed only if clinically indicated.
Laparoscopic Duodenal Switch with Biliopancreatic
Diversion
The laparoscopic duodenal switch with biliopancreatic diversion
(DS-BPD) is primarily a malabsorptive operation that involves preservation of the pylorus and creation of a short, 100-cm ileal “common channel” (Fig. 3). The DS-BPD is the least common bariatric
procedure performed because of its surgical complexity, potential for
severe malabsorptive nutritional deficiencies, and possible diarrhea.
This procedure can be performed in a single operation or in two
stages if the patient has a high BMI (>70). The first stage is similar to
a VSG operation with the creation of a gastric sleeve. After approximately 1 to 2 years, patients can be revised to DS-BPD and the malabsorptive second stage performed. This is performed by dividing
the small bowel 250 cm from the ileocecal valve. The proximal end
of bowel then is anastomosed to the distal ileum 100 cm from the
cecum.
The patient is placed in steep reverse Trendelenburg position, and
the liver is retracted. If the sleeve gastrectomy portion has not been
performed previously, then partial gastrectomy proceeds as previously described. The duodenum is then divided approximately 3 cm
distal to the pylorus with a blue Endo GIA 60-mm stapler.
The Roux limb is directed in an antecolic fashion, and a side-to
side anastomosis is performed with the first part of the duodenum.
Finally, the mesenteric defect is then closed between the Roux limb
mesentery and the transverse mesocolon.
Laparoscopic Single Anastomosis Duodenal Switch
The laparoscopic single anastomosis duodenal switch (Fig. 4), also
referred to as loop duodenal switch or single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S), was recently
approved by the American Society of Metabolic and Bariatric
Surgeons (ASMBS). When compared with duodenal switch with
biliopancreatic diversion, SADI-S is easier to perform with possibly
a lower rate of internal herniation than DS-BPD. However, it does
not divert the biliopancreatic fluid since there is no Roux limb but
instead there is a loop anastomosis that, if there is a leak, may potentially be more difficult to treat since biliopancreatic fluid is flowing
through where the small bowel is anastomosed with the duodenum.
Controversy exists with the size of the bougie for creating the sleeve
FIG. 3 Antecolic duodenal switch with biliopancreatic diversion. (Courtesy
Corinne Sandone, Johns Hopkins University.)
150 cm
100 cm
FIG. 4 Laparoscopic single anastomosis duodenoileal bypass with sleeve
gastrectomy (SADI-S). (Courtesy Corinne Sandone, Johns Hopkins University.)
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127
gastrectomy and length of the efferent or absorptive limb. Bougie size
has decreased down to a size of 40 French by many surgeons, and
the absorptive channel has increased from 200 to 300 cm to decrease
protein and vitamin deficiencies while maintaining excellent weight
loss. Diarrhea can be troublesome after DS-BPD and SADI-S, but by
increasing the length of the absorptive channel, this may become less
of a problem for most patients.
The sleeve gastrectomy is performed as previously described. The
dissection is then continued a few centimeters past the pylorus where
the duodenum is divided with the endoscopic linear stapler. The
omentum is then divided with the energy device at a point where the
path of the small bowel is unobstructed as it travels to be anastomosed to the first part of the duodenum.
The surgeon then measures the absorptive limb by starting at the
ileocecal valve and walking back the bowel 300 cm. This point on the
bowel is then carefully brought up to the duodenum and stay sutures
are then placed while making sure there is no twisting nor tension
present before creating the anastomosis.
The anastomosis may be formed using a stapler technique, in
which an endoscopic stapler is used to join the small bowel to the
duodenum and then the common enterotomy opening is closed with
either a suture or another stapler firing, taking care not to make the
open channel too tight. The anastomosis can also be formed by using
handsewn two-layer suturing technique.
It is recommended to place a stitch from the afferent limb, just
before the anastomosis, to the gastric antrum to prevent an obstruction from the limb rotating. The mesenteric defect between the small
bowel mesentery and transverse colon mesentery can be sutured
closed to prevent possible internal herniation, but in the SADI-S
operation this is still controversial when it is discussed, with many
surgeons finding that it is unnecessary. Hopefully, future analysis
of long-term outcomes data will help resolve the need for this step.
Intragastric Balloon
IGBs are gas- or fluid-filled devices that are deployed in the stomach
for a period of 6 to 12 months. As a result of being a temporary
implant, they require two endoscopic procedures (one for insertion
and another for removal of the IGB). Though initially appealing to
patients, IGBs have been plagued by poor tolerability and concerns
regarding safety. Furthermore, as a result of the device needing to
be removed, weight regain is somewhat expected. The mechanism
of action is unclear with theories ranging from that of effective
volume reduction due to space occupation to alterations in gastric
emptying; some believe there are even neurohormonal benefits.
Notably, regardless of the IGB type, weight loss seems to taper at
3 months, and this appears to be the result of an accommodation
phenomenon. Therefore, newer space-occupying devices attempt to
circumnavigate this by being adjustable. There is even a capsule that
is taken twice a day before meals that dissolves, releasing hundreds of
hydrogel beads that result in temporary space occupation.
Endoscopic Sleeve Gastroplasty
ESG was first reported in 2013 and, since then, has disseminated
globally, being performed by gastroenterologists and surgeons alike.
It attempts to recapitulate laparoscopic greater curvature plication
through an over-the-scope attachment of the OverStitch (Apollo
Endosurgery, Austin, TX) and 2-0 nonabsorbable monofilament
sutures. A running suture pattern is performed using a tissue helix
such that plications are made to the distal gastric fundus (a small
residual fundal pouch is inevitable). The procedure is performed
on an outpatient basis with 5 to 9 running full-thickness sutures
being placed with a total procedure duration of 1 hour. The current
technique results in a stomach with decreased gastric volume and
reduced compliance. Published data demonstrate outcomes that it
is more effective than even high intensity diet and lifestyle program,
but it is less effective than laparoscopic sleeve gastrectomy. ESG has
been used not only as a primary weight loss therapy but in patients
who have had weight regain and dilation of the stomach after surgical
sleeve gastrectomy.
ENHANCED RECOVERY AFTER SURGERY
We implemented an Enhanced Recovery After Surgery (ERAS)
program for bariatric surgery at our center in 2017 and published a
decrease in length of stay from 2.77 days to 1.77 days (P <0.001) with
a reduced 30-day readmission rate from 7.94% to 2.86% (P
On the day of surgery, patients have a scopolamine patch placed if
there is no contraindication. During the operation, opioids are minimized, acetaminophen 1000 mg IV is given, no Foley is placed, and
no drains are used for routine bariatric surgery operations. Dexamethasone 4 to 8 mg IV is given after induction, and postoperatively,
we give our sleeve gastrectomy patients a second dose of dexamethasone IV 8 hours after leaving the operating room. Ondansetron is
used intraoperatively and postoperatively to prevent nausea as well as
treat it. Metoclopramide is used if ondansetron is not enough to treat
a patient’s postoperative nausea complaints. Patients are instructed
to walk soon after surgery. Clear liquids are started that evening and
increased the following morning, with discharge on postoperative
day number one. Oral acetaminophen is used for pain control as
well as oral narcotics for breakthrough pain, but it is stressed to the
patient to try and avoid narcotics if possible. IV narcotics are discouraged and avoided if possible. The patient is discharged once they
are drinking enough to maintain hydration at home.
= 0.011).
OUTCOMES AND COMPLICATIONS
After any of the bariatric procedures, patients are seen in follow-up at
2 weeks to ensure that they are well-hydrated, tolerating oral intake,
and without wound complications. They are then seen at 3, 6, 12, 18,
and 24 months and then annually thereafter to follow weight loss
and nutritional issues. For patients who undergo flexible endoscopic
techniques, more rigorous surveillance in the first 24 months is necessary as there is a greater propensity for weight regain. Regardless
of the procedural technique, patients are encouraged to meet with
dieticians and remain with their support groups indefinitely.
For 1 month after surgery, patients are all maintained on a
high-protein puree consistency diet; after that they gradually are
advanced to solid food. They also receive multivitamins, calcium,
and vitamin B
patients with gastric bypass and DS-BPD who are at higher risk for
malabsorption and possible malnutrition. Supplemental iron should
be considered for menstruating women.
Weight loss after gastric bypass and DS-BPD occurs primarily in
the first 12 to 18 months after surgery and averages approximately
70% and 80% excess weight loss (EWL), respectively. Sleeve gastrectomy patients typically have less EWL, on average 50% to 60% over
a 2-year period.
One of the most important outcome measures after bariatric surgery is remission of obesity-related metabolic diseases, such as type 2
diabetes. More than 70% to 80% of patients with diabetes experience
complete remission after undergoing gastric bypass or DS-BPD. The
restrictive operations have a 50% remission rate of diabetes. Hypertension, sleep apnea, hyperlipidemia, and fatty liver disease have
similar remission rates after surgery. Flexible endoscopic approaches
confer less weight loss than their surgical counterparts and do not
appear to induce the weight-independent metabolic benefits seen
with bariatric surgery.
Overall complication rates after bariatric surgery are less than
15% in most reports. Like most surgeries, there are early and late
complications for bariatric surgery. Early or perioperative complications include bleeding, anastomotic leakage, and deep venous thrombosis. The mortality rate is less than 0.5% and is usually attributable
to a pulmonary embolus or sepsis from anastomotic leak. Persistent
supplements. This is especially important for
12
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unexplained tachycardia higher than 120 beats/min may be an early
sign of sepsis, and an appropriate workup should be considered.
Vitamin B
, calcium, iron, vitamin D, and protein deficiencies
12
are long-term complications that can occur within the first year after
surgery. Rigorous monitoring of nutrition status is necessary. Vitamin B
deficiency also can occur in patients with protracted vomiting
1
after surgery, and they may experience extremity paresthesias, confusion, and nystagmus. Lower extremity weakness and paresthesias
also can be seen with vitamin B
deficiency. Anastomotic stenosis
12
and obstruction at the gastrojejunostomy in the first few months
after surgery occur in less than 5% of patients after gastric bypass and
usually can be managed with endoscopic dilation.
Internal hernias are also a possible complication and can occur at
any time after surgery. The symptoms of internal hernia can be similar to an acute bowel obstruction or become chronic and described
as postprandial periumbilical cramping pain. If internal hernia is
suspected, operative intervention may be required to avoid possible
bowel ischemia.
In general, the results of weight loss surgery are excellent, with
most patients losing more than 50% of their excess weight with
dramatic improvement or remission of metabolic disease. Approximately 10% to 15% of patients either do not achieve significant
weight loss or partially regain their weight after 2 to 3 years. Ideally,
these patients respond to dietary counseling, although some may
need operative revision or conversion to a more malabsorptive procedure, such as the DS-BPD.
Unfortunately, no perfect method exists for choosing the best
operation for each individual patient. Certainly, a multidisciplinary
team approach is helpful in providing patient support throughout the
preoperative and postoperative course. Reducing obesity-related diseases should be the major goal, not merely cosmetic improvement.
Patients must understand that bariatric procedures are a tool to assist
with weight loss, and it must be combined with lifelong changes in
dietary, exercise, and lifestyle habits.
S u g g e S t e d R e a d i n g S
Adams TD, Gress RE, Smith S, etal. Long-term mortality after gastric bypass
surgery. N Engl J Me. 2007;357:753.
ASMBS. Estimate of Bariatric Surgery Numbers, 2011–2019. https://asmbs.
org/resources/estimate-of-bariatric-surgery-numbers. Retrieved March
2021.
Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systemic
review and meta-analysis. J Am Med Assoc. 2004;292:1724.
CDC. Adult Obesity Facts. https://www.cdc.gov/obesity/data/adult.html.
Retrieved June 2021.
Fayad L, Adam A, Schweitzer M, et al. Endoscopic sleeve gastroplasty ver-
sus laparoscopic sleeve gastrectomy: a case-matched study. Gastrointest
Endosc. 2019;89(4):782–788.
Kumbhari V, Hill C, Sullivan S, Kumbhari V, etal. Bariatric endoscopy: state-
of-the-art. Curr Opin Gastroenterol. 2017;33(5):358–365.
Taylor J, Canner J, Cronauer C, etal. Implementation of an enhanced recovery
program for bariatric surgery. Surg Endosc. 2020;34:2675–2681.
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