Since 1985 obesity has been recognized as a chronic disease. It affects
Weight reduction may sometimes be achieved through medically-supervised dieting and intensive behavior modification, but when this fails, surgery is an option. Over the years, refinements in surgical procedures have led to reports of results superior to those seen with the earlier operations. In an effort to evaluate the objective evidence for these new technologies, the NIH held a consensus development conference on GI surgery for Severe obesity. A 13-member panel developed a consensus statement after hearing scientific presentations from many physicians, scientists, health care professionals, etc. The generally accepted criteria for surgical treatment developed at the 1991 National Institutes of Health Consensus Development Conference Panel [ 24 ] include BMI greater than 40 or BMI greater than 35 in combination with life-threatening cardiopulmonary problems or severe diabetes mellitus.
The first bariatric procedure to be presented to a recognized surgical society and published in a peer reviewed journal was that of Linner and Kremen in 1954. The case which they presented was of a jejuno-ileal bypass.(JIB). Jejuno-ileal bypass involved joining the upper small intestine to the lower part of the small intestine bypassing a large segment of the small bowel, which is thus taken out of the nutrient absorptive circuit. The premise of this bypass was that patients could eat large amounts of food and the excess would either be poorly digested or passed along too rapidly for the body to absorb. In addition, the procedure caused a temporary decrease in appetite which also resulted in weight loss. The procedure was very successful at producing weight loss, however patients developed chronic diarrhea, kidney stones, and liver disease. So a search for a better procedure followed.
As a consequence of all these complications, jejuno-ileal bypass is no longer a recommended Bariatric Surgical Procedure. Indeed, the current recommendation for anyone who has undergone JIB and still has the operation intact, is to strongly consider having it taken down and converted to one of the gastric restrictive procedures.
In 1967 the gastric bypass was devised and performed by Dr. Edward Mason at the University of Iowa. Dr. Mason noted that patients who underwent subtotal gastrectomy for peptic ulcer disease remained below normal weight and could not gain weight easily. His approach involved stapling most of the stomach, bypassing the duodenum, and allowing the undigested food to pass directly into the jejunum. Most of the early operations failed because the pouch eventually became enlarged.
The technique was modified to obtain a 50 mL pouch and a Roux-en-Y limb to minimize bile reflux from the loop gastrojejunostomy. The roux limb was lengthened to 100-150 cm in order to increase malabsorption and improve weight loss. The technique has been modified throughout the years with regard to the gastric pouch and retrocolic position of the roux limb. This procedure has stood the test of time, with one series of 500 patients followed for 14 years with patients maintaining 50% excess weight loss.
Biliopancreatic diversion (BPD) does NOT refer to a specific operation. It describes any anatomic arrangement within the GI tract that diverts bile and pancreatic secretions from their usual anatomic paths. The goal of BPD is maintaining protein digestion/absorption but decreasing fat digestion by delaying the interaction between fat and biliopancreatic secretions. In addition, when the upper jejunum is bypassed, beneficial entero-humeral effects on carbohydrate metabolism is gained. The morbidly obese seem to overproduce insulin. With changes in jejunal hormonal release, insulin production and resistance are decreased. Starch metabolism in beneficially altered. Scopinaro’s procedure= distal gastrectomy to reduce the incidence of peptic ulceration, an alimentary limb consisting of the terminal 250 cm of ileum, and a biliopancreatic limb consisting of the rest of the small bowel. The common channel is 50 cm beyond the biliopancreatic to alimentary anastomosis. This procedure has two components. A limited gastrectomy results in reduction of oral intake, inducing weight loss, especially during the first postoperative year. The second component of the operation, construction of a long limb Roux-en-Y anastomosis with a short common &quot;alimentary&quot; channel of 50 cms length. This creates a significant malabsorptive component which acts to maintain weight loss long term. Dr Scopinaro recently published long term results of this operation, reporting 72% excess body weight loss maintained for 18 years. These are the best results, in terms of weight loss and duration of weight loss, reported in the bariatric surgical literature to this date. Disadvantages of the procedure are the association with loose stools, stomal ulcers, offensive body odor and foul smelling stools and flatus. The most serious potential complication is protein malnutrition, which is associated with hypoalbuminemia, anemia, edema, asthenia, alopecia, generally requires hospitalization and 2 - 3 weeks hyperalimentation. BPD patients need to take supplemental calcium and vitamins, particularly Vitamin D, lifelong. Because of this potential for significant complications, BPD patients require lifelong follow-up. In BPD patients who have received 200 - 300 cm alimentary limbs because of protein malnutrition concerns, the incidence of protein malnutrition fell dramatically to range from 0.8% to 2.3%
Listing of complications of biliopancreatic diversion: Protein Malnutrition 15% Incisional hernia 10% Intestinal obstruction 1% Acute biliopancreatic limb obstruction Stomal Ulcer 3.0% Bone Demineralization: Pre-op 25%; at 1-2 yrs, 29%; at 3-5 yrs 53%; at 6-10 yrs 14%. Hemorrhoids 4.3% Acne 3.5% Night Blindness 3% Operative Mortality 0.4% - 0.8% (1122 subjects, 1984-1993)
This bariatric procedure separates the stomach into an upper pouch along the lesser curvature of the stomach about 5 cm long with a diameter of approximately 1.5 cm and a volume of 20 to 40 mL, into which ingested food enters. This small restricted pouch then empties into the rest of the stomach through an 11-mm diameter channel. This channel is wrapped or banded externally with a ring of nonexpandable prosthetic material to prevent the stoma from enlarging over time and counteracting the restriction of anatomy and the success of the operation. This gastric restrictive approach was attractive in theory because of its technical ease, low morbidity, and lack of any bypass of the intestinal tract. Although this operation works quite well in patients who maintain a bulky diet of meat and potatoes by preventing ingestion of large volumes, 50% of patients quickly recognize that high-calorie liquids (e.g., ice cream and milkshakes) rapidly slide through the stoma and do not lead to a rapid early satiety; such patients change their diet, and their weight increases, many times back to their preoperative weight. The authors evaluated results at the Mayo Clinic with vertical banded gastroplasty in 70 patients from 1985 through 1989. [ 23 ] Although morbidity and mortality were low, at 3 years postoperatively, only 38% of patients had lost and maintained at least 50% of their excess weight. Despite the unsatisfactory results, many groups throughout the United States continue to advocate this operation because of its safety and lack of significant metabolic side effects.
1988 Doug Hess of Ohio modified BPD, called Duodenal switch with sleeve gastric reduction. Dr. Marceau and colleagues in Quebec have pioneered this approach. The procedure is accomplished by transecting the duodenum 5 cm beyond the pylorus. 250 cm of distal ileum becomes the alimentary limb and is anastomosed to the proximal duodenal segment. The balance of the small intestine is the biliopancreatic limb. The common channel is 100 cm. Sleeve gastrectomy preserves the pylorus, all or most of the antrum, and a significant amount of duodenum. Marginal ulcers are prevented. Increased iron and calcium absorption occurs compared to gastric bypass. Stomach size is ~200-250cc. Antum preservation results in minimal B12 deficiency. Dumping is prevented with normal
Wittgrove and Clark from San Diego publish there series on 5 Cases of Laparoscopic Gastric Roux-en-Y gastric bypass, the first of which is performed in 1993
GUIDELINES- approved the lap VBG and lap gastric bypass Roux-en-Y
Surgical Treatment of Morbid Obesity
SURGICAL TREATMENT OF MORBID OBESITY Scott D. Steinberg, M.D. St. Vincents Hospital and Medical Center Grand Rounds, May 30, 2001
OVERVIEW <ul><li>The problem of obesity </li></ul><ul><li>Indications for bariatric surgery </li></ul><ul><li>Evolution of bariatric surgery </li></ul><ul><li>Results of bariatric surgery </li></ul><ul><li>Conclusions </li></ul>
INTRODUCTION <ul><li>More than 50% of US adults are overweight (BMI > 25 kg/m 2 ) </li></ul><ul><li>The percentage of obese Americans (BMI > 30 kg/ m 2 ) has increased by more than 50% in the last 20 years </li></ul><ul><li>The number of overweight children has doubled over the last 20 years </li></ul>JAMA, 282(16), 1504-1506
<ul><li>The estimated number of annual deaths attributable to obesity among US adults is approximately 325,000 </li></ul><ul><li>More than 80% of these deaths occurred among individuals with a BMI of > 30 kg/m 2 </li></ul>MORBID OBESITY JAMA, 282(16), 1530-1538
BODY-MASS INDEX (Height in meters) 2 BMI = Weight in kg
<ul><li>100 lbs above ideal body weight </li></ul><ul><li>OR </li></ul><ul><li>BMI >40kg/m 2 </li></ul>CLINICALLY SEVERE OBESITY
THE FRAMINGHAM STUDY <ul><li>The first cohort to terminate because of demise of all participants was the morbidly obese </li></ul>
<ul><li>Results from a complex interaction of genetic, behavioral, and environmental factors </li></ul><ul><li>Second leading cause of preventable death, exceeded only by cigarette smoking </li></ul>OBESITY
MORBID OBESITY <ul><li>HTN </li></ul><ul><li>Diabetes </li></ul><ul><li>CAD </li></ul><ul><li>CHF </li></ul><ul><li>Cirrhosis </li></ul><ul><li>Osteoarthritis </li></ul><ul><li>Vascular disease </li></ul><ul><li>Gallbladder disease </li></ul><ul><li>Sleep apnea </li></ul><ul><li>Breast cancer </li></ul><ul><li>Uterine cancer </li></ul><ul><li>Prostate cancer </li></ul><ul><li>Colon cancer </li></ul><ul><li>Psychiatric disease </li></ul>
<ul><li>First treatment is lifestyle and dietary changes </li></ul><ul><li>Only 5-10% of patients maintain weight loss for more than a few years </li></ul><ul><li>When conservative measures fail, patients may consider surgery </li></ul>MORBID OBESITY Blue Cross/Blue Shield Medical Policy Manual, 1996
WHICH PATIENTS ARE CANDIDATES FOR BARIATRIC SURGERY?
<ul><li>Risk for M&M is proportional to the degree of overweight </li></ul><ul><li>Pts with BMI > 40 (*35) are at highest risk and should be considered for bariatric surgery </li></ul><ul><li>Diet and Drug therapy has limited success in the morbidly obese </li></ul><ul><li>Endorsed VBG and Roux-en-Y gastric bypass </li></ul>Gastrointestinal Surgery for Severe Obesity. NIH Consens Statement 1991 Mar 25-27;9(1):1-20.
<ul><li>BMI > 40 kg/m 2 </li></ul><ul><li>BMI > 35 kg/m 2 with serious co-morbid medical conditions </li></ul><ul><li>Repeated failure at conservative treatments </li></ul><ul><li>No history of significant psychiatric disorders </li></ul>INDICATIONS FOR SURGERY
GASTRIC BYPASS WITH ROUX-en-Y LIMB SUBSEQUENTLY MODIFIED 50 mL POUCH WITH A ROUX LIMB TO MINIMIZE BILE REFLUX ROUX LIMB WAS LENGTHENED TO INCREASE MALABSORPTION AND IMPROVE WEIGHT LOSS COMBINED RESTRICTIVE AND MALABSORPTIVE
Nicola Scopinaro Biliopancreatic Diversion (BPD) Any procedure that diverts bile and pancreatic secretions Combined Restrictive and Malabsorptive surgery 1976 “ BPD”
1982 VBG Vertical- Banded Gastroplasty <ul><li>Dr. Edward Mason </li></ul><ul><li>Stapled opening in </li></ul><ul><li>stomach </li></ul><ul><li>Staple line along angle </li></ul><ul><li>of His </li></ul><ul><li>Polypropylene mesh </li></ul><ul><li>around lesser curvature </li></ul>
<ul><li>N=500 </li></ul><ul><li>Excess weight loss of 80% in first year </li></ul><ul><li>95% of significant pre-operative </li></ul><ul><li>comorbidities well controlled </li></ul>2000 Obesity Surgery, 2000 18:233-239
<ul><li>N=1040 </li></ul><ul><li>Mean LOS 1.9 days </li></ul><ul><li>Mean OR time 60 min </li></ul><ul><li>No leaks </li></ul><ul><li>5 perioperative deaths </li></ul><ul><ul><li>3 PE, 1 asthma, 1 suicide </li></ul></ul><ul><li>Mean EWL 70% @ 1 yr </li></ul>
<ul><li>N=275 (1997-2000) </li></ul><ul><li>1-31 month f/u </li></ul><ul><li>One conversion </li></ul><ul><li>One death (PE) </li></ul><ul><li>11 Wound infections </li></ul><ul><li>Median LOS 2 days </li></ul><ul><li>EWL </li></ul><ul><ul><li>83% @ 24 months </li></ul></ul><ul><ul><li>77% @ 30 months </li></ul></ul>
CONCLUSIONS <ul><li>OBESITY IS A MAJOR PROBLEM IN THE UNITED STATES </li></ul><ul><li>CURRENT DIET AND DRUG THERAPY OFFERS LIMITED SUCCESS FOR THE MORBIDLY OBESE PATIENT </li></ul>
<ul><li>BARIATRIC SURGERY OFFERS THE MORBIDLY OBESE LONG-TERM WEIGHT LOSS WITH IMPROVEMENT IN MORBIDITY AND MORTALITY </li></ul><ul><li>LAPAROSCOPIC BARIATRIC SURGERY CAN BE PERFORMED SAFELY WITH EXCELLENT RESULTS </li></ul>CONCLUSIONS