BARIATRIC SURGERY Dr. Onkar Singh, Dr. Shilpi Gupta, Dr. Praveen Baghel, Dr. Mohan Soni -MGM Medical College & MY Hospital, Indore, India. Dr. Ankur Hastir -MGM Medical College & Hospital, Bombay, India.

Dr. Onkar Singh, Dr. Shilpi Gupta,

Dr. Praveen Baghel, Dr. Mohan Soni

-MGM Medical College & MY Hospital, Indore, India.

Dr. Ankur Hastir

-MGM Medical College & Hospital, Bombay, India.

BARIATRIC SURGERY Bariatric surgery: Surgical t/t for morbid obesity Alteration of metabolic process & durability of weight loss 1 st malabsorptive operations was done in 1950

Bariatric surgery: Surgical t/t for morbid obesity

Alteration of metabolic process & durability of weight loss

1 st malabsorptive operations was done in 1950

Indications: a) BMI > 40 or BMI > 35 with co morbid conditions {BMI=Wt / (Ht*2)} b) Failed dietary therapy c) Psychiatrically stable without addictions d) Motivated individuals e) Medical problems not precluding probable survival from surgery

a) BMI > 40 or BMI > 35 with co morbid conditions {BMI=Wt / (Ht*2)}

b) Failed dietary therapy

c) Psychiatrically stable without addictions

d) Motivated individuals

e) Medical problems not precluding probable survival from surgery

Co-morbid conditions: CVS: HTN, DVT, Pulm. HTN , cardiomyopathy Pulmonary: obstructive sleep apnea , asthma Metabolic: diabetes , hyperlipidemia GIT: GERD , Cholelithiasis Musculoskeletal: osteoarthritis, ventral hernias

CVS: HTN, DVT, Pulm. HTN , cardiomyopathy

Pulmonary: obstructive sleep apnea , asthma

Metabolic: diabetes , hyperlipidemia

GIT: GERD , Cholelithiasis

Musculoskeletal: osteoarthritis, ventral hernias

Co-morbid conditions: Genitourinary: stress incontinence, end stage renal disease Gynaecologic: menstrual disturbances Skin: fungal inf., boils, abscess Oncologic: uterus, breast, colon Neurologic: stroke, pseudotumor cerebri Psychiatric: depression Social: discrimination, abuse

Genitourinary: stress incontinence, end stage renal disease

Gynaecologic: menstrual disturbances

Skin: fungal inf., boils, abscess

Oncologic: uterus, breast, colon

Neurologic: stroke, pseudotumor cerebri

Psychiatric: depression

Social: discrimination, abuse

Pre-op investigations: Weight , height , BMI CBC , BT , CT , PT LFT , RFT , blood sugar, lipid profile X – ray chest PFT ECG , 2 D Echo Thyroid profile Insulin levels Serum cortisol

Weight , height , BMI

CBC , BT , CT , PT

LFT , RFT , blood sugar, lipid profile

X – ray chest

PFT

ECG , 2 D Echo

Thyroid profile

Insulin levels

Serum cortisol

Pre-op investigations: UGI Endoscopy Barium meal Venous doppler lopwer limbs Ct abdomen

UGI Endoscopy

Barium meal

Venous doppler lopwer limbs

Ct abdomen

Pre-op preparation: 1 st generation cephalosporin– 24 hrs before surgery Prophylaxis against DVT: 1. subcutaneous heparin 2. early ambulation post op

1 st generation cephalosporin– 24 hrs before surgery

Prophylaxis against DVT:

1. subcutaneous heparin

2. early ambulation post op

Operations & Mechanisms: RESTRICTIVE Vertical banded gastro-plasty Lap adjustable gastric banding Sleeve resection LARGELY RESTRICTIVE/ MILDLY MALABSORPTIVE Roux-en-Y gastric bypass LARGELY MALABSORPTIVE MILDLY RESTRICTIVE Bilio-pancreatic diversion (BPD) Duodenal switch

RESTRICTIVE

Vertical banded gastro-plasty

Lap adjustable gastric banding

Sleeve resection

LARGELY RESTRICTIVE/ MILDLY MALABSORPTIVE

Roux-en-Y gastric bypass

LARGELY MALABSORPTIVE MILDLY RESTRICTIVE

Bilio-pancreatic diversion (BPD)

Duodenal switch

Sleeve resection

Operative details: Patient position: Supine, hips flexed at 30 degree & abducted , anti trendelenburg position Surgeon position: French position Assistant 1 st : Right side of pt. Assistant 2 nd : Left side of pt.

Patient position: Supine, hips flexed at 30 degree & abducted , anti trendelenburg position

Surgeon position: French position

Assistant 1 st : Right side of pt.

Assistant 2 nd : Left side of pt.

Operative details: Port placement: supraumblical- 10 mm optical port Rt. subcostal- 12 mm retracting port Lt. subcostal- 05 mm retracting port Rt. umbilical- 05 mm working port Lt umbilical- 10 mm working port

Port placement:

supraumblical- 10 mm optical port

Rt. subcostal- 12 mm retracting port

Lt. subcostal- 05 mm retracting port

Rt. umbilical- 05 mm working port

Lt umbilical- 10 mm working port

Resected specimen: Greater curvature Fundus (upper end) Body pylorus junction (Lower end)

Postoperative care: Appropriate fluid resuscitation Foleys catheter – 24 hrs Adequate analgesia DVT proohylaxis GIT radiographic study Dietary management Long term follow up

Appropriate fluid resuscitation

Foleys catheter – 24 hrs

Adequate analgesia

DVT proohylaxis

GIT radiographic study

Dietary management

Long term follow up

Lap adjustable gastric banding

ADVANTAGES: Short duration op Early discharge Flexibility Resolving of comorbid conditions: DM, HTN, dyslipidemia , GERD ,

Short duration op

Early discharge

Flexibility

Resolving of comorbid conditions: DM, HTN, dyslipidemia , GERD ,

DISADVANTAGES: Band slippage Erosion Port access site problems Leakage of access tubing Kinking of the tubing

Band slippage

Erosion

Port access site problems

Leakage of access tubing

Kinking of the tubing

Roux-en-Y gastric bypass

DISADVANTAGES: Anastomotic leak Bowel obstruction Stenosis of GJ Marginal ulcer at GJ Dumping syndrome & dehydration Iron & vit b12 def

Anastomotic leak

Bowel obstruction

Stenosis of GJ

Marginal ulcer at GJ

Dumping syndrome & dehydration

Iron & vit b12 def

Bilio pancreatic diversion

DISADVANTAGES: Protein malnutrition Abdominal bloating Elevated parathyroid hormone levels Bone pains Iron & vitamin def Marginal ulcers

Protein malnutrition

Abdominal bloating

Elevated parathyroid hormone levels

Bone pains

Iron & vitamin def

Marginal ulcers

Duodenal switch

DISADVANTAGES: Same as BPD 2 stage operation

Same as BPD

2 stage operation

Thanks