Surgical management of obesity hegazy

The Surgical
Management of
Obesity
MOSTAFA HEGAZY
MD

Obesity is a disease process that
has reached epidemic proportions
worldwide, with the highest
prevalence in the United States,
where nearly 40% of the adult
population is obese and 5% is
morbidly obese (CDC, 2018.
www.cdc.gov/obesity/data/adult.html).
INTRODUCTION

Obesity is also becoming
increasingly prevalent in the
pediatric and adolescent
population.
INTRODUCTION

Severe or morbid obesity in
adults is defined as a body
mass index [BMI = weight
(kg)/height (m2)] equal to or
greater than 40, which
generally correlates with an
actual body weight 100 lb
greater than ideal body weight.
INTRODUCTION

In children, severe obesity is
defined as a BMI that is equal
to or greater than 120% of the
95th percentile or equal to or
greater than 35 kg/m2
(whichever is lower).
INTRODUCTION

The etiology of morbid obesity
is poorly understood with o
debate as to the role of
genetic, psychosocial, and
environmental influences.
Morbid obesity is associated
with a number of weight-
related comorbidities.
INTRODUCTION

Patients with central obesity
(android or “apple” fat
distribution) are at higher
risk for development of
obesity-related complications
than those with peripheral
obesity (gynecoid or “pear”
fat distribution.
INTRODUCTION

Due to increased visceral fat
distribution, producing increased
intra-abdominal pressure and
increasing fat metabolism (with
subsequent,hyperglycemia,hyper-
insulinemia, and peripheral insulin
resistance).
INTRODUCTION

Table-1 lists some of the
medical complications
associated with morbid
obesity (Arch Intern Med.
2000;160(7):898–904).
INTRODUCTION

Complications of Morbid Obesity
Cardiac
Hypertension
Sudden cardiac death (myocardial
infarction)
Coronary artery disease
Deep venous thrombosis
Heart failure
Venous stasis
Pulmonary
Obesity hypoventilation syndrome
Asthma
Obstructive sleep apnea
Metabolic
Type II diabetes
Hyperlipidemia
Hypercholesterolemia
Nonalcoholic steatohepatitis
Infectious
Fungal infections
Necrotizing soft tissue infections
Musculoskeletal
Degenerative joint disease
Lumbar disc disease
Osteoarthritis
Ventral hernias
Gastrointestinal
Cholelithiasis
Gastroesophageal reflux disease
Genitourinary/Gynecologic
Stress incontinence
Polycystic ovarian syndrome
Menstrual irregularities
Neuologic
Pseudotumor cerebri
Stroke

In addition to the
aforementioned
comorbidities, obesity
increases mortality. (N Engl
J Med. 2007;357(8):741–
752).
INTRODUCTION

Cardiac
 Hypertension
 Sudden cardiac death (myocardial infarction)
 Coronary artery disease
 Deep venous thrombosis
 Heart failure
 Venous stasis

Pulmonary
• Obesity hypoventilation syndrome
• Asthma
• sleep apnea

Metabolic
 Type II diabetes
 Hyperlipidemia
 Hypercholesterolemia
 Nonalcoholic steatohepatitis

Musculoskeletal
 Degenerative joint disease
 Lumbar disc disease
 Osteoarthritis
 Ventral hernias

Gastrointestinal
Cholelithiasis
Gastroesophageal reflux disease

Genitourinary/Gynecologic
Stress incontinence
Polycystic ovarian syndrome
Menstrual irregularities

Infectious
Fungal infections
Necrotizing soft tissue infections
Neurologic
Pseudotumor cerebri
Stroke

Treatment of morbid obesity is
of paramount importance due to
medical sequelae associated
with obesity, nearly all of which
are reversible on resolution of
the obese state.
TREATMENT
Of Morbid Obesity

Medical therapy including
physician-guided weight loss or
pharmacotherapy has limited short-
term and nearly no proven long-
term success.
Medical Therapy

In patients with morbid obesity, lifestyle
modifications alone have been shown to
create 5% to 10% weight loss at 6
months, but negligible weight loss at 1
year of maintenance and negligible
effects on comorbidities. (Surg Obes
Relat Disord. 2010;6:347).
Medical Therapy

However, in patients with BMI less
than 27, lifestyle changes alone
may be sufficient.
Lifestyle modifications including
changes in diet
and exercises remain first-line
treatment.
.
Medical Therapy

 However the NIH consensus
congress has recognized that for
the morbidly obese, medical
treatment is nearly uniformly
unsuccessful.
Medical Therapy

Pharmacotherapy is second-tier
therapy used in patients with BMI
greater than 27 in combination
with lifestyle changes.
Pharmacotherapy

Currently, sibutramine, a presynaptic
norepinephrine and serotonin-
reuptake
inhibitor that functions as an appetite
suppressant, and orlistat, a lipase
inhibitor that reduces lipid
absorption, are the only approved
drugs for weight loss treatment.
Pharmacotherapy

Weight loss with these agents is 6%
to 10% at 1 year, but relapse rates
after discontinuation of the drugs
are high.
Additionally, many patients have
difficulty with compliance
due to adverse effects.
Pharmacotherapy

Bariatric surgery is the most effective
approach for achieving durable
weight loss in the morbidly obese.
Bariatric surgery

Multiple studies have confirmed the
superiority of surgery to nonsurgical
approaches in achieving and
maintaining weight reduction in the
morbidly obese (N Engl J Med.
2004;351:2683).
Bariatric surgery

Indications:
Patients who have failed intensive
efforts at weight
control using medical means are
candidates for bariatric surgery if
they have a BMI index greater than 40
or greater than 35 with
weight-related comorbidities.
Bariatric surgery

 In addition, patients who have a BMI
index greater than 30 with poorly
controlled diabetes or metabolic
syndrome may be offered bariatric surgery
although long-term data
demonstrating benefit is still lacking.
Bariatric surgery

Proposed contraindications
include
 Untreated or uncontrolled severe
psychiatric illness,
 Binge-eating disorders,
 Active alcohol or drug abuse,
Bariatric surgery
Contraindications

Prohibitive operative
risks secondary to
 Severe medical disease,
 Inability to comprehend the nature of the
surgical intervention or
 Comply with required postoperative
nutritional and lifestyle changes.
Bariatric surgery
Contraindications

Further,
patients actively pregnant or intending to
get pregnant within 12 to 18
months postoperatively should not
undergo bariatric surgery.
(Surg Obes Relat Dis. 2005 1(3):371–
381).
Bariatric surgery
Contraindications

 A bariatric multidisciplinary team including
primary care physicians, dietitians, physical
therapists, anesthesiologists, nurses, and
psychiatrists or psychologists evaluates a
patient’s weight history, dietary habits,
motivation, social history, and comorbid
medical conditions prior to surgery.
Preoperative Evaluation

 Include its demonstrated effectiveness in
long-term weight reduction and reversal
of the disease processes associated with
severe obesity.
 Hypertension completely resolves in 62%
of patients and resolves or improves in
79% (Surg Obes Relat Dis.
2009;5(3):387–405).
Benefits of bariatric surgery

 Diabetes is completely resolved in 77% of
patients and resolves or improves in 86%
(JAMA. 2017;317(6):635–636).

Obstructive sleep apnea resolves or
improves in 85% of patients and
hyperlipidemia improves in 70%.
 The quality of life is markedly better.

 Most importantly, recent studies demonstrate
reduced mortality rates in morbidly obese
patients undergoing bariatric surgery compared
to matched controls and most strikingly an 80%
reduction in annual mortality among diabetics
who underwent bariatric surgery (N Engl J
Med. 2007;357(8):741–752).

 Bariatric surgical procedures can
generally be divided into two types:
Restrictive procedures
 Which limit the amount of food that can
be ingested.
Bariatric surgical procedures

Malabsorptive procedures
Which limit the absorption
of nutrients and calories from ingested food
by passing predetermined
lengths of small intestine.

 Though once performed via an open
technique, bariatric procedures are now
primarily performed by laparoscopic
technique when possible by a skilled
surgeon due to improved patient tolerance
with laparoscopic techniques.

 Open bariatric procedures are still
performed for inability to tolerate
insufflation,failure of laparoscopic
techniques, or difficult reoperations.
 The standard operations used to produce
weight loss in the morbidly can be
found in Table -2.

 TABLE -2
Restrictive Procedures
Adjustable gastric banding (AGB)
Laparoscopic sleeve gastrectomy (LSG)
Restrictive and Malabsorptive Procedures
Roux-en-Y gastric bypass (RYGB)
Primarily Malabsorptive Procedures
Biliopancreatic diversion (BPD)
Duodenal switch (DS)
Bariatric Surgical Procedures

 Adjustable gastric banding (AGB)
involves laparoscopic placement of
a silicone band with an inflatable balloon
around the proximal stomach
by division of the peritoneum at the angle
of His and creation of a tunnel
posterior to the stomach.

 The band is connected to a reservoir that
is implanted over the rectus sheath.

 The patient undergoes serial
adjustments to inflate the band and create
a small proximal gastric
pouch.
 Anticipated excess weight loss at the 1-
year mark will approach 50% to 60%. (J
Am Soc Bariatr Surg. 2007;3(5):496–
502).

 Sleeve gastrectomy (SG) was
originally developed as the first
component of a duodenal switch (DS)
operation and is now performed alone
as a purely restrictive procedure for
the treatment of morbid obesity.
Sleeve gastrectomy (SG)

 It does not produce malabsorption
and is technically easier to perform
than BPD or Roux-en-Y gastric
bypass (RYGB).

 Preliminary reports have
demonstrated 60% to 70% excess
weight loss at 1 year (Obes Surg.
2007;17(8):1069–1074).

 The SG procedure is performed by the
surgeon first taking down the greater
curve from within 4 to 6 cm of the
pylorus up to the angle of His,
exposing the right crus.

 Using a 30- to 40-Fr bougie, the
stomach is then divided from the
antrum to the angle of His
preserving the left gastric vessels.

 RYGBP is the most popular
bariatric surgical procedure
performed in the United States.
RYGBP

 To perform the procedure, a Roux
limb is created by division of the
jejunum at 30 to 40 cm beyond the
ligament of Treitz with a stapler.
RYGBP

 The length of the Roux limb is
determined by the patient’s BMI; a
75 cm limb is used for patients with
lower BMIs and a 150 cm limb for
those with BMI >50.
 Weight loss varies with Roux limb
length.
RYGBP

 Additional staple fires are used to
create a jejunojejunal anastomosis.
 The mesenteric defect is then
closed in a running fashion.
RYGBP

 The Roux limb is passed in a
retrocolic or antecolic approach.
RYGBP

 The antecolic limb is then passed
antegastric, while the retrocolic limb
can then be passed ante- or
retrogastric.
 The peritoneum between the spleen
and GE junction is divided.
RYGBP

 The lesser sac is entered and a
stapler is used to create an
approximately 15 cc gastric pouch.
RYGBP

 A gastrojejunal anastomosis is
created using a combination of
stapled and sutured closure.
RYGBP

 The mesenteric defect is then
closed to prevent Roux limb
herniation through the transverse
colon mesentery.
RYGBP

 Gastric bypass results in weight
loss superior to that achieved with
restrictive procedures, with mean
excess weight loss of 70%
(Surgery. 2006;140(4): 524–529).
RYGBP

 Biliopancreatic diversion (BPD) is
an additional procedure less
frequently performed for morbidly
obese patients.
Biliopancreatic diversion
(BPD)

 This procedure is done at select
centers for the super-obese and
those who have failed to maintain
weight loss following gastric bypass or
restrictive procedures.
(BPD)

 First, the surgeon measures the
terminal ileum to 50 cm and marks this
area with a stitchas the common
channel.
(BPD)

 An additional 200 cm of ileum is
measured and divided.
 The proximal end of this is then
anastomosed to the TI at the level
of marking and the mesenteric
defects are closed.
(BPD)

 A distal gastrectomy is performed
and the duodenum is stapled and
divided distal to the pylorus.
 Finally, the proximal end of the
200 cm limb of ileum is
anastomosed to the proximal
stomach.
(BPD)

 Long-term outcomes indicate excess
weight loss of 75% at 1 year but
nutritional deficiencies are more
common than for RYGB (Obes Surg.
2006;16(9):1138–1144)
(BPD)

 DS is an additional procedure
performed at select centers for the
super obese.
 The first step of a DS procedure is
performance of a SG, as described
above.
Duodenal switch

 In some cases this is performed as the
first stage of a two-stage operation.
 The duodenum is then divided 2
cm beyond the pylorus.
 A 100 cm common channel is
measured from the terminal ileum.
Duodenal switch

 An additional 150 cm of terminal
ileum are measured and a
duodenoileostomy is created.
 The biliopancreatic limb is then
reanastomosed at the common
channel.
Duodenal switch

 Long-term outcomes indicate excess
weight loss of 75% at 1 year, but as
with BPD, nutritional deficiency risk
exceeds that of RYGB (Semin
Laparosc Surg. 2002;9(2):125–129).
Duodenal switch

 Typical postoperative management
includes postoperative analgesia,
frequent measurements of intake and
output.
POSTOPERATIVE MANAGEMENT

 Monitoring for tachycardia which can
be the only evidence of
postoperative leak in this
population, as well as gradual
advancement of diet from NPO to
a high-protein liquid diet.

 Aggressive pulmonary management
with early institution of continuous
positive airway pressure (when
indicated) is necessary to prevent
hypoxemia.

 Early ambulation is highly
encouraged and mechanical and
pharmacologic venous
thromboembolism prophylaxis is
recommended for all patients due to
high risk of deep venous thrombosis.

 Careful monitoring of postoperative
blood pressure and blood glucose
measurements are performed, as
many patients will require down-
titration of their antihypertensive
and diabetic agents.

 Nonsteroidal anti-inflammatory drugs
should be avoided following many
types of bariatric surgery due to its
association with marginal ulcers and
perforations.

 Close follow-up for adequate weight
loss, improvement or resolution of
comorbidities, in addition to close
metabolic and nutritional monitoring
is crucial.

 All patients should be encouraged
to engage in physical activity for at
least 30 minutes daily, take smaller
more frequent meals chewed
thoroughly, and avoid high-fat or high-
sugar liquids which could precipitate
dumping syndrome and impede
weight loss.

 Of note, inadequate weight loss
following bariatric surgery should
warrant further evaluation to
determine the etiology (including
surgical failure potentially requiring
revision or poor compliance with
nutritional or lifestyle requirements).

 Lifelong nutritional supplementation
with multivitamins, iron, calcium,
vitamin D, and vitamin B12 is
indicated (Endocr Pract.
2013;19(2):337–372).

 Bariatric surgery has become
increasingly safe in the last decades
with improved understanding of the
physiology of the obese patient and
improved surgical procedures.
COMPLICATIONS

 However, surgeons must be mindful of
postoperative complications as signs
are often subtle and nonspecific.
COMPLICATIONS

 Any severe or persistent
gastrointestinal complaints warrant
further examination, typically
employing radiographic imaging
studies and possible surgical
intervention.
COMPLICATIONS

 Dumping syndrome results from
patients’ inability to regulate gastric
emptying of simple carbohydrates
or other osmotic loads.
Dumping syndrome

 Patients usually complain of
sweating, dizziness, palpitations,
abdominal pain, nausea, vomiting,
and/or diarrhea.
Dumping syndrome

 Treatment may involve dietary
measures including high-protein diets,
acarbose and somatostatin
analogues, or surgical reintervention
for refractory cases (Best Pract Res
Clin Gastroenterol. 2014;28(4):741–
749).
Dumping syndrome

 Anastomotic leaks are a serious
complication associated with high
morbidity and mortality rates.
Clinical findings include tachycardia,
leukocytosis, and fever.
Anastomotic leaks

 Typical findings of peritonitis and
sepsis may be absent until late in
the patient’s clinical course.
 Management of leaks is time
dependent and can include surgical
closure of the defect, drainage, or
placement of an intraluminal stent.
Anastomotic leaks

 Small bowel obstructions typically
present with abdominal pain, nausea
and vomiting, and minimal bowel
function.
Small bowel obstructions

 Etiologies include edema and/or
hematoma in the early
postoperative period and adhesions,
abdominal wall hernias,
intussusceptions, and internal
hernias in the late postoperative
period.

 Possible locations for internal hernias
following a RYGB include the opening
of:
 The transverse mesocolon,

 The small bowel mesenteric defect
at the jejunojejunostomy site, and
 The space between the transverse
mesocolon and Roux limb mesentery
(known as a Peterson hernia) (J
Hosp Med. 2012;7(2):156–163).

 Treatment of obstruction in an
unstable patient is prompt surgical
exploration

 Gallstone formation is a common
late complication following bariatric
 surgery. Therefore, regular use of
ursodeoxycholic acid during the rapid
weight loss period is recommended
(Obes Surg. 2016; 26:990–994).
Gallstone

 Nutritional deficiencies are a risk
after any procedure with a
malabsorptive component and the
risk increases with the amount of
small intestine bypassed.
Nutritional deficiencies

 The most common postop
deficiencies seen are iron and B12
deficiency.

 However, folate deficiency and
calcium deficiencies are also seen.
BPD and DS procedures carry the
additional risk of fat-soluble vitamin
deficiencies and protein deficiency.

 All patients require careful
postoperative monitoring and lifelong
supplementation.

 Specific considerations should also be
taken into account based on the type
of operation performed:
Specific considerations

 A. AGB
 1. Benefits: No risk of leak, low risk of
metabolic disturbance due to no
changes in GI tract anatomy.
 2. Risks: Band slippage, band
erosion, leakage or kinking of
tubing ,increased refluxing.

 B. Laparoscopic Sleeve
Gastrectomy
 1. Benefits: technical simplicity,
pylorus preservation leads to no risk of
dumping syndrome, low risk metabolic
disturbances.

 2. Risks: leak from gastric staple line,
reflux, gastric outlet obstruction due to
stenosis, increased reflux.

C- Roux-en-Y Gastric Bypass
 1. Benefits: increased weight loss
versus restrictive procedures,
improved gastric reflux.

 2. Risks: G-J stenosis, malabsorption
leading to nutritional
deficiencies(primarily iron and B12
deficiencies), marginal ulcer risk,
internal limb obstruction, anastomotic
leak.

 D. Biliopancreatic Diversion
 1. Benefits: Improved percentage of
excess weight loss and improved
 maintenance over RYGB, excellent
resolution of obesity-related
comorbidities.

 2. Risks: Difficult procedure,
marginal ulcer risk, anastomotic
leak,malabsorption leading to high
risk for vitamin and protein
deficiencies.

E. Duodenal Switch
 1. Benefits: Improved percentage of
excess weight loss and improved
maintenance over RYGB, excellent
resolution of obesity-related
comorbidities, pylorus preserved
leading to low risk of ulcers.

 2. Risks: Difficult procedure,
anastomotic leak, malabsorption
leading to high risk for vitamin and
protein deficiencies.

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