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Definition of Bariatric Surgery
• Bariatric surgery or weight loss surgery is a
variety of surgical procedures performed on
• It is done either by • Reducing the size & capacity of the stomach.
• OR by
• Resecting & re-routing the small intestines to a
small gastric pouch.
Bariatric Surgery - Goals
Surgery to Create Sustainable & significant
Weight Loss in Severely Obese Patients.
Resolution or Cure of Co-morbidities
Reduction of Obesity Related Mortality
• SAGES – Society of American Gastro Endo
• ASMBS – American society of Metabolic &
• NIH – National Institute of Health.
Whom do we advise Surgery ?
BMI > 40 without comorbidities.
BMI > 35 with 2 comorbidities .
Age – 18 – 60 years( < 12- 65 )
Stable obesity for > 5 years
Unsuccessful dietary / drug treatment
Absence of Endocrine disease
Pt. should be sufficiently comprehensive &
No h/o excessive alcohol or drug abuse
Acceptable Operative Risks
How do we classify the surgical
C. Combination – restrictive and
• Creation of a small gastric pouch & limiting
the gastric volume & continuity is not altered.
• Vertical banded Gastroplasty
• Adjustable Gastric Banding
• Sleeve Gastrectomy
• Gastric Plication
• BIB – Intra Gastric Balloon
INTRA –GASTRIC BALOON
A Restrictive Procedure is
Easier to cheat
Less Effective for Weight Loss
Less beneficial for Diabetes
• Malabsorption is achieved by creating a short
gut syndrome with distal mixing of bile and
pancreatic juice with ingested food.
• Bilio-pancreatic diversion
• Jejunal ileal bypass
• Endoluminal sleeve ( Endo-barrier)
MAL ABSORPTIVE PROCEDURES
BPD - DS
ENDOLUMINAL SLEEVE OR
DJ BYPASS LINER
A Malabsorptive Procedure is
More effective for weight loss??
More Nutritionally demanding
• Combination of restriction alongwith malabsorption .
• Small gastric pouch + a bypass.
• Early sense of fullness, combined with a sense of
satisfaction that reduces the desire to eat.
• LSG with DS
Selection of a procedure
There is No evidence on procedure selection -most
frustrating shortfall in bariatric surgery.
Best procedure should reduce weight, induce remission
of Diabetes, & improve quality of life.
Multi disciplinary team assessment .
The choice of procedure is determined by the individual’s
phenotype, the aims of therapy, & peri-operative risks.
Selection of Procedure
Each procedure should be tailor made for each
The choice of the procedure is a complex process with
patient & their interests at its core.
The surgeon’s experience to deal with the inevitable
complications of each procedure & to manage long
term follow up care should be the goal to success.
Patient should be physically & psychologically fit.
Patients must be determined to comply with the postop. care and instructions on diet.
They should be given the correct & realistic information
on what the procedure can achieve.
For each patient benefits of the procedure should
outweigh the operative risks.
Individualized assessment-is vital & Psychiatrist role is
• A special risk bond is signed by the patient and by
2 more family members.
• Procedure may vary in peri- operative assessment
ie ; diagnostic laparoscopy.
• Primary aim of surgery should
be weight loss with
Whom we deny Bariatric Surgery ?
• History of substance abuse, eating disorders, or
major psychiatric problems – untreated or
• Patients who are too ill or too high a risk for
• Women who may become pregnant soon
LAB EVALUATION : CBC,FBS, 2HRPGBS, HB1AC, LFT, Urea, Creatinine, Serum
Protein/albumin, Amylase, Serum fasting & post Insulin, C-peptide, lipid profile,
Serum Calcium, Vit. B12, Calcitonin, TFT,Serum & urine Cortisol. HOMA-IRHomeostasis Model of Assessment-Insulin Resistance
UGIE: To rule out inflammatory or ulcer pathology, & treat H.pylori infection.
USG Abdomen – To rule out cholelithiases, which would indicate Lap.
Cholecystectomy alongwith the primary surgery.
Cardio-Respiratory evaluation – To exclude any contraindications to GA by
TMT, 2D echo, PFT, ABG, CXR.
Psychiatry evaluation – To rule out any behavioural abnormalities that would
contraindicate limited food intake.
Endocrine evaluation – To rule out an endocrine abnormality as the etiology of
HOMEOSTASIS MODEL OF ASSESSMENT
OF INSULIN RESISTANCE
• INTERNATIONAL FORMULA
• FBG(mmol/L) X Finsulin(Mu/L) / 22.5
• To assess beta cell function & insulin
• Estimated by euglycemic clamp method
measuring glucose for an increased inslin level, without causing
Pathophysiology of Bariatric Surgery
ROLE OF GI HORMONES IN
REMISSION OF METABOLIC
Recent theory- Entero-insular axis
has got a role in maintaining
Bariatric surgery results in weight
loss due to surgical manipulation or
bypassing of the gut & by caloric
restriction - leading to remission of
WC > or – 40 inches
TG > or – 150 mg/dl
HDL < 40 mg/dl
BP > or – 130/85 mmHg
FBS > or – 100 mg/dl
WC > 35 inches
TG > 150 mg/dl
HDL < 50 mg/dl
BP > 130/85 mmHg
FBS > 100 md/dl
WHAT ARE INCRETINS ?
Incretins are a group of gastrointestinal hormones that
increase the amount of insulin release from the beta cells
They also slow the rate of absorption of nutrients into the
blood stream by reducing gastric emptying and reduces food
Inhibits Glucagon release from the alpha cells of the Islets of
1. GLP-1- Glucagon-like peptide-1
2 . GIP- Gastric inhibitory peptide or Glucosedependent
Mechanism of Incretin action
WHAT ARE ANTI INCRETINS?
• Anti incretins are a group of GI factors
secreted from the duodenum & proximal
jejunum, which counteract the actions of
GUT - BRAIN AXIS
•The gut–brain axis is a major component of appetite
•The gut hormones have either
( appetite depressant ) or orexigenic ( appetite
stimulant ) action on food intake .
•These gut hormone secretions are altered following
Ghrelin- (orexrgenic / satiety or appetite stimulant hormone)
produced primarily by gastric fundus.
-Its levels are supressed following resection of gastric rich
-It stimulates insulin counter-regulatory hormones.
– an anorexegenic (or appetite depressant)
hormone co-secreted with GLP-1 from the
response to food intake.
intestinal L cells in
- ( anorxegenic hormone )
-levels are increased following LRYGB, decreases food intake &
ameliorates insulin resistance and improves glycemia.
PROPOSED THEORIES FOR IMPROVED GLYCAEMIA
(A) RAPID HINDGUT DELIVERY
•Expedited or rapid delivery of ingested nutrients to
lower bowel due to intestinal bypass leads to
stimulation of L cells, ( distal ileum & colon ) which in
turn results in increased secretion of INCRETIN
hormones & improved glucose homoeostasis.
(LRYGB & BPD/DS.)
•Proximal nutrient- related signals that are transmitted
from the duodenum to the distal bowel by neural
pathways leads to increased Incretin secretion.
Hypothesis as to the mechanism responsible for the
control of diabetes after gastric bypass.
PROPOSED THEORIES FOR IMPROVED GLYCAEMIA
(B) FOREGUT HYPOTHESIS
•The proximal small intestine
(foregut / BPD limb ) is
excluded resulting in reduction in secretion of Anti –
incretin factors ( diabetogenic hormones) in
response to absence of nutrients in the fore gut.
•This leads to improved glycaemia.
•Decreased Intestinal Glucagon synthesis
ANTI-INCRETIN / INCRETIN HYPOTHESIS
After Bariatric Surgery - a physiological balance is
maintained between Anti –Incretins & Incretins,
Leads to proper beta cell function & to maintain Blood
Glucose excursions within normal range.
Release of excess Anti- Incretins are prevented & there
is a restoration of between Incretins & Anti-Incretins ,
leading to improved glucose homeostasis .
Diabetes, Obesity & Bariatric
DM linked with obesity has –
-- insulin resistance, inflammation & lipo-toxicity of beta
> progressive beta cell failure & hyper-glycaemia.
•After Bariatric Surgery - Glucose homeostasis improves.
- Insulin sensitivity increased markedly
- Adiponectin levels are improved
- Markers of insulin signals in key target tissues are
Medical Co-Morbidities Resolved with
Type 2 Diabetes
Complications of Bariatric Surgery
The other side of
Gutzon Borglum and his
son Lincoln Borglum
• Bariatric surgery
or cures many obesity
• But working with an
can increase your risk
Metabolic Surgery- A new dimension
RESOLUTION OF DIABETES AFTER
Present status of diabetes surgery
Bariatric surgery effectively reverses type 2 diabetes in a high
proportion of morbidly obese patients, within weeks or even days
well before these patients have lost a significant amount of body
Diabetes surgery should be considered in patients with BMI > 35
and may also be appropriate for patients with BMI 30-35
Rome Diabetes Surgery Summit 2009
Resolution of diabetes in non obese
Status of Ileal Transposition “Not to be done outside approved trials”
Rome Diabetes Surgery Summit, 2009
• Extensive Research in the field of Bariatric surgery
( Metabolic surgery, Technology, Endoscopy )
• A career in Bariatrics is very promising……. And
• Within 5 years, will
gastrointestinal surgery be
considered an acceptable
option for the treatment
of Type 2 Diabetes in the
CONCLUSIONS- TAKE HOME MESSAGE
BS should be considered with BMI > 40 or BMI > 35
with obesity related 2 co-morbidities.
Not all pts. are suitable for surgery.
The choice of the surgical modality should take the
individual’s goals, surgeon’s experience & existing comorbidities.
A multidisciplinary assessment is essential to select the
CONCLUSIONS- TAKE HOME MESSAGE
Individualised care is determined by clinical evaluation.
Procedure selection - should effectively treat & prevent all
co-morbidities alongwith sustained weight loss.
Experienced anaesthesist & trained OT & ICU staff is
necessary for success.
Long term follow up and repeated counselling is
mandatory for a safe outcome.
Should be performed in experienced centres- with back up
ICU and trained staff for favourable outcomes.