ug surgery bariatric

1. BARIATRIC SURGERY
(part 2)
NUR FARRA NAJWA
082015100035

2. LEARNING OBJECTIVES
At the end of seminar student should be able to
• List the type of bariatric surgery and their
component
• Explain about the choices of surgical methods
• Discuss the result expected from bariatric surgery
• Explain the complications from bariatric surgery
• Get a glimpse of future of bariatric surgery

3. INTRODUCTION
• There is no perfect operation
• What the end point of bariatric surgery ?
– Maximum weight loss regardless of risk ?
– Just enough weight loss to alleviate comorbidities
at minimum risk?
Maximum weight loss with least risk and side
effects

4. BARIATRIC
SURGICAL
PROCEDURE
Restrictive
procedure
Limit amount of
food that can be
digested
Mal-absorptive
procedure
Limit absorption
of nutrients and
calorie
Bypassing
predetermined
length of small
intestines

6. CURRENT SURGICAL OPTIONS
1. Laparoscopically
2. Fewer access ports
3. Single umbilical incision
4. Transvaginally procedure
Least: Pure
(banding)
Severe: Standard
biliopancreatic diversion
(BPD)
Varying degrees of gastric restriction
Least: pure
(banding)
Severe: standard bilio-
pancreatic diversion
(BPD)
Varying degrees of mal-absorbtion

7. SURGICAL METHODS
1. Gastric banding (AGB)
2. Sleeve gastrectomy (GS)
3. Roux-en-y gastric bypass (RYGB)
4. Standard biliopancreatic diversion (BPD)

8. 1. GASTRIC BANDING
PROCEDURES DETAILS • Putting an adjustable band around the
upper stomach
• Inserted as a day-case procedure
MECHANISM • Provide restriction to gastric
• Controlled by the amount of fluid injected
into the subcutaneous port.
WEIGHT LOSS • Around 45–50 % of excess weight with
intensive follow up
RISK • Least risky procedure (0.1 per cent
perioperative mortality)

9. Implanted over
area of rectus
sheath

10. ADVANTAGES • Safe, adjustability and reversibility
DISADVANTAGES • Requires a lot of patient compliance
• Need for continual band adjustments
in the early postoperative period and
occasional long-term adjustments.
COMPLICATION (band failure) • Due to prolapse of the stomach
through the band or the band can slip
up or down from its initial position.
• Bands erode into the stomach.
FAILURE RATE • Band failure is relatively low (<5 per
cent)
• Long term failures due to insufficient
weight loss , up to 30 per cent of
patients

11. REVISION PROCEDURE INDICATION • Poor weight loss
• Adhesions and gastric wall thickening
SUITABLE PATIENT • Relatively easy operation to perform in
most patients who have a BMI <50
kg/m2
• Should be avoided in binge eating
patients
• Should be avoid in eating habits
involve excessive sweets and chocolate
NOT SUITABLE IN • Poorly selected patient
• Poor quality of their follow up

12. 2. SLEEVE GASTRECTOMY
PROCEDURES DETAILS • New operation
• Less postoperative monitoring
• Does not require any adjustments
MECHANISM • Removes the grehlin-secreting area of
the stomach, beneficial effect on
reducing appetite
WEIGHT LOSS • Around 65 per cent excess weight loss
at two years
• As good as gastric bypass without any
mal-absorption issues
RISK • Riskier procedure than gastric banding
(0.2 per cent operative mortality)
DISADVANTAGES • Tendency for the sleeve to expand
over time

14. COMPLICATION • The long staple line can leak despite
various manoeuvres to avoid leakage
FAILURE RATE • Regain weight post gastrectomy
• Probably around 10–20 per cent
REVISION PROCEDURE INDICATION • A re-sleeving procedure (sleeve
expand)
SUITABLE PATIENT • Initial procedure in super-obese (BMI
>50kg/m2)
• To induce enough weight loss to make
bypass surgery feasible
NOT SUITABLE IN • Still unclear and more long-term data
are needed

15. True Place For Sleeve Gastrectomy As A
Primary Bariatric Procedure?
• Still unclear and more long-term data needed
• But this procedure is accelerating at a
remarkable rate largely
– Relative technical ease of doing the procedure
– The lack of potential mal-absorption problems
– Option of doing a relatively safe second-stage
procedure if needed.

16. CONCEPT ??
• Bariatric surgery as a staged procedure
– first stage being a sleeve gastrectomy
– second stage, a gastric bypass or BPD with a
duodenal switch.
• The second stage in most cases will not be
needed.

17. 3. ROUX-EN-Y GASTRIC BYPASS
PROCEDURES DETAILS • A very effective weight loss procedure
• Variety of techniques
MECHANISM • Very effective for alleviating and curing
permanently type II diabetes (80% of
patient)
• Result almost immediate and
independent of weight loss.
WEIGHT LOSS • Around 65–75 per cent excess weight
loss
RISK • A higher risk of around 0.5 per cent
perioperative mortality
DISADVANTAGES • Many variations in the actual gastric
bypass technique

18. 30ml proximal
gastric pouch
1cm
anastomosis
• Small reservoir
• Small passage
• Bypass distal stomach,
duodenum and
jejunum
ROUX LIMB (length correlates with
degree post operative weight loss
• Standard : 75 cm
• Superobese : 150 cm

19. THEORIES ON MECHANISMS OF HOW A GASTRIC BYPASS/BILIOPANCREATIC
DIVERSION AMELIORATES DIABETES
Foregut hypothesis
• Bypass of proximal duodenum and
jejunum
• Reduces stimulated secretion of anti-
incretin factors (anti-incretin factor
inhibit insulin secretion)
• Thus stimulate insulin secretion
Hindgut hypothesis
• Rapid delivery of small bowel content
into the distal jejunum and ileum
• Exaggerates stimulated incretin
(glucagon-like peptide-1 and peptide-
yy) release
• Thus stimulates insulin secretion
• Banding and sleeve gastrectomy
• Dependent on weight loss to resolve the diabetes

20. Variations In The Actual Gastric Bypass
Technique
• Antecolic versus retrocolic roux limb
placement
• Varying alimentary and biliary limb lengths
• Additional banding of the gastrojejunal
anastomosis to prevent dilatation
• Varying methods of doing the gastrojejunal
anastomosis
• Varying methods of closing potential hernia
spaces .

21. 1. ANTECOLIC VERSUS RETROCOLIC
ROUX LIMB PLACEMENT

22. https://www.researchgate.net/figure/Possible-herniation-sites-after-antecolic-Roux-and-Y-
gastric-bypass_fig1_235904221

23. https://www.researchgate.net/figure/Possible-herniation-sites-after-antecolic-Roux-and-Y-
gastric-bypass_fig1_235904221

24. 2. Varying alimentary and biliary limb lengths
https://www.researchgate.net/figure/Roux-en-Y-
gastric-bypass-configuration-The-proximal-
jejunum-is-divided-distal-to-the_fig1_281197667

25. https://bmcsurg.biomedcentral.com/articles/10.1186/1471-2482-10-33/figures/1
3. Additional banding of the gastrojejunal
anastomosis to prevent dilatation

26. 4. Varying methods of doing the
gastrojejunal anastomosis
• Different method for gastro-jejunal
anastomosis
– hand-sewn (HSA)
– circular-stapled (CSA)
– linear-stapled (LSA) anastomotic techniques
• Differ in terms of stricture rates and their
impact on subsequent weight loss.
https://www.ncbi.nlm.nih.gov/pubmed/24595472

29. 5. Varying methods of closing potential
hernia spaces .
Figure 1. Arrows 1–3 indicate potential spaces for hernia formation: (1) Petersen’s space,
between the Roux limb mesentery and the transverse mesocolon; (2) the mesenteric opening at
the biliopancreatic limb; and (3) the opening through the transverse mesentery when the
bypass is in retrocolic fashion. (Image from Kim Y, Crookes PF. Complications of bariatric surgery.
In: Essentials and Controversies in Bariatric Surgery. Huang, C-K, ed. Available at:
https://www.intechopen.com/books/essentialsand-controversies-in-bariatric-
surgery/complications-of-bariatricsurgery. © 2014 Kim Y, Crookes PF. Published under CC BY 3.0
license. Available from: http://dx.doi.org/10.5772/58920. Accessed February 16, 2016)

30. COMPLICATION (failure) • Pulmonary embolism, tachycardia,
gastro-jejunostomy anastomotic leak
• Early : wound infection, remnant
gastric dilatation, roux limb
obstruction
• Late : stomal stenosis, incisional
hernia, bowel obstruction, internal
hernia
• Nutritional complication
• Dumping syndrome
FAILURE RATE • -
REVISION PROCEDURE INDICATION • -
SUITABLE PATIENT • Superobese
• 2nd stage procedure
NOT SUITABLE IN • -

31. Cont.
• Nutritional deficiency
– multivitamins, iron, calcium, vitamin-B12, folate
• Periodic bone densitometry measurements
– to avoid premature osteoporosis.

32. 4. BILIOPANCREATIC DIVERSION (BPD)
PROCEDURES DETAILS • Biliopancreatic diversion (BPD) with or
without a duodenal switch (DS)
MECHANISM • Rapid effect as a gastric bypass for
alleviating diabetes independent of
weight loss
WEIGHT LOSS • Most effective with 75–85 per cent
excess weight loss
RISK • Highest perioperative mortality of 1–2
per cent
DISADVANTAGES • Extreme malabsorption of all
operation
• There is a need for a high protein
intake of around 90 g/day

33. STANDARD BPD DUODENAL SWITCH VARIATION
Approximately two-thirds of the distal
stomach is removed
Vertical sleeve gastrectomy
Anastomosis made to the stomach Anastomosis is made to the first part
of the duodenum

34. Antrectomy1
2
3
Sleeve
gastrectomy1
Duodenal
swith
2
3

35. B-P-D?
1. A sleeve gastrectomy is performed. A large portion of the stomach
is removed with a stapling instrument, leaving a narrow tube, or
sleeve, from the top to near the bottom of the stomach. With less
stomach to fill, feel full more quickly and eat less food and fewer
calories.
2. Reroutes food away from the upper part of the small intestine,
which is the natural path of digestion. This cuts back on how many
calories and nutrients body is able to absorb. The small intestine is
divided and a connection is made near the end of the small
intestine.
3. Last procedure changes the normal way that bile and digestive
juices break down food. This cuts back on how many calories
absorb, causing still more weight loss. One end of the small
intestine is connected to the duodenum, near the bottom of the
stomach

36. BPD
• Will induces a state of decreased absorption,
patients will likely experience
– more frequent and looser bowel movements
– increased flatulence
– need to be very closely monitored for vitamin,
mineral and protein levels

37. Duodenal Switch- DS?
• Duodenal switch preserves the outlet muscle
(pylorus)- controls emptying of the stomach
• So dumping syndrome is unusual.
• Duodenal switch results in
– the greatest, most reliable and longest lasting
weight loss of all the weight loss procedures.

38. COMPLICATION (failure) • Severe risk of many deficiency
syndromes.
• Protein calorie malnutrition, anemia,
dumping syndrome, marginal ulcer
FAILURE RATE • -
REVISION PROCEDURE INDICATION ?
SUITABLE PATIENT • Patients with a very high BMI.
NOT SUITABLE IN • Patient does not adhere to their
vitamin and micronutrient
supplementation regime

39. In A Nutshell

40. RESULT

41. • Outcomes indicators
– Achieved weight loss
– Improved quality of life (comorbidities)
• Successful weight loss?
– Losing at least 50 per cent of the excess weight in the first 12–24
months.
– Excess weight = their current weight - their ideal body weight (at BMI
25 kg/m2).
• Comorbidities?
– Improved with only 10–20 per cent of excess weight loss
Thus the end point of removing as much weight as possible may not always
be necessary from a health and longevity point of view.

42. In general terms
• Strive for an effective operation.
• Resolve or ameliorate any of the
comorbidities which are linked to obesity

44. Drawback?
• Weight regain
– Difficult to manage
– Result in revisional surgery that more risky than a
primary procedure.
• Patients often ‘move the goal posts’
– Wanting a better result than the surgery promises.
– So we need clear understanding of the end point of
surgery must be agreed before
– Must have a plan written down and agreed
preoperatively to avoids misunderstandings
postoperatively.

45. WHAT OPERATION TO GET AND
RIGHT AT THE FIRST TIME FOR
AN INDIVIDUAL?

46. • Its doctor responsibility
• Need a thorough understanding of what risks, what outcome and
patient preparedness for it.
• Vary from patient to patient.
– Those patients who are very risk averse, often young with young children,
will understandably often want an operation with the least postoperative
mortality even though it may not result in as much weight loss as another
more risky procedure.
– Conversely, a patient without children who is older and much heavier may
be keen to undergo a more risky procedure to maximise their weight loss.
• It is a considerable judgement on both the patient and surgeon’s part
• Desirably
– Discussion at a bariatric MDT
– Every member has a chance to express their views about the suitability of
any particular procedure for the patient

47. COMPLICATIONS

48. COMPLICATIONS
• Most common
– General risks, such as bleeding and infection
– Specific risks in relation to the actual surgical
procedure will vary from procedure to procedure
• Obese patients
– Generally is more risky than surgery in lean patients
– No matter what type of surgery
– More likely to suffer from cardiorespiratory
comorbidities
– Often hypercoagulable

49. Cont.
• Perioperative mortality
– Should be minimal
– But higher in those
• With the most severe comorbidities.
• Severe unstable cardiovascular disease (absolute
contraindication to bariatric surgery)
• Super-obese (BMI >50 kg/m2) males also have a higher
risk of perioperative mortality
• Patients with a past history of pulmonary embolism.

50. Cont.
• Laparoscopic surgery
– Leaks from resection margins, anastomoses site
– Off-camera injuries with internal hernias

51. Prophylactic
• Preoperative caval filter
• Precautions of graded calf compression
stockings,
• Intraoperative calf compression,
• Intraoperative low molecular weight heparin,
• Early mobilisation
• Extended postoperative low molecular weight
heparin administration.

52. Clinical Implication
• When suspected complication
– Carry out investigations immediately
– Don’t delay
– As morbidly obese patients often have relatively few
clinical signs and symptoms despite overt peritonitis.
• Laparoscopy to assess the situation rather than
wasting time doing other investigations.
• Have strategies to minimise risks during and
following surgery.
– Be part of well established bariatric team
– Adequate training and throughput of surgical patients.

55. EMERGING TRENDS

56. 1. Neuromodulation using gastric-implanted
electrodes
2. Vagal blocking using electrodes around the
abdominal vagus
3. Endoscopically placed intraluminal sleeves
4. Endoscopic gastric restriction procedures
5. Improvements in the current operations (less
abdominal wall trauma)
1. Single incision
2. Transvaginal approaches.

59. SUMMARY
List the type of bariatric surgery and their
component
Explain about the choices of surgical methods
Discuss the result expected from bariatric
surgery
Explain the complications from bariatric
surgery
Get a glimpse of future of bariatric surgery

60. REFERENCES

61. THANK YOU