Evelyn Inga
Biography
First generation American immigrant, native Peruvian Quechua indigenous person. Internal medicine resident at UNM. Formal second-year surgical resident at SUNY. Formal Research Training at Harvard University and worked as a research fellow at Beth Israel Deaconess Medical Center. I continue to provide volunteer medical care to Indigenous groups in Peru to access high-quality health care. Interested in Gastroenterology. My goal is to help underrepresented minorities achieve better outcomes in Gastroenterology care.
Research Interest
Internal Medicine resident PGY-2, the University of New Mexico July 2023 to present General Surgery resident, the State University of New York – Stony Brook July 2021- July 2023 Medical Doctorate in Peru completed in 2015. Active Medical License Peru Number: 072533. US citizenship.
Abstract
Post-Bariatric Upper Endoscopies after a LSG
Morbid Obesity contributes to the constellation of medical comorbidities that comprise Metabolic Syndrome. As >2/3 of America is Overweight (BMI 25-29.9) or Obese (BMI 30+). There are many treatment modalities for Morbid Obesity, but none is more effective long term than Bariatric Surgery, not even the newest GLP-1 agonists can compete with the Laparoscopic Sleeve Gastrectomy (LSG) or the Roux-en-Y Gastric Bypass (RYGB). About 300,000 Metabolic and Bariatric Surgery (MBS) procedures were performed yearly (1/1000 population of the US per year). As surgical treatment for Morbid Obesity becomes more common, we as Gastroenterologists must continue to learn about the topic and how to treat potential complications. Sleeve Gastrectomy continues to be the most performed procedure, RYGB continues to be 20-25% of the MBS volume yearly. Sleeve Gastrectomy complications that may require Endoscopic interventions may include: Leak (which is usually proximal or distal) and may require stenting, Stricture (which may require dilation with either an endoscopic balloon or with a bougie, Bleeding (which can require any number of methods to control endoscopically, owing to the stomach’s rich blood supply) and worsening GERD. GERD is increasingly prevalent in Morbid Obesity and the incidence rises with BMI. GERD can worsen after a LSG especially if a Hiatal Hernia is present pre-operatively and isn’t fixed. Post-operative weight loss can also decrease GERD due to decreased Intra-abdominal pressure. The workup for GERD involves obtaining an Upper GI (UGI) imaging study, Manometry probe placement and Esophagogastroduodenoscopy (EGD) alongside Bravo probe placement for pH monitoring. Subsequent options include medication or surgical intervention. Often GERD is not suppressed adequately even with BID Proton Pump Inhibitors (PPI), H2 Blockers and even Antacids. At that point, a surgical intervention must be performed. This takes a great relationship between the Gastroenterologist and the Bariatric Surgeon. The surgical intervention options include: revision of LSG to RYGB or a Laparoscopic Lower Esophageal Sphincter Magnetic Augmentation (LINX) Device placement over the Esophagus above the Esophagogastric Junction. The LINX device is made of Titanium and is composed of magnets on a metallic string and is FDA approved for Anti-Reflux primary procedures and for patient who have had a LSG. LINX placement requires ages 18-75, at least 50-60% intact swallows, <15 integrated relaxation pressure (IRP) of the LES, minimal or no hypercontractile swallows, normal distal contractile integral (DCI), no pre-operative dysphagia. This case presentation is about a patient who unfortunately developed worsening GERD after LSG, had the appropriate workup and underwent a LINX device placement when medical intervention didn’t improve their symptoms. 34 year old female who underwent a LSG 12/2023, she had minimal GERD pre-operatively well controlled with occasional PPI and occasional antacids. Within 6 months, she was down to a BMI of 34, she began having some epigastric pain and heartburn symptoms 1-2x a week, a trial of low dose PPI was started. Within 1 year, her BMI was down to 27, she had lost nearly 90 lbs, but her GERD symptoms were worsening to multiple episodes daily. At that point she was on 40 mg PPI BID and taking multiple antacids daily as well. She underwent the standard GERD workup: Upper GI (UGI) imaging study, Manometry probe placement and Esophagogastroduodenoscopy (EGD) alongside Bravo probe placement for pH monitoring. UGI showed a Hiatal Hernia and Moderate GERD to the Thoracic inlet. Manometry showed a Hiatal Hernia, 60 % of swallows are intact, normal motility, normal Integrated Relaxation Pressure (IRP), normal Distal Contractile Integral (DCI). EGD showed a slightly enlarged sleeve (as retroflexion was possible, Figure 1) and Los Angeles (LA) Grade B Esophagitis (Figure 2). The Bravo Probe was placed 6 cm above the Esophagogastric Junction (EGJ) in the usual fashion. The DeMeester score was 35.8 (Upper Limit of normal is 14.72). Discussion was held with the patient and the decision for a Lap Hiatal Hernia Repair and LINX was made. The procedure was performed in the usual 4x 5 mm port placement and operative time was ~75 min due to the previous adhesions from the LSG and GERD in the mediastinum. EndoFlip (Endoluminal Functional Luminal Probe) was used to measure the Diameter and Distensibility index to guide the closure of the Hiatus to be neither too tight nor too loose. Too tight may result in stricture and Dysphagia post-operatively, meanwhile too loose may result in recurrence of GERD symptoms and recurrence of the hiatal hernia. Intra-operative images are shown in Figures 3-6. A Lower Esophageal Sphincter Magnetic Augmentation (LINX) Device has been approved for post-Sleeve Gastrectomy patients suffering from GERD without the morbidity of revision to a RYGB. Intra-operatively, the LINX device is sized for the patient and sizes range from 14-17 (each size is 1 bead). Due to the previous surgery, multiple GastroHepatic adhesions were encountered and addressed with blunt and sharp dissection (Figure 3). The Hiatal Hernia is demonstrated in Figure #4. The diaphragmatic crura is then opened and the hiatal hernia is then reduced, allowing at least 3 cm of Esophagus to be brought down into the abdomen (Figure 5). Afterwards, the crura is closed with permanent sutures. The LINX sizer is placed after a window is made between the posterior Esophagus and the posterior Vagal nerve, and the LINX device is then placed and buckled anteriorly. The sizer determined that a size #14 LINX was ideal; this was placed (Figure 6). The patient did well post-operatively, was slowly weaned off her PPI’s and had minimal GERD issues
Post-Bariatric Upper Endoscopies after a RYGB
Morbid Obesity contributes to the constellation of medical comorbidities that comprise Metabolic Syndrome. As >2/3 of America is Overweight (BMI 25-29.9) or Obese (BMI 30+). There are many treatment modalities for Morbid Obesity, but none is more effective long term than Bariatric Surgery, not even the newest GLP-1 agonists can compete with the Laparoscopic Sleeve Gastrectomy (LSG) or the Roux-en-Y Gastric Bypass (RYGB). About 300,000 Metabolic and Bariatric Surgery (MBS) procedures were performed yearly (1/1000 population of the US per year). As surgical treatment for Morbid Obesity becomes more common, we as Gastroenterologists must continue to learn about the topic and how to treat potential complications. Sleeve Gastrectomy continues to be the most performed procedure, RYGB continues to be 20-25% of the MBS volume yearly. RYGB complications that may require Endoscopic interventions may include: Leak (which is usually at the Gastro-Jejunostomy/GJ) and may require stenting, Stricture (which may require dilation with either an endoscopic balloon or with a bougie, Formation of Marginal Ulcers, Bleeding (which can require any number of methods to control endoscopically, owing to the stomach’s rich blood supply), Perforation, Pouch or GJ enlargement. Small Leaks may be excluded with a stent or closed with Endoscopic suturing techniques or even large clip placement. Larger leaks may need to be excluded, drained with either Interventional Radiology Drain placement under imaging guidance or Laparoscopic vs. Laparotomy and drain placement/intra-abdominal large volume lavage. Stricture formation can occur due to a wide variety of reasons, including but not limited to: surgical issues: tissues under tension, blood supply, extensive smoking history, Steroid Use, large volume Non-Steroidal Anti-Inflammatory (NSAID’s) use. The options for dilation includes: Savory Dilator or Endoscopic Balloon Dilation. The goal of dilation is to create a more normal diameter to eliminate symptoms. Gastric Pouch or GJ anastomosis enlargement typically occurs either from a technical problem intra-operatively or due to non-adherence of the appropriate post-Bariatric diet. Larger portion sizes, carbonation and eating very quickly can all contribute to an enlargement of the gastric pouch or the GJ itself. Intra-operatively, we try to keep the gastric pouch 3-5 cm in size. Enlargement of the pouch can significantly decrease satiety and Endoscopic Gastroplasty along with Transoral Outlet Reduction (TORe) can be performed for both pouch size and GJ anastomosis reduction. Clinically significant marginal ulcers can occur in ~5% of patients and usually cause post-prandial pain or dysphagia. They can present with bleeding, stricture formation or perforation. For circular staple Gastro-Jejunostomy (GJ) anastomosis, staples may contribute to both dysphagia and stricture formation. It may necessitate Endoscopic vigilance to remove any loose staples from the GJ. It is important to note that marginal ulcers usually form on the Jejunal side of the anastomosis and retroflexion may be necessary to view them fully. In this case, we have a 42 yo F who initially underwent a LSG in 2017 and due to weight regain (only has 18% Excess Weight Loss [EWL] compared to the average 60-70%, and worsening GERD symptoms she was worked up (with Upper GI study [UGI], EGD and Bravo pH monitoring), found to have GERD on UGI, EGD showed a hiatal hernia and a Schatzki’s Ring (indicative of GERD) and an elevated DeMeester score of 33.6. She subsequently underwent a LSG à RYGB + Lap Hiatal Hernia repair in 2023. She was able to lose a significant amount of weight, was most recently EWL of 66% which is more in line of expectation for a RYGB. The patient began to have issues ~1.5 years after the RYGB after taking a round of steroids (Prednisone) for an Upper Respiratory Disease. Her symptoms began with Dysphagia to Dried Breads and Meats, along with epigastric abdominal pain. She was empirically started on PPI BID Open Capsule for concern for stricture/marginal ulcer. Shortly thereafter, the patient had an improvement after several days. The patient underwent an Upper Endoscopy, found to have 2 staples (Figure 1) with marginal ulceration around the staples. These two staples were removed with cold forceps and placed into the Roux Limb of the RYGB (Figure 2), biopsies of the gastric pouch were taken to rule out H. pylori infection. Subsequently the patient was continued on the Open Capsule PPI BID and Sucralfate QID was added. At the post-Endoscopy follow-up, the patient had near resolution of symptoms (Dysphagia, Epigastric Pain).
Endoscopy after Bariatric Surgery Case Series
The G-G Fistula Morbid Obesity contributes to the constellation of medical comorbidities that comprise Metabolic Syndrome. As >2/3 of America is Overweight (BMI 25-29.9) or Obese (BMI 30+). There are many treatment modalities for Morbid Obesity, but none is more effective long term than Bariatric Surgery, not even the newest GLP-1 agonists can compete with the Laparoscopic Sleeve Gastrectomy (LSG) or the Roux-en-Y Gastric Bypass (RYGB). About 300,000 Metabolic and Bariatric Surgery (MBS) procedures were performed yearly (1/1000 population of the US per year). As surgical treatment for Morbid Obesity becomes more common, we as Gastroenterologists must continue to learn about the topic and how to treat potential complications. Sleeve Gastrectomy continues to be the most performed procedure, RYGB continues to be 20-25% of the MBS volume yearly. RYGB complications that may require Endoscopic interventions may include: Leak (which is usually at the Gastro-Jejunostomy/GJ) and may require stenting, Stricture (which may require dilation with either an endoscopic balloon or with a bougie, Formation of Marginal Ulcers, Bleeding (which can require any number of methods to control endoscopically, owing to the stomach’s rich blood supply), Perforation, Pouch or GJ enlargement. The Gastrogastric Fistula (GGF) is a rare (1%) but complex problem that requires clinical insight and suspicion. GGF typically presents with: weight regain, pain, worsening GERD symptoms. It may occur because of a complication from surgery (leak, infection, bleed) where a fistula forms between the gastric pouch and the remnant stomach due to a staple line breakdown. Alternatively, it may result from iatrogenic methods. Case Description: This is a 60 yo F who underwent a Laparoscopic antegastric antecolic RYGB >15 years ago. Post-operatively she lost >135 lbs and was able to keep the weight off successfully for more than 10 years, with an Excess Weight Loss (EWL) of >60%. In 2013, she began to have post-prandial pain and persistent nausea and emesis. Workup demonstrated cholelithiasis, elevated bilirubin and transaminitis. Due to the abnormal anatomy post-RYGB, she was sent to the University hospital for an Endoscopic Retrograde Cholangiopancreatography (ERCP) and a Cholecystectomy. As the Duodenum is now disconnected from the Esophagus, often an advance GI technique called Endoscopic Ultrasound-directed transgastric ERCP (EDGE) involving a lumen-apposing metal stent (LAMS) placement between the gastric pouch and excluded stomach. This then allows for access to the Duodenum from the Esophagus. Usually this is a staged procedure, and the fistula is then closed after the ERCP is performed. After the procedure, the patient had dramatic improvement in post-prandial pain and persistent nausea and emesis. However, several months afterwards, she began feeling malaise, epigastric pain and slowly began regaining some weight. After several months her appetite became voracious and in the last 1.5 years, she has gained >80 lbs so far. She had presented to an ER and a CT Abd/Pelvis (Figure 1) non-contrast showed a possible GGF. X-ray Upper GI with Small Bowel Follow Through (XR w/ SBFT, Figure 2) showed: Surgical changes related to Roux-en-Y gastric bypass with most of the contrast opacifying the excluded stomach. Upper Endoscopy showed a large GGF and easy passage of the Gastroscope into the remnant stomach and easy access to the Duodenum without requiring an enteroscope. After realizing that the EDGE technique using a LAMS likely resulted in a persistent fistula, she was sent back to the University Hospital for closure. Discussion: GGF requires strong clinical suspicion. It is unfortunately a complication of both the RYGB and of several Endoscopic procedures. For post-RYGB ERCP, there is a challenge, as the Duodenum is now disconnected from the Esophagus, often an advance GI technique called Endoscopic Ultrasound-directed transgastric ERCP (EDGE) involving a lumen-apposing metal stent (LAMS) placement between the gastric pouch and excluded stomach. This then allows for access to the Duodenum from the Esophagus. Usually this is a staged procedure and the fistula is then closed after the ERCP is performed. Alternatively for post-RYGB a Laparoscopy assisted ERCP can be performed intraoperatively, requiring surgical access to the remnant stomach, usually followed by surgical closure and the added advantage of post-ERCP simultaneous Laparoscopic Cholecystectomy. In addition a Balloon Enteroscopy-assisted ERCP can be performed and this has the advantage of not requiring a fistula nor a surgical procedure. GGF as a complication of EDGE with LAMS is noted to occur, especially with a prolonged dwelling time of the LAMS (>89 days), larger diameter (>20 mm) and with having Diabetes. After removal of the LAMS, Argon Plasma Coagulation (APC) of the fistula followed by Endoscopic fistula closure are performed. Unfortunately there can be a dehiscence or even an enlargement that forms a persistent GGF. There are a variety of option to close this persistent GGF: Endoscopic full-length suturing or cardiac septal occluder (CSO) placement.
