Principles of bariatric surgery
Dr anand (pg)
Under gudience of
(SURGERY FOR MORBID OBESITY)
(Bariatric =Baros: heaviness, and pressure.)
Bariatric surgery is currently only modality that
provides a significant sustained loss of weight
for the patient with morbid obesity.& with
The goal of bariatric surgery is to improve health in morbidly obese
patients by achieving long-term, durable weight loss.
It involves reducing caloric intake and/or absorption of calories from
food, and may modify eating behavior by promoting slow ingestion of
small boluses of food.
Restrictive operations restrict the amount of food intake by reducing
the quantity of food that can be consumed at one time, which results in
a reduction in caloric intake.
Malabsorptive procedures limit the absorption of nutrients and calories
from ingested food by bypassing the duodenum and predetermined
lengths of small intestine.
In 1969, Mason and Ito performed the first gastric
bypass, in which a loop of jejunum was connected to a
transverse proximal gastric pouch.
Bile reflux esophagitis was severe postoperatively,
In 1977 Griffin to developed the Roux-en-Y
modification of the gastric bypass
In 1980, Mason described vertical banded gastroplasty
(VBG), a restrictive procedure in which stapling was
used to create a proximal gastric pouch of the upper
lesser curvature of the stomach,
with placement of a restrictive band to form its outlet to
the rest of the stomach
In Italy, late 1970, Scopinaro had developed and
popularized the biliopancreatic diversion (BPD)
procedure along with its modification to include a
duodenal switch (DS), has been the only major
malabsorptive operation to enjoy long-term success.
The laparoscopic approach to bariatric surgery
became available in the 1990
In 1994 Belachew and colleagues performed the
first laparoscopic adjustable gastric banding
(LAGB) operation .
Wittgrove and Clark performed the first
laparoscopic Roux-en-Y gastric bypass (LRYGB)
the same year.
In 2001 LAGB was approved for use in the United
States by the U.S. Food and Drug Administration.
Obesity now considered as a "Killer lifestyle"
disease is an important cause of preventable death
According to the World Health Organization
(WHO), 1.2 billion people worldwide are officially
classified as overweight.
This is probably the most sedentary generation of
people in the history of the world.
In the Indian scenario, even with the growing
awareness about health and fitness, more than 3
percent (3 crores ) of the Indian population is obese
An excess of caloric intake in relation to caloric
expenditure results in deposition of fat or
Obesity is multifactorial
Genetics plays an important role in the
development of obesity.
Although the children of parents of normal
weight have a 10% chance of becoming obese,
The children of two obese parents have an 80
to 90% chance of developing obesity by
The weight of adopted children correlates
strongly with the weight of their birth parents.
Furthermore, concordance rates for obesity in
monozygotic twins are double those in
Differential Diagnosis and Related
A few endocrine diseases are associated with
obesity, including hypothyroidism,
Cushing's disease, and adult-onset diabetes
However, patients who seek medical or surgical
treatment for morbid obesity rarely have an
endocrine etiology of their obesity.
syndrome X.( combination of central obesity,
glucose intolerance, dyslipidemia, and hypertension)
The degrees of obesity are defined by body mass index,
BMI (calculated as weight in kilograms divided by height in
Fatal cardiac arrhythmias, right-sided heart failure,
deep vein thrombosis,
Fungal skin rashes, skin abscesses,
Stress urinary incontinence, infertility,
Abdominal wall hernias,
Increased incidence cancers such as those of the
uterus, breast, colon, and prostate.
Obesity has a profound effect on overall health and
largely secondary to weight-related comorbidities.
It is estimated that a man who is severely obese at
age 21 will live 12 years less than a nonobese
and a severely obese woman will live 9 years less.
This is largely due to the fact that severely obese
men often are dead of comorbid medical
conditions, especially cardiac arrhythmias and
coronary artery disease, by age 50
Treatment and mangement
LIFE STYLE MODIFICATIONS
a deficit of 500 kcal per day, resulting in a
weekly deficit of 3500 kcal, translates to the loss
of one pound of fat a week.
Pharmacotherapy is a second tier therapy
usually used in heavier patients (BMI >27)
when lifestyle changes alone have failed.
It is employed alone or in combination with
Sibutramine & orlistat are c (FDA)–approved drugs
for weight loss treatment.
Orlistat is a potent and selective inhibitor of
gastric and pancreatic lipases that reduces lipid
sibutramine is a noradrenaline and 5-
hydroxytryptamine reuptake inhibitor that
works as an appetite suppressant.
Despite their different MOA they effectively
produce weight loss of 6 to 10% of initial body
weight at 1 year,
TYPES OF SURGICAL PROCEDURES
POST SURGICAL MANGEMENT
FOLLOW UP &OUTCOME
Patients that have a BMI of 35 kg/m 2 or more with
those with a BMI of 40 kg/m 2 or greater regardless
Candidates must have attempted weight loss in the
past by medically supervised diet regimens,
exercise, or medications.
patients aged 18 to 60 years.
Adolescent patients with morbid obesity may be
considered for bariatric surgery under select
Patients who are unable to undergo
generalAnesthesia because of
cardiac, pulmonary, or hepatic disease,
Patients with ongoing substance
abuse, unstable psychiatric illness,
inadequate ability to understand the
consequences of surgery are also considered to
be poor surgical candidates.
those who are unwilling or unable to comply
with apostoperative lifestyle
changes, diet, supplementation, or follow-up
may not undergo these procedures.
PRE OPERATIVES EVALUTIONS INCLUDES
Pre operative prepartion
Multidisciplinary team evaluation
Specific nutritional counseling and education is
required based on the operation to be
Treatment of the depression is felt to improve
comorbidities and other medical problems
Screening for coronary artery disease in
patients >50 years of age
sleep apnea in severely obese patients, when
all routinely undergo sleep studies
GERD taking medication, a preoperative
screening upper endoscopy to rule out Barrett's
esophagus and intrinsic lesions of the stomach
or duodenum is recommended
patients who are taking anticoagulants for
prosthetic cardiac valves or
recent venous thromboembolism,
anticoagulation therapy must be managed
H/O venous thromboembolism or who are felt
to have multiple risk factors for postoperative
venous thromboembolism are potential
candidates for preoperative placement of a
temporary inferior vena cava filter.
Such filters are placed the day before surgery &
removed 3 to 6 weeks postoperatively
Ultrasound of the abdomen in patients planning to
undergo LRYGB who have an intact gallbladder to
rule out the presence of gallstones.
Evaluation of thyroid function is recommended
preoperatively, because hypothyroidism is not
uncommon in this patient population.
Serum chemical analysis, liver function tests, and
the usual screening blood tests are performed.
Blood tests to determine baseline nutritional
parameters commonly reveal abnormally low iron
and vitamin D levels
Cardiopulmonary evaluation to identify any
underlying pathology that requires preoperative
treatment to decrease perioperative morbidity from
Two major difficulties the anesthesiologist faces
when administering a general anesthetic to a
severely obese patient are vascular access and
Alterations in the metabolism of specific anesthetic
drugs in the severely obese include a larger volume
Indications for Conversion from
Laparoscopic to Open Surgery
1. Failure to establish an adequate
2. Hemodynamic adverse reaction to
3. Intra-abdominal adhesions precluding safe access
or presenting excessive difficulty in accessing
4. Hepatomegaly such that retraction is not feasible
or organ visualization is obscured even with
5. Intraoperative complications such as hemorrhage
that are best managed with an open approach
6. Exceedingly thick body wall precluding adequate
trocar access or manipulation
Silicon band with adjustable diameter placed at
the entry of stomach (cardia)
Two types of bands have been used
The original Lap-Band Adjustable Gastric
Banding System, ( Allergan) most frequently.
The Swedish adjustible gastric band, Realize
Adjustable Gastric Band by Ethicon
Adjustable gastric banding
• Sep/1993= first
• Types of Adjustable
1-Bioenterics = Lap-
Mechanism of Action
Adjustable gastric banding involves the
minimally invasive (laparoscopic) or open-
placement of a silicone band around the
proximal stomach to restrict the amount of solid
food that can be ingested at one time.
the adjustable nature of the band allows the
amount of restriction to be increased or
decreased, depending upon the patient's
The patient is placed in the steep reverse Trendelenburg position.
Six laparoscopic ports are placed. A 5-mm liver retractor is used to
elevate the left hepatic lobe.
A 15-mL gastric calibration balloon is used to identify the locationbegins
with division of the peritoneum at the angle of His, then division of the
gastrohepatic ligament in its avascular area (the pars flaccida) to expose
the base of the right crus of the diaphragm
Once the band is passed around the proximal stomach, it is locked into its
ring configuration through its own self-locking mechanism.
Once the band is securely locked in place, the buckle portion of the band is
located on the lesser curvature of the stomach
Patient Selection and Preparation
Most LAGB procedures are done on an
the relative risk of the procedure is lower than
that of most other bariatric operations,
which makes this procedure more suitable to
offer to older, more medically ill, or higher-risk
Poor candidates for LAGB
patients who have had previous upper gastric
surgery, such as a Nissen fundoplication, due
to the potential tissue compromise in taking
Pateint who , are immobile, are unable to
exercise, nibblers on high-calorie sweets, and
expect to be able to continue their dietary
Patients are given clear liquids a few hours after the
A Gastrografin swallow is obtained on the first
postoperative day to confirm band position and
Patients can generally be discharged 1 to 2 days after
surgery with a liquid diet for 4 weeks.
At that time, a gradual transition to a regular diet is
Band adjustment may be performed with fluoroscopic
guidance initially at 10 to 12 weeks.
Patients are assessed monthly for weight loss and
tolerance of oral intake.
Band adjustments are made accordingly every 4 to 6
weeks during the first year following laparoscopic
adjustable gastric banding.
Laparoscopic adjustable gastric banding is a
relatively simple procedure that takes less
operative time than the more complex
procedures such as laparoscopic RYGB or
laparoscopic biliopancreatic diversion.
The mortality rate is low (0.06%), as are
conversion rates (0 to 4%).
No staple lines or anastomoses are required.
Recovery is rapid and hospital stay is short.
The adjustable nature of the laparoscopic
band allows the degree of restriction to be
optimized for the patient's weight loss.
With this procedure, there is a potential for port
site complications and the need for frequent
postoperative visits for band adjustment.
Some patients (5 to 10%) experience band
slipping or gastric prolapse, which usually
Other potential problems include band
reflux, alterations in esophageal motility, and
Should inadequate weight loss occur, revision
to Roux-en-Y gastric bypass is feasible, but
EARLY COMPLICATIONS OF ADJUSTABLE
Injury of stomach or oesophagus
Food intolerance or noncompliance
Band slippage(stomach prolapse)
Band erosion into stomach
Re operation rate
Failure to lose weight
Leakage of ballon or tubing
Open Roux-en-Y Gastric Bypass
Mechanism of Action
RYGB is both a gastric restrictive procedure
and a mildly malabsorptive procedure.
A small gastric pouch restricts food intake,
while the Roux-en-Y configuration provides
malabsorption of calories and nutrients.
Mason described the optimal parameters for
restriction necessary for adequate weight loss,
including a gastrojejunostomy of 1.2 cm or less
in diameter and a gastric pouch of 15 to 30 mL.
The abdomen is entered through a midline
incision and is thoroughly explored. The
gallbladder is inspected and palpated for
Three superimposed staple lines are applied to
the stomach so as to create a proximal pouch
of 15 to 30 mL
The ligament of Treitz is identified and a point
15 to 45 cm distally is identified.
The jejunum is divided with a linear stapling
The mesentery is divided between clamps and
a side-to-side jejunojejunostomy is created with
a linear stapler to create a 45- to 75-cm Roux
limb for a standard gastric bypass,
a 150-cm limb for a long-limb modification in
the superobese. With a lengthened Roux
limb, there is a greater degree of malabsorption
for improvement of weight loss.
The Roux limb is brought through the transverse
A 1-cm gastrojejunal anastomosis is created
between the gastric pouch and the jejunum, using a
circular stapler or a hand-sewn, two-layer technique.
The hand-sewn anastomosis is created over a 30F
If a nasogastric tube is left in place at the time
of surgery, it is removed within 24 hours.
Gastrografin swallow is generally obtained on
the second or third postoperative day and
liquids are started thereafter.
Patients are generally discharged 2 to 6 days
TheRYGB is more effective than vertical banded
gastroplasty in terms of weight loss.
In a more recent study in which sweet-eaters were
assigned to gastric bypass and non–sweet-eaters
were assigned to vertical banded gastroplasty,
RYGB has been demonstrated not only to
prevent the progression of non–insulin-
dependent diabetes mellitus, but also to reduce
the mortality from diabetes mellitus, primarily
due to a reduction in deaths from
Durable control of diabetes mellitus is
achieved following gastric bypass, along with
or resolution of other comorbidities such as
hypertension, sleep apnea, and
including distal gastric distention and internal
Laparoscopic Roux-En-Y Gastric Bypass
The laparoscopic approach to gastric bypass
(LRYGB) was first described in 1994
The major feature of the operation is the creation
of a proximal gastric pouch of small size (often <20
mL) that is totally separated from the stomach
A Roux limb of proximal jejunum is brought up and
anastomosed to the pouch.
The pathway of that limb can be anterior to the
colon and stomach, posterior to both, or posterior
to the colon and anterior to the stomach.
The length of the biliopancreatic limb from the
ligament of Treitz to the distal enteroenterostomy is
from 20 to 50 cm, and the length of the Roux limb
is 75 to 150 cm.
• First Laparoscopic
gastric bypass was
in 1993 by
Wittgrove, Clark, a
Patient Selection and Preparation
LRYGB is an appropriate operation to consider
for most patients eligible for bariatric surgery.
Relative contraindications to LRYGB include
previous gastric surgery, previous antireflux
surgery, severe iron deficiency anemia,
Distal gastric or duodenal lesions that require
ongoing future surveillance, and Barrett's
esophagus with severe dysplasia
Preoperative flexible upper endoscopy for all
patients contemplating RYGB is advocated by
some to rule out lesions of the stomach or
Postoperative Care and Follow-Up
Patients undergoing LRYGB usually are
hospitalized for 2 to 3 days
We routinely perform a postoperative oral
contrast study on the 1st POD to rule out a leak
an early asymptomatic leak or to edema or
stenosis of the enteroenterostomy or to any
other obstructive pattern of the proximal bowel
follow-up visits are usually for 3 mthen onths,
6 months, and 1 year after surgery, annually
testing for postoperative nutritional
Patients undergoing LRYGB usually lose
between 60 and 80% of excess body weight
during the first year after surgery
Postoperative nutritional complications after
LRYGB include :
iron deficiency anemia in 20%,
vitamin B12 deficiency in 15%,
and vitamin D deficiency in at least
15%, which usually is present preoperatively.
EARLY COMPLICATIONS of Roux-en –y
Anastomic leak (1-3%)
Wound infection(mc open apprroach)
Acute distension of distal stomach
Stomal stenosis mc
Micro nutrient deficiencies
Staple line distruption
Ventral hernia(MC open approach)
Life long oral or IM vit B-12 supplememtation
Iron,folate,calcium specific nutrient deficency
Biliopancreatic diversion (BPD) was first
described by,Scopinaro and colleagues in ItalY,
It involves resection of the distal half to two
thirds of the stomach and creation of an
alimentary tract of the most distal 200 cm of
ileum, which is anastomosed to the stomach
The biliopancreatic limb is anastomosed to the
alimentary tract either 75 or 100 cm proximal
to the ileocecal valve, depending on the protein
content of the patient's diet
Mechanism of Action
A 50- to 100-cm common absorptive
alimentary channel is created proximal to the
ileocecal valve; digestion and absorption are
limited to this segment of bowel.
This procedure is primarily indicated for the
superobese or for those who have failed restrictive
Less commonly, some surgeons perform BPD as a
primary operation in the non-superobese.
Patients with anemia, hypocalcemia, and
those who are not motivated to comply with
stringent postoperative supplementation regimens
may not be appropriate for this procedure.
the malabsorptive component of the BPD
allows for excellent results in terms of weight
This operation may be more effective than
gastric bypass or restrictive surgery in patients
with severe morbid obesity (e.g., BMI greater
than 70 kg/m 2 ),
The BPD is technically a more complex
procedure than the restrictive procedures.
Protein malnutrition with
anemia, hypoalbuminemia, edema, and
alopecia are among the serious adverse
sequelae of this operation.
Severe vitamin deficiencies may occur, leading
to osteoporosis and night-blindness.
Treatment requires prolonged
hyperalimentation and supplementation
COMPLICATIONS biliopancreatic diversion
with duodenal switch
Fat malabsorption leads to diarrhea foul smelling
Malabsorption of fat soluble vitamins (ADE&K)
First introduced by Ganger Micheal in 2002
It is the first step when you do Biliopancreatic
diversion with Duodenal switch procedure
It is temporary step to reduce weight before the
permanent procedure which is BPD+DS (when
BPD+DS is difficult to be done duo to excessive fat
or huge Lt. liver lobe)
Patient Selection and Preparation
Patients undergoing SG two groups.
One group is high-risk superobese patients
considering eventually undergoing the second
procedure to complete the DS operation.
The other group is patients who have a BMI of
<50 kg/m2 and have decided that they prefer
the SG operation.
The surgeon begins the gastric resection by dividing
the vessels along the greater curvature of the
stomach using the Harmonic scalpel.
Division is begun 2 to 3 cm proximal to the pylorus
and continued to the angle of His
SG results in excellent short-term weight loss
Depending on body size, weight loss is in the
range of 45–50% of excess weight for patients
with a BMI of >60 kg/m2,
For patients with a BMI of 35 to 50 kg/m2 with
a 32F pouch size, excess weight loss at 3
years was recently reported as being 60%
Vertical Gastrectomy Advantages
Stomach volume is reduced, but it tends to function
normally so most food items can be consumed in small
Eliminates the portion of the stomach that produces the
hormones that stimulates hunger (Ghrelin).
No dumping syndrome because the pylorus is
Minimizes the chance of an ulcer occurring.
By avoiding the intestinal bypass, the chance of
intestinal obstruction (blockage), anemia, osteoporosis,
protein deficiency and vitamin deficiency are almost
Very effective as a first stage procedure for high BMI
patients (BMI >55 kg/m2).
Limited results appear promising as a single stage
procedure for low BMI patients (BMI 35-45 kg/m2).
Appealing option for people with existing anemia,
Crohn’s disease and numerous other conditions that
make them too high risk for bypass
As with any surgery, there can be complications.
Complications can include:
DVT (blood clot in leg)
Pulmonary Embolus (blood clot to lung)
Gastric leak and fistula.
Small bowel obstruction
Big…big size single meal eater
Does not loss significant by dieting history
60% a mean excess weight loss
Less than 10% early morbidity rate
Less than 1% perioperative mortality
Nearly 80% failure rate (long term follow-up
Poor weight loss maintenance
15% to 20% reoperation rate duo to stomal
outlet stenosis or severe reflux
Special Issues Relating to the Bariatric
Bariatric Procedures in the Female Patient:
Pregnancy and Gynecologic Issues
Hormonal levels in female patients are related to
Obesity alters the levels of estrogen and
progesterone available for normal ovulation, which
results in abnormal ovulation
patterns, amenorrhea, and difficulty conceiving.
the increased chances of gestational diabetes and
hypertension make the pregnancy high risk.
Macrosomia is increased.
RYGB had a lower incidence of
Bariatric Surgery in Morbidly Obese Adolescents
Bariatric surgery in morbidly obese adolescents
Surgery may be indicated in this population
because of the dismal failure of the
conservative methods of weight control,
adolescent obesity, and the many disabling
and deadly obesity-related comorbidities of
Bariatric surgery should be seriously
considered after conservative methods have
Most clinical trials exclude older patients, and
little is known about the benefits of diets or
drugs that induce weight loss in these age
Mechanical complications of obesity, such as
osteoarthritis and static respiratory
complications, seem to improve with weight
loss, even at higher ages.
Recent studies suggest that bariatric
surgery, previously considered contraindicated
in obese patients above age 60, can be safely
performed even in patients above age 70, with
Type 2 Diabetes
surgeons performing RYGB that patients who had
undergone the operation showed improvement or
near resolution of type 2 diabetes well before they
had achieved maximum weight loss.
Metabolic syndrome is characterized by central
obesity, glucose intolerance, dyslipidemia, and
Metabolic syndrome is a common finding in
patients with severe obesity, occurring in 52%
of individuals in one report.
All the associated metabolic problems of
metabolic syndrome respond to surgical
therapy to produce weight loss.
Diabetes and pre-diabetes (fasting plasma
glucose of 100–124 mg/dL) are effectively
treated by both RYGB and LAGB
Resolution of Other Comorbid Medical Problems
with Bariatric surgery:
Obstructive sleep apnea
degenerative joint disease and
low back pain,
Post operative follow up:
High protein,low-fat diet,supplement
Ursodil minimize the risks of development
Nutritional and metabolic blood tests need
Performed on frequent basis.3 months,
6months,12 months after surgery,then annually
Post bariatric surgery body
Massive weight loss associated with flabby
skin,abdominal skin overhang and pendulous
Redundant roll of tissue associate with hygiene
Conventional surgery lipoplasty
Combination of 2 procedures
Abdominoplasty , buttock lift, lower body lift
Thigh lift ,upper arm lift. Facelift, breast