E15 Shahzeer Karmali On Bariatrics And Dealing With Industry

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Chad Ball  00:15

Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it.

Ameer Farooq  00:50

Hi, everyone. In this episode, we had the opportunity to talk to Dr. Shahzeer Karmali. Dr. Karmali is a bariatric and MIS surgeon at the Royal Alexandra Hospital in Edmonton, Alberta. And we talked to him about post-bariatric complications and things that every general surgeon really should know how to manage if they see these patient patients on call. In addition, we got to talk to him about some really interesting research that he’s done related to intracranial hypertension, and finally closed off by talking about what it means to have a relationship with industry and doing research. We hope you enjoy.

Chad Ball  01:25

Thanks so much for joining us on Cold Steel, Dr. Karmali. You know, you know, it’s kind of a crazy time and everyone’s quite, quite busy dealing with all the issues that surround COVID. So thank you in advance. For viewers that are or I should say listeners that don’t maybe know you as well as we do. Tell us where you grew up what your training pathway was, and maybe why you chose bariatrics at the end of the day.

Shahzeer Karmali  01:49

That sounds good. Chad, thanks for the invitation. I really appreciate being on the Cold Steel podcast today. So I was actually raised in Edmonton, Alberta, and I did my medical school in Edmonton. Thereafter I did my residency at the University of Calgary. Following that, I did a fellowship training at the Baylor College of Medicine in Houston, Texas. My fellowship was focused on minimally invasive surgery as well as a bariatric surgery. Thereafter, I’ve taken up academic position at the Royal Alexandra Hospital, which is affiliated with the University of Alberta in Edmonton. As to why bariatrics, so, you know, I didn’t have too much exposure to bariatrics during my medical school, nor during my residency. It was more of an interest I had in minimally invasive and laparoscopic surgery. But as I entered my fellowship, I had an ability to really get immersed in a world of, you know, bariatric surgery. And it really fascinated me because it’s one of the you know, first of all, as a surgical operation its quite a challenging laparoscopic operation. But more than that the patient cohort was was really interesting because you’re dealing with individuals who are suffering from severe obesity and a lot of the comorbidities associated with it. And you see the impact you can have by applying this tool called bariatric surgery and not only improving their health, but improving their quality of life, their quantity of life. And the most interesting thing is improvement of comorbidities. And as we know from you know, major studies like the STAMPEDE trial, bariatric surgery, especially surgery, like a gastric bypass is shown to the cure for conditions like type two diabetes, which is which is amazing. You’re using a surgical operation to treat a medical problem. So that’s kind of what generated my interest in bariatric surgery and kind of keeps me going in that field currently.

Chad Ball  03:54

I think it’s, I think it’s kind of neat, you know, both both you and Scott Gamora have now been on the podcast. And we talked to Scott, about surgical training and kind of the interesting way that we do that. But, you know, both of you guys came out of a residency that really didn’t have much bariatrics at all. And both of you guys have become such great national leaders. It’s pretty awesome to see. To that extent, then, when you look at that when we look at the evidence in group from the outside, you guys have been really productive on the academic bariatric side. How have you done that? And how do you view that? And what makes you guys really honestly stand out from most of the other groups in the country?

Shahzeer Karmali  04:31

Well, I think I think the main thing, you know, you know, in learning about bariatric surgery, and with most other surgical disciplines, you realize that, you know, evidence and publishing and, and really getting your name out there helps with helps with recognition as well as well as maintaining your association with other centers. So we really got immersed in this idea of the MBSAQIP, which is equivalent to the NSQIP. And now what it is, is it’s a cohort of bariatric surgical centers that work together to share outcome, share data, share research in a common goal of providing high-quality care and management to our patients. So part of that care goal is obviously to study our outcomes, study what we’re doing and use methods to improve our overall quality of care delivered. So, in essence, by being involved in such a large consortium really drives us to not only provide good clinical care, but study our care, research our care and publish what we do. So that’s really what drives it. And I think everybody’s bought into that idea. And this MBSAQIP idea really propagated in the US and it started to kind of grow in Canada now. So there’s more and more centers have gone on board, this  MBSAQIP idea, and as we hope it centers develop in Canada and really get integrated into that, they can add to the research engine in Canada especially.

Ameer Farooq  06:01

That’s awesome. Dr. Karmali. As one of the R5s, who supposedly is going to be writing this exam, at some point, yet to be defined, but at some point, we are going to write that Royal College exam, I thought that it’d be really useful for us as well as for anyone who might have to deal with bariatric patients, perhaps on call etc. to talk a little bit about some of the common things that you can expect from a bariatric patient in terms of complications. And maybe I thought it would be useful to just have you define the problem of obesity in Canada, as your group has written a lot about that. Like how big of a problem is obesity in Canada, and to what extent is bariatric surgery really caught on in the country?

Shahzeer Karmali  06:50

So I mean, obesity is an interesting condition, because you know, the past obesity was just seen as you know, a cosmetic necessarily cosmetic problem, but people being overweight, and just not looking good and just having some extra pounds. But as kind of evidence and research has developed, we realized that obesity itself, and as a classified as a chronic disease, and especially severe obesity. So those are, that’s the obesity that we tend to deal with. So those are individuals who have, you know, body mass indices of over 40, or body mass indices over 35 with obesity related comorbid comorbidities. So these are the severely obese patients and these severely obese patients really suffer. So a person who has severe obesity usually has about a 10 to 12 year reduction in overall life expectancy as compared to individuals who don’t. And as I mentioned, severe obesity, being a chronic disease is closely linked with other chronic diseases. So people who are severely obese aren’t just obese are usually also type two diabetic, suffer from high blood pressure, high cholesterol, COPD, sleep apnea, the list goes on and on. So there’s a big congregation of this chronic disease entity of severe obesity, that’s kind of evident and permeating, you know, nationally and internationally. Now, when we look at Canada itself, you know, so what, what percent of the population would be considered to be severely obese. And there’s different ranges in different provinces, but on an average in Canada, you know, it’s probably around 25 to 30% of the population is considered to be on that severe obese spectrum, which is, which is huge, right? Like that’s a, that’s a large number of individuals who are suffering from this chronic disease condition. And so because of that, you know, a lot of centers have developed to to facilitate management of it. Now, bariatric surgery, when we talk about management is a tool and it’s a tool used to manage a severe obesity. And you know, how much bariatric surgery is being done? Well, interestingly, although 30% of the population is severely obese, probably only about 1.5 to 2% of those individuals actually go on to have bariatric surgery, because there’s an access problem too. There’s you know, when I look at countrywide, there’s probably only around 15 bariatric surgeons offering bariatric surgery across the country. So there’s obviously a supply and demand imbalance going on right now.

Ameer Farooq  09:24

You know, obviously, bypass and sleeves are probably the most common operations, but is, is there anyone doing some of the other operations and maybe you could actually describe the differences between, you know, let’s say, a sleeve versus a bypass versus some of the other lesser known things like a duodenal switch or biliary pancreatic diversion.

Shahzeer Karmali  09:50

So, you know, in terms of operations being done, so, you know, in Canada, there’s probably three common operations being done. The gastric bypass as probably the commonest, the gastric sleeve, which is a close second. And then there’s other operations, variants of the duodenal switch or single anastomosis single anastomosis duodenal procedure. So those are the common three. In the past, there was an operation very commonly done, called the adjustable gastric band. It’s not really been done being done anymore in Canada, but it’s an important operation to know about because a lot of individuals who have issues or complications with that operation. In the US our partners down south, interestingly enough, the commonest operation is actually the gastric sleeve, followed by the gastric bypass. So I guess, to your question, you know, just to go through the operation, I can just kind of go through each kind of, in general, in terms of, you know, what they look like, what they do, and then we can talk a bit more. So just starting with, just to get it, get it, get it get it by, because I did mention is the adjustable gastric band. So this operation really became very popular kind of in the late 2000s. And really tapered off, you know, by 2010 to 2012. But there was a lot of adjustable gastric bands being done. What the adjustable gastric band is, is it’s a silastic band that is attached to a port, and it’s kind of like a port-a-cath . So, when you fill that port with saline the band, the band has a reservoir, and that reservoir gets tighter and tighter and tighter. And so what the operation did was that surgeons placed this adjustable band in the upper portion of the stomach. And what it did was it created essentially a reservoir at the top and stomach. So there was the band was sitting, so you got food coming down the esophagus, and before it filled the entire stomach, it filled as a reservoir above the band. And when it filled a reservoir above the band, what happened is that people who had this band in felt this kind of idea of fullness, it’s kind of fooling your body into a portion control reductions. People like, Hey, you know, I’m eating this food, and I can feel full on less food. So what happened is, for example, if somebody eats, you know, five cups of food to feel full, with the band in place, they’re eating one and a half to two cups to fill this reservoir first, and like, Hey, I feel full and, and that’s the facility the weight loss. So that’s what the band worked. The issue with it is that to really get the band to work, patients had to come in and keep having the band filled and adjusted to a point where you could reach this kind of green zone or a happy medium where you got that fullness. And the problem that came about is that it required a lot of effort to do it, a lot of patients didn’t follow-up, a lot of surgeons were just doing the band and losing patients to follow-up and not really following the protocols that had to be followed. So because of that, there was a high failure rate with the band. Right now, probably around 50 to 60% of patients who’ve had a band have now had it removed, because it just didn’t work. So that’s the that’s the nuts and bolts of the mechanism of action of the the gastric band. And again, not not being done very frequently. In terms of the next kind of operation is probably in terms of you know, and I am doing it kind of by runs of complexity. So the next one is follows a gastric sleeve. So the gastric sleeve is an interesting operation. This operation, probably started really picking up interest, kind of in 2006 to 2007. It was initially done as a stage operation to another operation, which I’ll discuss a little bit called a biliopancreatic diversion duodenal switch. But what happened is that, when patients had this initial operation called a gastric sleeve, a lot of patients sort of losing weight. So the surgeon said, hey, let’s let’s think about doing this gastric sleeve as a standalone operation. So that’s kind of where it developed. Now, what the gastric sleeve is, is it’s essentially a restrictive operation where surgeons use surgical staplers or other methods and they they work to decrease the reservoir size of the stomach. So for instance, if somebody has a stomach, that’s usually I say, tell patients, you know, you’re stomach’s probably the size of a small watermelon. What happens that surgeons use surgical samplers or other techniques to change the configuration and size of something from a watermelon to probably the size of a large banana. And by doing that by decreasing that reservoir size. What happens that patients get that portion control reduction, so same kind of idea. They feel full on less food. So rather than eating four to five cups of food per meal, they can eat two to two and a half cups and feel that feeling of fullness. In addition, there’s a secondary effect that also happened with the gastric sleeve, which kind of came about with research. And people found that you know, after the gastric sleeve not only were people getting this kind of portion control reduction, they’re also finding their hunger urge reduced for some reason. This wasn’t seen what the band and as research started developing, they found people found that people who have a gastric sleeve start noticing that their hormonal levels of a hormone called ghrelin have also diminished. And the reason for that is the ghrelin is stored in a gastric fundus. And with the gastric sleeve that’s gastric fundus is removed. So lo and behold, patients who have a gastric sleeve have lower ghrelin levels. And ghrelin is a hormone that drives hunger. So when you drop ghrelin levels, your hunger urge also diminishes. It’s kind of a dual effect. So it’s very interesting. The gastric sleeve is is a good operation, it resulted in pretty decent weight loss. We usually quote around a 50 to 55% excess weight loss with the gastric sleeve. So it’s pretty strong, pretty robust. The issues with the sleeve are that the stomach is a very pliable organism. And if patients don’t follow appropriate dietary recommendations, that stomach can stretch backup. So that’s probably around a 5% failure rate that we quote with the sleeve. And finally, the one concern with the sleeve is because we are reconfiguring the stomach, we’re always concerned about you know, changing the orientation of the upper esophageal area or the angle of his or the gastric reflux mechanism. So some individuals who have a lot of reflux preexisting can get worsening reflux after a sleeve, so that’s always a one concern with the sleeve is gastric reflux. The next operation in terms of complexity is the gastric bypass. So, the gastric bypass, you know, like I said the sleeve is probably done since 2007. I mean, the gastric bypass dates back to the 1960s when it was done as an operation. So, obviously change in the way in which we do it, the fact that we do it laparoscopically now, but the idea and the philosophy of what it does and how it works remains the same. So, with the gastric bypass, couple of things, a couple of things happen. So, the first thing that happens is that when you look at the gastric bypass or a picture of it, you’ll you’ll see that there we form a little pouch right? So we take this stomach and we form a pouch for the stomach using a stapler. So rather than food filling your entire stomach, it fills this pouch so by filling the pouch and not filling your entire stomach, you get that same reservoir effective. You feel feel full on less food the same similar to the band similar to the sleeve, they get that portion control reduction. The difference though with the gastric bypass is rather than having the food just enter into the rest of the stomach, we actually bring up a loop of small bowel called the jejunum and we join it to that gastric pouch. And what happens is that the food travels down this loop of of jejunum for a variable distance depending on centers, but usually on average about 100 to 125 centimeters, before it reaches the biliopancreatic secretion. So the reason this operation is called a gastric bypass is what we’re doing is we’re bypassing your food from seeing your belly or pancreatic secretions. It is not a huge bypass of stomach or bowel from seeing food because really, the only portion of your intestinal tract that’s not seeing food is your remnant of your stomach. That’s probably around 20 to 30 centimeters of duodenum and jejunum. However, your food is not seeing the secretions from your pancreas and your biliary tree right away. It’s giving getting more time. And as that happens, different things happen. So this is where the interesting stuff comes to the bypass. This is where a lot of a lot of literature still kind of terming exactly how does bypass work. We know it causes restriction, but it also causes changes and there’s a lot of neuro hormonal changes that we’re seeing happen with the gastric bypass where there’s shifts in different neural hormones, especially neural hormones that drive weight and neural hormones that drive type two diabetes. Important ones are things such as cholecystokinin, ghrelin, and cretin. And all these hormones start start changing and varying. And by doing these sort of things, we find that these deep neural hormones diminish. And by diminishing these things, patients notice weight loss, as well as improvement in comorbidities. And so when we talk about numbers, with the gastric bypass, people are now pushing much higher weight loss because you have this dual restrictive effect and neurohormonal effect. And so patients are pushing around 70 to almost 80% excess weight loss. And much more stable, and much less variable because you’ve got this kind of dual effect happening. So that’s the gastric bypass. And finally, the biliopancreatic diversion duodenal switch. So others tamper with the fact that this operation isn’t performed very commonly when we look, you know, nationally is probably represents probably 0.5 to 1% of all operations being done. It’s quite a complex operation. But, you know, in general terms what this operation is, is it’s a combination of gastric sleeve. So we do a sleeve gastrectomy on the stomach to make it smaller. And then we essentially create a malabsorptive operation. So, the bypass isn’t necessarily a malabsorptive operation, this is a malabsorptive operation. So, for this operation, we essentially have joined the loop of usually distal small bowel to the stomach. And that we reanastomose that to ileum. So it causes a large malabsorption in your small bowel. So in this operation, most of your small bowel from your duodenum to a large portion of your to jejunum is not seeing food. And the only portion of your bowel, that seeing food is that sleeve portion of the stomach, probably around 50 centimeters of distal jejunum and ileum. And that over to the colon. So really a really high malabsorptive operation. And it’s malabsorption, that causes a weight loss. And the weight loss for this operation is really high, patients can get around 90%, excess weight loss very, very high. But it comes at some consequences because people are also experienced a lot of malabsorption. So people usually have to be on a lot of multivitamins, a lot of minerals, and be very careful with these patients because it can be really malabsorptive operation. And because of that this operation hasn’t really been adopted nationally or internationally as as the most commonest operation that we do. So.

Ameer Farooq  21:33

That was an awesome overview of the operations. And that was excellent. I was wondering if you could talk a little bit about what the pathway is for patients in your hospital. So they come in for their let’s say their bypass. What do you do in terms of their swallow? When do they get discharged? And what kind of medications and things like that do you put them on post-op?

Shahzeer Karmali  21:55

Sure. So postoperative care?

Ameer Farooq  21:56

Yeah.

Shahzeer Karmali  21:57

Sure. So there. So there’s definitely off I’ll focus on the bypass and the sleeve as a two key operation. I’ll tell you kind of what we do and and in general what what the outcome is. So with both operations, we do both operations laparoscopically. In our center, we admit admit all patients after the operation for usually a period of 24 to 48 hours. In terms of imaging after the operation, there’s debate about the utility of upper GI series post-op day 1 to to assess anastomosis or assess a sleeve. Really, there’s no good evidence to indicate that these studies are useful. So you know, I don’t think they’re necessary as a postoperative tool. Some surgeons do like to use them just for for their own safe, safety or sake. But there’s no good evidence that an upper GI series is needed post operation to rule out a leak. We do a lot of intra operative testing, we that that’s been proven. So we intraoperatively use endoscopy to assess anastomosis with saline and methylene blue dye. As long as those are normal, the chance of leak is usually diminished quite substantially. So after the operation, the patients are usually admitted to the floor and plus or minus a floor on post-op day one. And thereafter, they’re usually started immediately on a progressive diet from clear fluids to a bariatric full fluid diet and then over to discharge. So most patients are discharged either post operative day one, or post operative date two. We usually really try to maintain patients to be up and about and moving. So we tend not to keep them on bedrest. We don’t use Foley catheters. We take take off any compression garments after the operation and really get them moving. In terms of postoperative medications, there’s a couple of keywords that we put patients on, which is similar for both operations. We put gastric bypass and gastric sleeve patients on Pantoloc. Now we put them on a dose of about 20 milligrams, b.i.d or sometimes 40 milligrams b.i.d for a period of six months. And the reason we do that is to prevent the formation of marginal ulcers. There’s been evidence shows that there’s a higher risk of marginals, especially after gastric bypass operation and marginals cause problems. So we leave patients on Pantoloc for six months after the operation. The other medication we have started put patients on also is Urso or Actigall or ursodeoxycholic acid for patients who haven’t had previous cholecystectomy, because we know that with rapid weight loss comes increased risk of gallstone formation and we really don’t want our patients to have a symptomatic gallbladder disease after having, you know, a gastric bypass or gastric sleeve. So, patients also go on Urso or Actigall if they haven’t had a cholecystectomy for a period of six months. And finally, we just placed patients on regular pain medication, not too much, we usually give them either a Codeine Elixir for about seven days or Tylenol extra strength for seven days. We really discourage the use of non-steroidal antiinflammatory drugs because those can predispose to alteration and gastritis. So we, we don’t promote the use of NSAIDs for surgery.

Ameer Farooq  25:23

How about heparin? Are you sending people home on heparin?

Shahzeer Karmali  25:28

We’re not. No, we’re not sending people home on heparin. We do, obviously use heparin postoperatively in the in a usual post-op surgical period, but we don’t send patients home on injections of enoxaparin currently.

Ameer Farooq  25:45

Okay, awesome. Something that seems to come up on exams a lot is talking about a variety of kind of bariatric complications. And I thought we could sort of look at this from an early or elite type of phase. So you know, you get let’s say, you have a patient bariatric patient who’s post-op day one, their hemoglobin is dropped or their tachycardic heart and you think they might be bleeding. How do you kind of approach that?

Shahzeer Karmali  26:19

Yeah, so I mean, I think just as I was saying you know, I think as we as you look at you know, Royal College exams or exams in the US, we’re seeing more and more bariatric complication questions being more evident, because it’s a real deal. Like I told you, the amount of individuals are obese, the amount of and the more and more bariatric surgery we’re performing. Even if you don’t do bariatric surgery yourself, or you don’t believe in it, you’re gonna see a patient who’s at least had bariatric surgery in your hospital or out in the community. So when we look at complications, like you said, I mean, it’s good to fall focus initially on will focus on a post operative complications first, now we can look at, you know, patients who are discharged. So postoperative complications are common, as ones, we see somebody who’s had, for instance, a gastric bypass or gastric sleeve, so his number one would be hemorrhage, right? So hemorrhage, you know, obviously, it’s a condition that can happen after, you know, either these two those two operations, some people put a Jackson-Pratt Drain in, which can be you know, you know, a monitor and obviously won’t prevent a hemorrhage. But if you see, obviously, Jackson-Pratt Drain filling with blood, and that’s always an indication to be worried about. So when we look at bleeds, an easy way for me to understand or classify it or figure out how to deal with it is, first of all determine whether this is an intra abdominal bleed, or an intraluminal bleed, right? So for instance, if you have somebody who’s had a bariatric operation, and they’re convalescing on the floor, and suddenly you notice that hey, their hemoglobin is dropped, or they’re, they’re experiencing some signs, obviously, you assess the patient to determine Okay, what’s going on is this there’s there should be this by a bleed going on somewhere, because I’m not sure why the hemoglobin is dropped. The first thing is, obviously check the patient parameters. I mean, if they’re hemodynamically labile, like they’re hypotensive tachycardic, especially tachycardic, then obviously that’s that’s measurement. That’s, that’s significant concerning. So obviously start your resuscitation effort efforts, start fluid, start blood as needed. And then get to the idea, figure out, you know, where this is coming from what I need to do. If I have somebody who’s hemodynamically labile or unstable or tachycardic, and I’m worried about a postoperative bleed, then usually my next step is taking that patient back to the OR for usually a combination of things, usually a combination of a diagnostic laparoscopy plus a minus and interoperative gastroscopy. If they’re if they’re tachycardic, and you’re worried about a bleed, especially after bariatric operation, our threshold is pretty low to take them back to have a look on the inside and have a look on the outside. So that’s the first thing. If they’re hemodynamically stable, and then you say, Okay, you know what, they’re hemodynamically stable, postoperative day one and suddenly, why is the hemoglobin level drop down from, you know, 120 to 90 or 80? And but they’re stable. So this is this is where you get into the investigation of Okay, is this intra-abdominal or is this intraluminal? Because that that can change what you do. And that in this is where sometimes a drain can help you if you have a drain in and you know, there’s no blood in the drain at all, then maybe you’re thinking intraluminal or if the drain is full of blood, you’re like maybe its intra-abdominally. If you don’t have a drain and then obviously you have to do a bit more history taking and figure out what’s going on, you know. Is the patient experiencing, you know, if they have an intra-abdominal bleed, I expect at least some sort of discharge from some of the ports with some blood, or some, some skin changes may indicate intra-abdominal bleed or maybe some tenderness. If you have an intraluminal bleed again, they may manifest with, you know, hematemesis or even  malena. So this can kind of lead you to your next steps. If it’s an intraluminal bleed, we usually try to you know, settle it down as much we can with reversal of any anticoagulant medications, plus or minus potentially adding adding in adding in blood products as needed. And and if not, then switching to you know endoscopy to to manage it. If its an intra-abdominal bleed, and again, it depends on you know where where we’re sitting in terms of the patient. The patient is obviously a lot of distress and discomfort. And sometimes the best thing to do is take them back laparoscopically to evacuate the hematoma. If they’re fairly reasonable, you see these hematomas will resolve then we’ll leave them alone. So, again, managing an intrahemorrhage is similar to probably hemorrhage after any operation, but just understanding whether you think it’s intraluminal or intra-abdominal.

Ameer Farooq  30:46

Awesome. And then I think the the other big one, obviously, that we worried about in the early postoperative phase is a leak.

Shahzeer Karmali  30:54

Yeah, so leak is probably the big one that you’re probably going to hear about. And leaks are always hard. And the problem with leaks is that the take-home message for any resident or fellow or community surgeon is, if you think they even have a leak or you’re worried about a leak, take them back to the OR. That’s that’s the end message. But in the end, you know, how do you how do you what what ideas would lead you to think about that. So the main thing we look at with leaks for patients is obviously don’t want to wait till they’re manifesting signs of sepsis. So using corollary markers, like a fever, an elevated white blood cell count, abdominal tenderness, peritonitis, usually too late. So we don’t tend to use that as a caveat. And interestingly, the main caveat we use is actually heart rate, which is very interesting, because studies have looked at different parameters for leak and what parameter is the most consistent in terms of potentially diagnosing a leak. And what they’ve shown is that patients have had, especially a gastric bypass. If somebody had a gastric bypass, and postoperatively, there’s a run of sustained tachycardia of a heart rate of over 120, which is sustained for a period of two to three measurements, or one to two hours, a sustained tachycardia over 120, there’s a high higher than normal likelihood that something has gone on, like a potential leak in the abdominal cavity. Now, that tachycardia could be from bleeding. So you have to sort that out. But I think if you’ve seen a patient, if I, my fellow comes to me and said, Hey, listen, we did a gastric bypass on this lady at around 2 pm. I’m seeing her at 10 pm. She’s had this kind of sustained tachycardia after the operation, what should we do next? You know, should we, you know, do an upper GI? Should we do a CT scan? Should I watch it for a couple hours or physically sounds pretty unremarkable? The answer to that question is take her back to the OR for a diagnostic laparoscopy period and stop. That’s the answer. So that is what needs to be done. And the reason it needs to be done is that because patients who have bariatric surgery are severely obese, they can really mask symptoms of sepsis. So to wait for a patient to get abdominal pain, you may have missed that window and they can, you know, circle down the drain, proverbially pretty quickly, right. And it’s very hard to catch up and taking them to an OR for a diagnostic laparoscopy is very quick, you have a look, if there’s no leak, then you’re good. If there’s a leak, you can put a stitch in and not too much contamination and you can move on. So you know, we have that as our protocol. If somebody has a sustained tachycardia over 120 on repeat measurements, then the next call is to the fellow and to the staff surgeon. And usually we’re back in the OR have to look.

Ameer Farooq  33:43

Let’s talk about that operative approach. Let’s you’re in the operating room, and you see a leak, I guess the places that you could see a leak or it would be, you know, off the off the staple line off the anastomosis, etc. Is there anything that you would do differently depending on where the leak came from?

Shahzeer Karmali  34:04

Yeah, I mean, the common, if you have a leak, the commonest point of a leak for a gastric bypass is usually at the gas or jejunal anastomosis. So that’s usually the commonest place that you’ll you’ll see the leak and that’s where the leak happens usually right at the anastomosis. So again, it depends on when you’re seeing it and how much contamination there is. So obviously this is all interoperative decision-making. So if you get in there and that’s not too too much contamination again, we we liberally use endoscopy quite a bit. So you put an endoscope in, have a look at to see a little bubble coming in then what we tried to do is essentially try to stitch stitch the leak point up so we’ll do intracorporeal suturing, suits the leak up so close the hole back up. After that then it depends on surgeon. Some surgeons say okay, I got the leak to sutured up and then a lot of them will place a piece of omentum, its like a graham patch over that sealed leak area. So just to buttress it, and thereafter obviously drain the area quite well. Well, so most people will put a couple Jackson-Pratt drains around the area. The last thing is if I, if I see a leak and usually most of my colleagues if we see a leak at the gastric zone anastomosis you want to have this area healing and you want to be able to feed the patient. So most of us, if we’re seeing a leak and we manage a leak with a suture or a buttress, we’ll usually literally place a gastrostomy tube into the gastric remnant. And by placing into the gastric remnant, it allows the source of feeding, right? Because by accessing the gastric remnant, you can now feed the patient through the gastric remnant, and that feed will go down to duodenum passage jujenum and jejunum into the common channel for the rest of small bowel. So you can actually let that anastomosis anastomosis, you know, heal, not put any food through it, feed the patient and give it time. So most of us we get in there for a leak, we’ll either suture the hole closed, put a patch over top of it, drain wildly, and then do a gastrostomy tube. And that’s usually the the main principles of managing a leak. If you get in there, and there’s a huge hole and you can’t suture it back together, obviously it’s it’s it’s hard to manage. So at that point, usually we go into a bit of a damage control situation where we try to, you know, cover at least the hole with a piece of omentum, wide drainage, do the gastrostomy tube and leave alone again. Like like most leaks, it should heal, let it decompress, put a gastrostomy tube, feed the patient and then move on.

Ameer Farooq  36:29

Gotcha. Because usually the leak will not be at the jejunojejunostomy, because that’s a small gas mobile anastomosis.

Shahzeer Karmali  36:37

Very uncommon to be at the jejunojejunostomy. Obviously it’s not impossible. Most commonly, it’s the gas or jej. But if we get in there and there’s and the gas or jej looks okay, obviously we always check both anastomosis. So well, you know, if you want to check to the JJ if it’s there, then usually same kind of ideas we’ll suture it sutured up.

Ameer Farooq  36:55

So for an early leak, do you ever consider doing things like stenting? Or does that ever come into your management or it’s always going back to the operating room?

Shahzeer Karmali  37:05

No, for an early leak? Always back to the operating room.

Ameer Farooq  37:08

I think that’s a good segue to talk about maybe perhaps some of the let’s say, the discharged patient who now comes back in with some issues. And maybe we could we could stay with the leak. Let’s meet someone like I actually saw someone recently, who came back two weeks post bypass with kind of just malaise and a fever, and got a CT scan done by the emergency department, which showed an abscess in the leftover quadrant. How would you sort of deal with that situation?

Shahzeer Karmali  37:37

Yeah, so lately, so the other big issue. So lately, it’s again, I think the best way to understand is let’s separate the operations to a gastric bypass and the gastric sleeve I didn’t really talk about leak an early leak after a gastric sleeve. That’s it’s quite uncommon. But again, if that happens, and yes, it was a gastric sleeve was an early leak, same kind of principle. Take them back to the OR, find the leak point, usually the sleeve its usually in the sleeve, staple line, you know, over sow it, put a drain right next to it. And consider distal feeding access. For that there’s no gastric remnant so you see a feeding tube into the duodenum somewhere. So that’s just to get that other way. So now, lately lately, so lately to somebody who’s let’s say have been discharged home and comes back to the hospital. So same kind of principle, let’s just deal with a bypass first. Lets say you have a somebody with gastric bypass comes back in and you know, you’re worried about a leak, again, depends on stability of the patient. If they’re unstable signs of sepsis, you know, looking unwell then taken back to the OR and see what’s going on. Okay, so you have to get in there, drain the, the surgical goals, obviously drain the contamination. So there’s a leak, you know, try to suck out all the entire contents, clean it out, wash it out, try to figure out where the leak is coming from. If you’re if you’re in the OR, and they’re unstable, usually at this point in two to three weeks, it’s usually quite quite hard to to suture anything back up because the tissue is probably quite quite friable. So it may come to a point of just draining, trying to patch what you can and get feeding access, right. Most of those most of the times though, these late leaks are stable, kind of like your patients where they come in, they kind of look unwell, but they’re not hemodynamically unstable, maybe a bit of a fever, or maybe a bit of a white count. And they do some imaging or do some X-rays and say, hey, there’s a bit of a collection going on. So how do you manage those. So the main management for those is again, same kind of idea. You want to deal with the deal with the infected collection. So there’s an abscess, drain the abscess, get sort of sort of feeding access, if you can, obviously it can be kind of hard. But a lot of times we can get our interventional colleagues to put a CT guided or ultrasound guided gastrostomy tube into the gastric remnant. And as soon as you’ve got that done, you’ve got time on your sides. You drain the drain the assets, drain the collection, and you start feeding access and then you’re good. Then the point is, you know how does this leak heal and usually after gastric bypass leak as long as it’s drained, controlled, you see, definitely usually tincture of time will allow that leak to heal. If it doesn’t heal, then usually we tend to use more interventional endoscopy techniques to facilitate the leak healing. And then those can be things such as intraluminal suturing. Sometimes clips, sometimes using adjuncts like internal drains, or intraluminal, injection of of sealing agents, or sub situations putting a stent across that, that anastomosis. Where we’re quick, we’re kind of worried as what’s standing across gastric bypass and how small it is because the problem with the stent there is that it’s such a small area, and with with stent there’s the risks of stent migration. So, we will stent bypass leaks, but that’s usually lower in our algorithm in terms of managing them. In terms of sleeve leak, so totally different. So with a sleeve leaks, the same kind of idea, if you have somebody who has a sleeve that comes with a leak, if they’re unstable, they don’t look good. And again, take them to the OR wash out the contamination. At that point, what do you do so for sleeve leaks, stents are a great option for leaks sleeve leaks. They work really, really well. And the reason it worked well is not necessarily that the stent feels a leak. But it seals a problem with the pressure in that remnant stomach. Because a lot of patients who have sleep leaks the issue is there’s this issue with high pressure because with the sleeve, you’re making the stomach much smaller. And as you know, with  Poiseuille’s law, as you decrease your your radius or diameter, your pressure increases right exponentially. So with a stent, what it allows your stomach to do is it decreases of pressure in your stomach, and allows the flow to go up into your esophagus or down to your duodenum. And by decreasing the pressure allows that area to heal. And most sleeve leaks won’t heal without that pressure diversion. So, with sleeve leak stents are kind of the number one thing we do. So interoperability if there is somebody is unstable, we drain the collection, and then we put a stent in. fFr somebody who’s stable with a sleeve leak, same kind of idea we’ll drain the collection, usually nonoperatively with a CT or an ultrasound, and then send them for stenting to seal that area or, or like sorry, more importantly, decrease the pressure in the area to allow that area of sleeve leak to heal up and most of them interesting enough heal up after a period of stenting.

Ameer Farooq  42:29

That’s awesome. So stenter friends for sleeves and then there’s kind of lower down in your algorithm for for bypass leaks.

Shahzeer Karmali  42:38

Correct.

Ameer Farooq  42:39

Okay, awesome. Then I think the other huge topic is the bypass patient who comes back with an obstruction?

Shahzeer Karmali  42:48

The probably the biggest question that you’ll probably you know, residents or concerns you will get is this kind of idea of, of somebody who has a gastric bypass and comes to the emergency room with, you know, especially a laparoscopic gastric bypass and comes to the emergency room with signs and symptoms of intermittent abdominal pain and then is kind of feeling bloated, and there’s worry about an obstruction. Whether it’s abdominal distension are they do three views of the abdomen and there’s dilated loops of small bowel so we know what’s going on what’s what’s the next step? So the major concern and this is again, one of those big, big areas of bariatic surgeries is the idea of internal hernias. Right and and an internal hernia in essence is where you get a loop of small bowel go into an area where its not supposed to happen. And with the gastric bypass is usually three areas when internal hernias could happen. The first area and the commonest area we see currently is a is an inter mesenteric internal hernia. And this happens at the jejunojejunostomy because we’re creating a jejunojejunostomy and there’s a there’s an area of a mesentary, which are the two areas of jejunum,that we have to oversow. And sometimes that opening can weaken up and you can get a loop of small bowel that pops to that opening. So that’s an inter mesenteric hernia there. Second hernias is called a Petersen’s hernia that happens when when we do an anticolic which is the commonest one in anticolic gastrojejunostomy so there’s always this area in the lateral aspect of the anticolic loop between the anticolic loop and the transient mesocolon where there’s a little bit of an area there called Petersen space and you can get a loop a small loops of small bowel that can pop to that area. And the final line is transmesocolic hernia which happens if people do a retrocolic anastomosis and make a hole in the transient colon mesentary and you get a liquid ball of super small bowel leaking through there. So the issue with these are these internal hernias  obviously you get bowels that goes into these spaces and and you know, if this bowel gets caught and it dies off, you’ve got a big problem because you’ve already bypassed section the small bowel and losing small bowel and something’s already been bypassed is a major issue. So for any patient who has a gastric bypass that presents with the signs of you know, intermittent abdominal pain, they usually say I, you know, that’s a pain off and on off and on. And now I’ve got this more pain and, and I’ve got some bloating and distension. The key thing to do with this this patient, the next step, is that back to the operating room. So there’s always questions, hey, you know, should I confirm this hernia with a CT scan and or do an upper GI series? And the answer is no. A CT scan is a useful test, you know, if you do a CT scan of somebody and maybe see signs of, you know, swirling of the mesentary, and a large predominance of small bowel left upper quadrant Well, that’s great. That’s internal hernia, take them back to the operating room. The problem with it is that the sensitivity of a CT scan for an internal hernia is around 80%. So it’s about 20% of patients that you will miss with a CT scan, because a CT scan may not pick it up. And if you miss it, and you leave the patient, and they go on to infarct that small bowel, that’s going to be a major issue in a life changing or life threatening issue. So anybody who has any signs and symptoms of internal hernia based on physical examination, or index of suspicion, you take them back to the operating room. There’s no there’s no role for any test, whether it’s a CT scan, or upper GI series, take it back to the operating room to manage it.

Ameer Farooq  46:25

Once you’re in the operating room, what’s your approach? Because I’ve found this can be quite confusing. Once you’re in there, it’s hard to tell what’s what.

Shahzeer Karmali  46:33

Yeah, so the main thing, you know its funny I did an internal hernia for non-benign patients, the key thing is where to start because you go in there and you’re like, hey, just looks like the surgeon just hooked this up backwards, I can’t figure out what’s going on. So the key starting point, I tell any surgeons you know, we have our own general surgeons to take back internal hernias if we’re not around. The key starting point is starting distally. Start at the terminal alley, because that’s consistent. You know, that’s always going to be there, you haven’t done anything with the gastric bypass to alter the anatomy of the cecum, or the distal small bowel. So what you do is you start there. And by starting there, what you do is you start just running the bowel from distal to proximal. You start kind of pulling that bowel and start running it. And what you start finding is as you start running the bowel, you’ll start finding that you’ll start reducing stuff and as you start reducing stuff, you’ll come to the point of obstruction. As you reduce off you’ll kind of start reducing the small bowel for the TI to the ileum to jejunum and you’ll come up to an area the first area we’ll come up to is the, like I said, intermesenteric defect because a jejunojejunostomy, so if you’re reducing bowels, you come to that point, you’re like, hey, there’s no bowel in there. Then you keep going. As you keep going, you’re gonna turn the corner and start reducing bowel and it comes to neck defect, which is the Petersen’s defect, where the where the rythm goes up and you can see is there any hernia there you look, there’s nothing there, then you’re done. If they’ve had a transmesocolic or retrocolic anastomosis, the last area you are going to run into is that area where the roux goes, goes below the transmesocolic, and you can that’s your last place to look. So the key teaching point, is start distally at the terminal ileum and run distilled approximately and you will always find the defect. And when you find a defect, if there is an internal hernia, then you close it up with permanent suture. That’s the that’s the take-home message and hopefully you’re there before there’s any infarcted bowel

Ameer Farooq  48:20

On one, one last technical point on this when you’re doing your initial bypass, are you closing Petersen’s?

Shahzeer Karmali  48:28

So depends on surgeon. So interestingly, I don’t use the closed Petersen’s defect my colleagues do.

Ameer Farooq  48:39

Gotcha. Yeah, I think that the guys here the same, they close the jejunojejunostomy, but they don’t close Petersen’s.

Shahzeer Karmali  48:45

Yeah, the reason for that, I mean, it’s just the reason for that is that when you’re closing Petersen’s you have to be very careful about making sure you do a complete closure of that lateral defect because what we see in terms of publications for Petersen’s defects is that there’s actually sometimes more hernias if you if you close Petersen’s, not improperly, right? So you know you’re making a big defect, it’s a small defect and that’s where the problems come about, right? So I haven’t normally closed Petersen’s but that might be debated and people on the podcast might challenge me to that.

Chad Ball  49:18

Shahz that was, was absolutely fantastic. And thank you for that masterclass in bariatrics. You know, we certainly need refreshers, really at every, every level no matter if we’re super sub specialists are or not. It’s interesting in my HPB job, we were just lucky enough to be in Calgary part of a four country multinational 28 multicenter study. It was retrospective, but it looked at patients that had previously undergone in particular Roux-en-Y gastric bypass, and then needed subsequent Whipples and it was a good reminder you know, number one, that these patients can get other diseases and will get diseases as they go on to life. But number two, the the results of that study that’s out in JOGS, Journal of Gastrointestinal Surgery was really interesting because no single center had very much experience with it, you know, the busiest centers worked three or four patients over many years. And then also their reconstructive options were clearly very broad, and the selections were almost as broad. You have any thoughts on that?

Shahzeer Karmali  50:23

But there’s gonna be that that’s very interesting. And it’s actually changed bariatric surgeons actually, to tell you Chad. And the reason is this idea of the biliopancreatic limb, right. And previously, you know, obviously the biliopancreatic limb where the you know, where the turn of the duodenum happens and the distance between, you know, where the distance a biliopancreatic limb are the common channel previously surgeon making that pretty short, right? So right from, you know, ligament of treitz to, to the jejunojejunostomy surgeon repeating a pretty short around like, you know, 5 10, maybe 15 centimeters. And obviously, that’s for sure, that makes it technically difficult for you. Because if you go on there for a Whipple, it’s not only left you 10 to 15 centimeters, and then you have a JJ, I’ll make it pretty hard for you to get that resection done. So interesting enough, and for both reasons, people are finding that we’re actually lengthening that biliopancreatic limb. Both for that idea that if there’s something else to be done, it gives you more opportunity to do it. We’ve also found that actually biliopancreatic limb length, a longer biliopancreatic limb length actually affords better weight loss. So people are lengthening the builder pancreatic limb, to now, you know, we usually go I usually go around 40 to 50 centimeters. In some groups has gone up to about 100 centimeters and actually decreasing their roux limb length. So very fascinating idea. And like I said, you know, bariatric surgery is just changing. And we’re we’re very adaptable. And they’re saying that, you know what, there’s no need to keep it as short, because it may affect, you know, nonbariatric surgery in the future. And by making a longer it helps both of us. So it’s a very interesting article. It’s changed practice, right?

Chad Ball  52:03

That’s fascinating. Well, on behalf of all HPB surgeons and internationally, thank you. The other really interesting paper that you wrote in the Canadian Journal of Surgery and elsewhere, and quite honestly, in a few different formats, was the idea of idiopathic intracranial hypertension in these morbidly obese patients, and that bariatric surgery is likely a treatment for a lot of that as well. Can you comment on that for us?

Shahzeer Karmali  52:29

Yeah, so I mean, intracranial hypertension or being intracranial hypertension, you know, that other name is obviously pseudotumor cerebri. And we know that it’s, it’s a condition, when you look at like heavy, the demographics of it, it typically affects young overweight females, right. And we know that when when they manage patients who have intracranial hypertension, when I talked to my neurosurgery colleagues, the standard of care for patients actually, you know, obviously acetazolamide to decrease the pressure, but also weight loss. So they said, you know, let’s use this, you know, fluid reduction technology, as well as weight loss. And, and they found that interestingly, when, when patients lost weight, there’s pseudotumor cerebri symptoms improved. The issue with just, you know, regular weight loss going on diet and exercise is like, like all patients who found their severe obesity, it’s hard to maintain that long term. And what tended to happen is that that, that the amount of weight loss is needed to really improve ICH is about a 10% overall excess weight loss and very hard to defeat, established with just dietary therapy. So what’s going on is that, hey, let’s you know, what about bariatric surgery as as a tool to just help with weight loss, but also maybe improve this symptom long term? And so what we did is we studied, you know, what effect would bariatric surgery have on intracranial hypertension and what we found fascinatingly and I’ve kind of intuitively is that patients who suffer from intracranial hypertension after bariatric surgery find relief of their symptoms, and more than that, almost complete resolution of their, their condition. So it’s almost like a cure we’re getting for a nonbariatric condition, non gastrointestinal tract condition. We’re getting cure of this intracranial hypertension, which is which is fascinating. We’ve had, you know, that patients who had all that, you know, we know with pseudotumor cerebri, patients can have significant visual disturbances and we had patients who were, you know, at the point of not being able to see at all and the concern was, you know, these people are, are never going to get their sight back. And after, you know, bariatric surgery and weight loss, you know, their ICH improves as their visual disturbances which were initially thought to be irreversible. So, I’m very fascinated again, an area that that’s why you know, the idea of really researching and publishing things get get get new ideas developed and understood.

Chad Ball  55:04

Yeah, I couldn’t agree more Shahz and you know there are two perfect examples of, you know, the interrelationship between multiple different subspecialties and specialties, quite honestly. And it’s so important. Well, let’s just finish on that note, then I wanted to ask you specifically what your views are on sort of the, you know, the pyramid relationship between industry, you know, advanced MIS training and the concept of innovation. And again, Scott Gamora and Ameer and I had an interesting conversation about that sort of concept superficially, but you guys in Edmonton are known to be really linked to all three of those those curious what your thoughts are?

Shahzeer Karmali  55:47

Yeah, you know, I get, you know, indices always this concern about conflict of interest, and, you know, having industry involved and then being too involved in what we do. And I think the other tactics, I mean, we all work together, and we all have a common goal, you know, you have to understand the industry is there for business, but they also have an idea that, by promoting good health, it’ll improve what they do and what they offer. So we have, we have a very, you know, I see a symbiotic relationship with industry. And when we work together, we realize that we’re working together and sharing our ideas and thoughts and support, we can, we can work at, you know, improving or improving care to our patients. That’s kind of our take on it. And, you know, we work in, although, you know, industry is involved in supporting our research they, by no means drive what we do or drive, what we publish. A lot of the grants we get are obviously, on restricted educational grounds, they put certain amounts of funds for grants that we can do what they want, what we want to do with that, whether the results are positive or negative, whether results are related to their product or not. It’s kind of the idea of, of promoting a good relationship between businesses with a common goal. And that’s kind of the understanding, and that’s, you know, that’s also based on, you know, the ethics of research and being involved in a big center like yours and ours where, you know, there’s a stringent ethics process. There’s a stringent process of looking at what we do, and really having defined conflicts of interest. You know if I publish something that’s industry funded, then I’ll state it and explain what it is. So I think that’s, that’s very, very important. And, and that ties into innovation too, because, you know, in, in able to innovate and grow and develop, you need that support, because you need support from a big business that can help with, you know, fostering innovation and putting forward ideas or putting forward new ideas or new products and help develop the next stage isn’t just by if you just shut them out. I mean, it’s very hard, especially within Canada to to get the funding capability or the contacts to really innovate and develop. So that’s, that’s kind of my idea. I think the idea of a symbiotic relationship is the most most integral and it just understanding conflicts and having them out to people so they understand where you’re at, and there’s nothing kind of hidden hidden behind the rug or behind the curtain.

Ameer Farooq  58:23

You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback.  So feel free to email us at podcast.cjs@gmail.com or connect with us on Twitter @CanJSurg. Thanks again.