6. • Early 20th century – Obesity becoming apparent.
• 1920 - Medical treatment experiments.
• Achieving weight loss – yes [ only for mild obese ]
•Maintaining weight loss - NO
• Low calorie balanced diet
• Anorectic drugs
• Behavioral therapy
• Exercise
No effect on
morbidly
obese patients
7.
8. INDICATIONS
International Asia-Pacific
BMI > 40 BMI > 35
BMI > 35 with co-morbidities BMI > 32 with comorbidities
Failed medical therapy and lifestyle
modification
BMI > 30 & Central obesity with atleast 2
criteria for metabolic syndrome
Co-morbidities – HTN, IGT, DM, Hyperlipidemia & OSA
Metabolic syndrome – HTN, DM, Raised TG, Reduced HDL cholesterol
Recently – Even BMI < 35 – Surgery is better Glycemic Control c/w medical Rx
9. CONTRA-
INDICATIONS
Untreated major depression/ psychosis
Binge eating disorders
Current drug/ alcohol abuse
Severe cardiac disease with prohibitive risks
Severe coagulo-pathy
Inability to comply with nutritional needs eg lifelong vitamin replacement
>65 years or <18 years Controversial
11. • Last 7 decades – Accidental finding of unrelated procedure to specific
newer techniques & multiple procedures.
• Traditionally 3 mechanisms for weight loss.
12. MALABSORPTIVE
PROCEDURES –
INTESTINAL BYPASS• 1952 – Dr Viktor Henrickson – Swedish surgeon
• Removal of generous segment of small intestine for other reasons
Significant weight loss
• 1953 – Dr Varco – First Jejuno-Ileal bypass
• 1963 – Dr Payne & colleagues – Jejuno-colonic shunts as reversible
procedures
• Temporary measure
• Expected weight loss Reversal
13.
14. • Disadvantages
• Bypass enteritis
• Pneumatosis intestinalis
• Liver disease from protein deficinecy Liver failure
• Malabsorption & Diarrhoea
• Electrolyte imbalance
• Nephrolithiasis & cholelithiasis
• Arthritis & Osteomalacia
• Many patients – reversal or modifications.
• DARK HISTORY - >30,000 BYPASS PROCEDURES BEFORE IT
WAS RECOGNIZED THAT THE COMPLICATIONS WERE
UNACCEPTABLE.
16. GASTRIC BYPASS
• Gastric ulcer diseases Gastrectomy
Weight loss common
• 1967 – Mason & Ito loop gastric
bypass
• Modificaton of billroth II with different
goal
• Bilious vomiting
• Marginal ulcers
• Dumping syndrome
• Anastomotic tension
Mason & Ito loop gastric bypass
17. ROUX-EN-Y GASTRIC BYPASS
• Modification of Mason loop gastric
bypass.
• Small gastric pouch – 15-20 ml
• Division of jejunum 40-60 cm from
LOT.
• Distal jejunum anastomosed to Neo-
stomach
• Proximal jejunum anastomosed to
ileum.
• Common channel 100-150 cm
18. BPD & BPD/DS
• 1979 – Scorpinaro and colleagues
• Partial gastrectomy
• Closure of duodenal stump
• Transection of jejunum 20 cm
distal to ligament of treitz
• Gastro-distal jejunostomy with
alimentary limb of 250 cm
• Proximal jejuno-distal ileostomy
• Common channel 50 cm
19. Advantages Disadvantages
Excellent initial weight loss &
maintenance of weight
Diarrhoea, Foul smelling stools,
flatulence
Excellent reduction in co-morbidities Poor iron absorption Anemia
Protein malabsorption
Stoma ulceration
Dumping syndrome
Peripheral neuropathy
Wernicke encephalopathy
Poor Ca & Vit D absorption Bone
demineralization
• Protein Malnutrition – Most serious Cx & Most common cause of late mortality
• Excellent weight loss BUT SIGNIFICANT LONG TERM MORBIDITY
21. • Advantages c/w BPD
• Excellent weight loss
• Longer Common channel
• Less protein
malabsorption
• Less liver failure
• Less renal failure
• Less electrolytic
abnormalities
• Well preserved pylorus
• Less marginal ulcers
• Less dumping syndrome
22. BOTH BPD & BPD+DS
• Long procedure
• Difficult open & lap approaches wise
• Most serious Cx – Internal hernia
• Risk of bowel incaceration & necrosis Immediate attention
• Less Cx with lap approach
24. BANDED GASTROPLASTY
• Printen – Horizontal Gastroplasty – Functional gastric transaction with
1-1.5 cm conduit
• Disadv. - Widening & Stretching of common channel
- Reflux Esophagitis
25. • 1981 – Laws – Silastic ring with
vertical gastric partition
• 1982 – Mason – VBG [ Vertical
Banded Gastroplasty ]
• <50 ml pouch
• Banding lesser curvature pouch
outlet with polypropylene mesh/
silastic ring.
• Disadv
• Breakdown of stapled partition
• Weight regain long term
• RARE & OUTDATED
26. ADJUSTABLE GASTRIC
BANDS• More physiological without disturbing continuity.
• Idea originated from Nissen’s FP & gastric wrapping with
polypropylene mesh.
• Benefits from reflux
• Early satiety without any metabolic & physiological changes
Non-
adjustable
bands
Adjustable
bands/
Reversible
bands
Marlex mesh
Silicone bands
Obstruction
High re-operation
Reflux esophagitis
Liquid filled silastic cuff with
subcutaneous valve
Less Short term Complications
Better weight loss
REVERSIBLE
SELF CONTROL
27. • Disadvantages
• Band erosion
• Band slippage
• Foreign body infection
Recent years – fallen out of favor
STILL AGB remains an option for patients
28. SLEEVE GASTRECTOMY
[ SG ]
• Originally – Staging procedure
• Regan & Gagner – 2 stage procedure as part of BPD/DS
• Initial SG over 60F catheter bougie
• 6-12 months after plateau of weight loss
• 2nd stage BPD/DS or gastric bypass
• BUT
• Most – lost enough weight with SG ALONE
C/W AGB
•Decreased need of
reoperation
•No FB
•Decreased Ghrelin
production
29. Advantages
Technically easy
Minimal morbidity
No FB
No marginal ulcers
No dumping
No internal hernia
No nutritional deficiency
Cx
Staple line leak
StrictureMOST COMMONLY PERFORMED IN
USA
EMAM in mumbai
40. Early Cx [ Within 30 days of
surgery ]
Late Cx [ >30 days after surgery ]
Bowel Obstruction Anastomotic stricture
DVT Cholelithisis
GI / Peritoneal bleeding Dehiscence / Fistulization
Leaks Incisional hernia
Pulmonary embolism Marginal ulceration
Wound infection Nutritional deficiencies
Internal hernia Bowel obstruction
COMPLICATIONS
41. AGB / VSG Malabsorptive
Surgeries
Combined
Band serosal erosion Bowel obstruction Haemorrhage
Mucosal erosion &
perforation
Leakage/ Ulcer at
anastomotic site
Dumping syndrome
Port malfunction GJ stenosis DVT
Gastric prolapse Incisional hernia PE
GERD Wound dehiscence Sepsis
Dysphagia
Nutritional deficiencies – Common to ALL
42.
43. • Most significant long term Cx – Nutritional deficiencies
• Risk factors
Preop deficiencies Reduced food intake
Poor adherence to supplements Altered digestion &
absoption
• MC Vitamin deficiencies s/p RYGB
• Vit B12
• Thiamine
• Vit D
• Others [ Vit A, Folic acid, Iron ,Copper ]
• Lifelong nutritional monitoring & Vitamin
supplementation –
MUST for ALL
45. LGGCP
[ LAPAROSCOPIC GASTRIC GREATER CURVATURE PLICATION
• Adopted for salvage of failed
bariatric surgery
• Dilated sleeve gastrectomy
• Pouch dilatation after gastric
bypass
• Inadequate weight loss after
LAGB
46. • Continuous suturing from the fundus of the
stomach to the antrum
• Making one or two layers of plication from the
anterior wall of the stomach to its posterior wall.
• 00 prolene or nylon
• 2-cm interval
• 2-cm distance from the lesser curvature.
• Volume of stomach – 100 cc
• Sutures were initially intra-mucosal later on
extramucosal, so it prevented the absorption by
gastric acid over a long-term period.
66. CONCLUSION
• Bariatric/metabolic surgery can be performed as safe as
laparoscopic cholecystectomy with operation mortality around 0.1%
• Metabolic syndrome - more severe complications - higher mortality
rates.
• Most important for weight loss - restriction and reduced calories
intake
• Reason for weight regain after surgery - lost restriction
• Goal of revision surgery is to rebuild the restriction
67. • BMI did not predict the effect of bariatric surgery on mortality or
cardiovascular disease and patients who may benefit from bariatric
surgery are those with insulin resistance.
• BMI 40 – 55 Gastric restrictive technique
• BMI >55 Restrictive + Bypass
• Most commonly performed – LSG
• Gold standard – Roux-En-Y gastric bypass
• Promising – LGGCP with/without LSG
• Future - EBTs