newer modalities in bariatric surgery

1. RECENT ADVANCES IN BARIARTIC
SURGERY

2. OBESITY TRENDS……..

3. ❑ Chronic disease
❑ Increasing prevalence in adults, adolescents and children
❑ Now considered a global epidemic
❑ Morbidly obese - at risk of physical and metabolic co-morbidities
❑ Severely impair health
❑ Increase mortality.

4. HARMS CAUSED:
❑ Higher relative risk of Hypertension
❑ Hypercholesterolemia
❑ Diabetes Mellitus
❑ Reduces Life expectancy (by an average of 8-10 years in the
case of severe obesity)

5. It is now considered that the principal driver
of the increasing incidents of D.M. is
increasing prevalence of obesity…….
RECENT FACT…..

6. BARIATRIC SURGERY TRENDS…….

7. ❑ UnitedStatesofAmerica&Canada- Regionswith thehighestnumberof
bariatic procedures (154,276procedures in 2013)
❑ InEurope-Franceistheleadingcountry(37,300 proceduresin 2013)
❑ SoutheastAsiaandChina -emergingwith increasingnumbersof
procedures donecurrently

8. Some trends about procedures……
❑ Mostcommonlyperformedprocedureintheworldin2013-laparoscopicRoux-en-Y
gastricbypass(45%)
❑ followed by laparoscopicsleeve gastrectomy (37%)and laparoscopicadjustable gastric
Banding(10%).

9. Contd….
❑Roux-en-Y gastric bypass - decreased from 2003 to 2008(-16%) and
continued to decrease slightly from 2011 to 2013(-1.6%)
❑But still represents the most performed bariatric/metabolic
procedure in theworld.
❑ Sleeve gastrectomy - steep increase from 2003 to 2013(+37%)
❑ Thus becoming the second most performed bariatric /metabolic
procedure in the world

10. RYGB
❑ Roux en Y gastric bypass - considered as the gold standard bariatric
surgery procedure
❑ Because….
 Provide durable weight loss
 Improve metabolic profile of patients
 Reduce mortality associated with the complications of obesity such
as cardiovascular disease and cancer

11. Contd….
❑ Laparoscopic adjustable gastric banding-peaked in 2008(42.3%)
❑ Then had a significant ↓ in 2011(-24.5%) & in 2013(-7.8%)

12. Contd….
❑ Almost at the same time, when the popularity of the LAGB was ↓ ,
SG emerged as a new procedure with ↑ worldwide acceptance
❑ Reasons behind it-
▪ Technically less demanding
▪ Good short and mid-term results,
▪ Lower incidence of short & long term complications and re-
operation rates

13. So…
Sleeve gastrectomy now consists of more than 50% of the bariatric surgical
procedure in Asia…….

14. SURGICAL PROCEDURE :
WHATS NEW???

15. MINI GASTRIC BYPASS(MGB)

16. ❑ Developed by Dr Robert Rutledge in 1997
❑ First reported by him in 2001
❑ Consists of first creating a long vertical gastric pouch along the
lesser curvature side usually starting at the antrum distal to the
crow's feet
❑ Second, a Billroth type II loop gastrojejunostomy formed with a 200-
cm or longer afferent limb from the ligament of Treitz.

17. CONTD.
Mini gastric bypass Roux-en-Ygastric bypass

18. Advantages over RYGB
❑ Simpler procedure as compared to RYGB
❑ Only one anastomosis
❑ Shorter operative time
❑ Fewer sites of anastomotic leaks and internal hernias
❑ Easy to teach with a shorter learning curve
❑ Ease of reversibility - technically much easier than the RYGB
❑ Better reported regarding weight loss and comorbidity

19. DISADVANTAGES:
❑ Higher incidence of side effect like
 Anemia
 Diarrhea

20. Around 1.8% of the bariatric procedures performed
nowadays are MGBs and this is expected to increase
over the next few years……

21. ENDOSCOPIC BARIATRIC
INTERVENTIONS……

22. ❑ Lastyearshaveshown↑indevelopmentofendoscopictechniquesfortreatmentofobesity&metabolic
disorders
❑ Theseproceduresare-
 Lessinvasive
 Reversible
 Decreasedcost

23. Thus, they can be used as……
❑ Primary therapy
❑ As a bridge to bariatric surgery
❑ As a revisional procedure after bariatric sugery

24. CURRENT PRIMARY ENDOSCOPIC BARIATRIC THERAPIES
INCLUDE:
❑ Restrictive procedures
Suturing/Stapling devices
Space occupying devices
❑ Malabsorptive procedures
Endoluminal Bypass
❑ Others
Neuro-electro stimulators
Injection of substances such as botulism toxin

25. ENDOLUMINAL RESTRICTIVE PROCEDURES
(STAPLING/SUTURING TYPE DEVICES)…….

26. ❑ Main principle of this procedure is to reduce gastric
volume (Endoscopic gastroplasty) via suturing or
stapling or tissue anchor placement.
❑ Available devices for endoluminal gastroplasty are:
1. EndoCinch System
2. Transoral Gastroplasty System (TOGA)
3. Primary Obesity Surgery Endoluminal (POSE)

27. TRANSORAL GASTROPLASTY SYSTEM (TOGA)
❑ First endoscopic device for gastric restrictive surgery
❑ 8 cm. long tube (stapled pouch) is created along the lesser
curvature of stomach
❑ Less invasive
❑ Less complications
❑ Faster recovery
❑ 46% excess wt. loss in 6month
s.

29. ENDOCINCH SYSTEM
❑ Originally developed for GERD
❑ It is a suturing device that endoscopically uses a suction
chamber to capture the gastric wall and creates pleats using
tagged suture to reduce gastric volume
❑ Mean excess wt. loss of 21% at 1 month & 58% at 12 months

31. PRIMARY OBESITY SURGERY ENDOLUMINAL
❑ Simple restrictive endoscopic method
❑ Suturing/plicating gastric fold
❑ mainly in Fundus & antrum
❑ Reduces capacity of stomach & induces early satiety
❑ 44.9 % excess wt. loss in 1 yr

33. SPACE OCCUPYING DEVICES
❑ Bioenteric Intragastric Balloon - mostpopular and commonlyusedIGB
❑ consists of asilicone spherical balloon (very resistant to gastric acids) with asmooth surface
to reduce gastricmucosaerosion risk
❑ filled with isotonicsaline
❑ possessesaradiopaque self sealing valvethat allows localizing it with simple radiation
❑ capacity = 600 -800 mLsalıne
❑ Themaximum duration accepted forthe balloonin situ is6months

35. MALABSORBTIVE TECHNIQUES…..

36. .Duodenal – JejunalBypass-
❑ Endoscopically implanted deviceshavebeen developed to
reproduce the bypasseffects similar to surgical procedures
❑ E.G.-The EndoBarrier gastrointestinal linerissingleuse
endoscopicimplant mimickingaduodenal-bypass.
❑ It is60cmimpermeable polymersleeve.
❑ Proximal end containsnickel titanium implant
anchored in the duodenalbulb
❑ Distal end extendsinto the proximal jejunum
❑ Placement under endoscopically under G.A.
under fluoroscopy

37. Endobarrier gastrointestinal barrier

38. THE FUTURE : WHAT’S NEXT
❑ Traditionally It was believed that weight loss after bariatric surgery was
entirely due to reduced calorie intake due to mal-absorption or
restriction
❑ Recently Scientists have postulated other mechanisms of
bariatric surgery which favor weight loss & diabetic control
❑ E.g. metabolic effects of bariatric surgery
❑ hormonal response after bariatric surgery
❑ Role of gut microbia
❑ Role of bile acid
❑ By knowing these mechanism it may help us design safer, more effective
& less invasive therapy

39. KEY POINTS
▪ Obesityisaworldwideepidemic,with increasingratesacrosstheworld
▪ The prevalence of obesityin the UnitedKingdomis the highestin Europe
▪ There hasbeen aworldwide decreasein the LAGB asaprimary bariatric procedure with asteep
increase in the SG,whichhasalready become the mostfrequent primary bariatric procedure in some
countries
▪ Mini gastricbypass isanattractive bariatric procedure asitcould be asimpler and saferalternative
to the gold standardRYGBwith shorteroperative time, lower complicationrates, betterweight
loss,reducedhospitalizationin the long term, and with ashorterlearning curve.
▪ Mini gastric bypassisassociatedwith a30-daymortality of 0.14%,1%leak rate and 76% EWLat 12
months. Thisgivesthe MGBasaferand more effectiveprofile than the gold standard RYGB

40. • In recent years ,there hasbeen an increase in the development of
endoscopic techniques for managing obesity.
• Thesedifferent techniques have been usedasprimary therapy, asabridge
to bariatric surgery, or asarevisional procedure after bariatric surgery.
• Understanding the mechanisms by which the different bariatric
surgical procedures work will help usin the development of safer, more
effective and lessinvasive therapies