Bariatric surgery by Dr B D Soni, army hospital

Bariatric surgeryDR B D SONI

What is Bariatric Surgery?

1950- first operation , malabsorptive procedure

1960- Jejunal bypass

1988- sleave gastrectomy – Bowling Green

classification BMI (principle cut off)

Underweight < 18.5

Severe wasting <16.00

Moderate wasting 16.00- 16.99

Mild wasting 17.00-18.49

Normal 18.50 – 24.99

Pre-obese 25.00 – 29.99

obese ≥ 30.00

Obese class I 30.00 – 34.99

Obese class II 35.00 – 39.99

Obese class III ≥ 40.00

Treatment of obesity

What is morbid obesity?

100 lb above ideal weight

Twice of ideal body weight

BMI > 40 kg/m2

Class III obesity

NIH 1991- severe obesity ↔ morbid obesity

Why to treat?Medical condition/ risk associated with sever obesity

CVS – HTN, sudden cardiac death MI, cardiomyopathy, Venous stasis disease, DVT Pulmonary HTN

RS- OSA, hypoventilation syndrome of obesity

Metabolic- metabolic syndrome, Type II DM, hyperlipidemia, NASH/NAFLD

GIT- GERD, cholelithiasis

Musculoskeletal- degenerative joint disease, PIVD, ventral hernia

Why to treat?GUT- stress incontinence, ESRD

Gynecological- menses irregularity/ DUB

Oncologic condition - uterus, colon, kidney, breast, prostate

CNS- depression, CVA

Bariatric surgery in obese?

Recommends bariatric surgery for obese people:

BMI > 40 without co morbidities

BMI >35 with 1 or more co morbidities.

or

BMI of 30 to 35 with significant or serious co morbidities.

or

When less invasive methods of weight loss have failed and the patient is at high risk for Obesity-associated morbidity and mortality.

criteria for surgery 1. A Body Mass Index (BMI) ≥ 40 or a BMI ≥ 35 with obesity related co-morbid conditions.

2. Age – 16 to 65 yrs

3. Screening for mental or behavioral disorders

4. no tobacco products & alcohol, 4 weeks prior to surgery.

5. No absolute contraindication to major abdominal surgery

6. Obesity of long standing

Criteria for surgery6. Should have completed a weight loss program is recommended

7. counseling by a credentialed expert.

8. Follow up on regular basis

9. Adherence with wt loss /exercise programme.

contraindication

Bariatric surgery carries the potential for serious complications, morbidity and possibly mortality

1. Cardiac complications with poor myocardial reserve.

2 Chronic obstructive airways disease or respiratory dysfunction.

3.Significant psychological disorders, or significant eating disorders.

Classification of bariatric surgery

1. Predominantly restrictive procedures

2. Predominantly malabsorptive procedures

3. Mixed or combination procedures

Restrictive procedureProcedures that are solely restrictive by creating a small gastric

pouch & a degree of outlet obstruction leading to delayed gastric emptying

• Reduce oral intake by limiting gastric volume

• Produce early satiety

• Leave the alimentary canal in continuity

• Minimizing the risks of metabolic complications

1.VERTICAL BANDED GASTROPLASTY

2.ADJUSTABLE GASTRIC BANDING (LAGB )

3. SLEEVE GASTRECTOMY

4.GASTRIC PLICATION

5. INTRA GASTRIC BALLOON (GASTRIC BALLOON)

Malabsorptive procedure

Malabsorption is achieved by creating a short gut syndrome and/or by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption

Purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1. BILIOPANCREATIC DIVERSION2.THE JEJUNAL-ILEAL BYPASS

3. ENDOLUMINAL SLEEVE

Mixed procedure

1. GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2. SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3. IMPLANTABLE GASTRIC STIMULATION

Vertical Banded Gastroplasty (VBG)

The stomach is partitioned along its axis

with a non- adjustable poly-urethane band

and with linear& circular staples to create

a small upper stomach pouch with a

restrictive orifice to the rest of the

stomach

No malabsorption of micro or macro

nutrients is expected

No longer done

Adjustable gastric banding (Lap band surgery/ LAGB

Restrictive Procedure

An inflatable silicone BAND is placed around the top portion of the stomach, to form a small stomach pouch

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL – PORT).

During follow up visits, we inject or remove saline solution to make the band tighter or looser.

LAGB

This Band in the stomach induces weight-loss in 3 ways:

1. The small stomach pouch causes a sensation of fullness

2. Squeezing of the stomach pouch like an hour glass prolongs the sensation of fullness

3. Suppresses appetite by central action

LAGB- complication• Perforation of Stomach

• Mal positioning

• Abdominal Pain

• Heartburn

• Vomiting

• Inability to Adjust the Band

• Failure to Lose Weight

• Slippage

• Gastric Erosion

• Dilated Esophagus

• Infection of System

• Fatigue or malfunction

Lap sleeve gastrectomy Laparoscopic sleeve gastrectomy (LSG) is a

standard procedure for the surgical management of morbid obesity

Rapid and less traumatic operation

Good resolution of co-morbidities and good weight loss

A further second surgical step/combine the procedures

Lap Sleeve gastrectomy Stomach is reduced to about 25% of its original

size

A bougie between 36 - 40 Fr is used with the procedure

Ideal approximate capacity of the stomach after the procedure is about 30- 60 ml pouch

Sleeve gastrectomy greater curvature gastrectomy,

vertical or longitudinal gastrectomy or

Pylorus preserving ‘gastric tube creation’

Sleeve gastrectomy

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms:

1.MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility. Also called ‘Food limiting’ operation.

2.HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue.

LABORATORY EVALUATION:Basic chemistry panel, full blood count, thyroid function tests. Serum cortisol, urine cortisol, lipid profile, vitamin (A, B1, B6, B12, C).Serum Insulin, C-Peptide.UPPER ENDOSCOPY:Rule out inflammatory ulcerous gastric pathology, search and treat H pylori infection when present.ULTRASOUND OF THE ABDOMEN:To rule out cholelithiasis, which would indicate cholecystectomy along with the gastric sleeve.

Preoperative evaluation

CARDIOVASCULAR/RESPIRATORY EVALUATION:Exclude any contraindications to anesthesia by TMT, Echo, PFT, ABG , CXR etc.PSYCHIATRIC EVALUATION:To rule out any behavioral abnormalities that would contraindicate limited food intake.ENDOCRINE EVALUATION: Rule out an endocrine abnormality as the etiology of morbid obesity.DENTAL EVALUATION

Steps

1. 4 port placed usually2. Liver Retraction –using Nathansons Liver Retractor3. Gastrolysis of greater curvature- distal to prox. (Upto angle of of His.)4. Resection of stomach by Stapling – starts from 4 cm distal to pylorus5. Suturing for staple line reinforcement6. Leak test- Methylene blue, air or UGIE7. Extraction of specimen8. Closure of Ports- by needle passer.

No nasogastric tube is placed at the end of the procedure

GASTROGRAFFIN STUDY:A water-soluble upper gastrointestinal study is performed all cases , and for patients with clinical symptoms and signs of leakageIf no leak observed, then patient is allowed to drink

Postoperative period

From D2 to D14, the patient remains on a liquid diet. Over the next 3 weeks on soft diet

Normal diet after 1 month

Peri-operative:

Complications of anesthesia, bleeding, positioning or pressure, and those of a technical nature. Injury to

Liver or Spleen.

Early Post-operative Complications (30 days):

Bleeding, anastomosis leak, infection secondary to leak, wound or other infection, strictures, and deep

venous thrombosis/pulmonary embolism.

Pulmonary complication -Atelectatsis, pneumonia, pulmonary embolism, respiratory arrest secondary

to sleep apnea, and acute respiratory distress syndrome (ARDS).

Gastrointestinal (GI) complication - Ulcer, stricture, anastomonic obstruction, and small bowel

obstruction.

Complications

Late Complications (greater then 30 days):

GI ulcer (stricture, obstruction), nutrition deficiency (one or more nutrients,

protein, vitamin or mineral), internal/ incisional hernia, redundant skin, failure of

weight loss or regain of lost weight

Psychological Side effects –

Increased manifestations of depression, disruption of social relationships

Intragastric balloon involves placing a deflated balloon into the stomach, and then filling it to decrease the amount of gastric space

Soft silicon balloon

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5–9 BMI over half a year.

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a stepdowm procedure

Intra gastric balloon

Endo barrier liner system

Mimics the effects of gastric bypass surgery It’s designed to work by inserting a flexible tube-like barrier into the duodenum & prox. Jejunum

The barrier is placed endoscopically via the mouth and thus helps patients to loose weight by delaying digestion

Has to be removed after 6 months

Mal- absorptive procedures

Rearrange and/or remove part the digestive system which limits the amount of calories and nutrients that the body can absorb. Treatments with a large malabsorbtive component result in the good amount of weight loss but tend to have slightly higher complication rates.

1. JEJUNAL ILEAL BYPASS 2. ILEAL TRANSPOSITION- For treatment of DM type 2 and metabolic disorders.

Combination procedures Restrictive + malabsorbtive

1. LAP. GASTRIC BYPASS – ROUX-EN- Y – more malabsorption than the restrictive

2. MINI- GASTRIC BYPASS- mainly restrictive

3. DUODENAL SWITCH – the sleeve stomach is the restrictive portion &the intestinal bypass( duodenal switch) is the mal absorptive component

Lap. Gastric bypass/ LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake, however there ismore amount of mal absorption that occurs with this operation

1. Most commonly performed.2. Most reliable operation for long term weight loss.3. Long term weight loss averages 60 to 75 percent of EBW.6. Malnutrition is unusual.7. Substantial improvement & resolution in many co-morbid obesity conditions:            Type 2 DM – 90%             Sleep apnea -90%            Hypertension-70%           Hyperlipidaemia -70%   Heartburn from GERD- all patients.            Urinary stress incontinence-75%

89%reduction in mortality over 5 yrs. Following surgery, compared to non-surgically treated group. 

Advantages:

Gastric bypass/ lrygbp

• The stomach is stapled into 2 pieces, one small and one large.

The small piece becomes the “new” stomach pouch

• The larger portion of the stomach stays in place, however will lie dormant for the remainder of thepatient’s life

• The small intestine (the jejunum) is divided using a surgical staplerApprox. 50-70 cm from the DJ Junction

Y- LIMB/ BP LIMB

• The end of the Roux limb is then attached to the newly formed stomach pouch

• The Roux limb carries food to the distal intestine.

• The Y limb or BPD limb carries digestive juices from the pancreas,gall bladder, liver and duodenum to the intestines

• The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-170 cm from DJ

Roux limb or alimentary limb

100-150 cm

1. Not reversible.

2. Mortality 0.5- 1%

3. Peri operative complications 5-10%

4. Stricture of gastrojejunostomy.-10% (long term)

5. Long term risk of protein &vitamin deficiency, and marginal ulceration of GJA.

6.Long term risk of intestinal obstruction – 2%.

Complications

BPD Open/ lap

Wt loss- malabsorption>> restrictive

Distal hemigastrectomy

Effective ileum length – 250 cm

Distal common chennal- 50 cm

Bile + pancreatic + intestinal juice mix for

only short length,

So proper digetion/absorption doesn’t take

Place.

Duodenal switch Less incidence of marginal ulcer

Mechanism same BPD

Open/ lap , lap- preferred.

Common channel- 100 cm

Entire length of alimentary length -250 cm

First step- sleeve gastrectomy (150-200ml)

Duodenum divided, distal connection same as

BPD (100 cm common channel), perform DIA (EEA)

DS

Two hypotheses have been proposed to explain the early effects of bariatric surgery on diabetes--

The Hindgut hypothesis theory- Diabetes control results from the more rapid delivery of nutrients to the distal small intestine, thereby enhancing the release of hormones such as glucagon-like peptide-1 (GLP-1).

The foregut hypothesis theory – Exclusion of the proximal small intestine reduces or suppresses the secretion of anti-incretin hormones, leading to improvement of blood glucose control as a consequence increases GLP-1 plasma levels which stimulate beta cells to produce insulin secretion and suppress glucagon secretion, thereby improving glucose metabolism.

  RESOLUTION OF  DISEASES FOLLOWING BARIATRIC SURGERY

Thanks …