spotlight on bariatric surgery in brief

1. Overview on bariatric surgery
By
Dr Alas ElSewefy
Assistant prof. of general surgery & laparoendoscopy

2. Obesity: BMI of 30 or more
BMI= W in kg/(H in meter)2

3. Epidemiology
• 600 million obese
• 13% adults are obese
• 39% adults are overweight
• Worldwide obesity has doubled between 1980
and 2014

4. Pathophysiology
4
Bray GA, et al. Lancet. 2016;387:1947-1956.
Obesity
Epigenetic
Genetic
Physiologic
Behavioral
Sociocultural
Environmental

6. Treatment
• Dietary changes
• Exercise and activity
• Behavior change
• Prescription weight-loss medications
• Weight-loss surgery

7. Bariatric Surgery Criteria *
• Age ≥ 18 years < 60
• Body Mass Index (BMI) ≥ 40
• BMI ≥ 35 with significant co-morbidities
– Heart disease, Type 2 diabetes, Hypertension, Sleep
Apnea, GERD
• 30–35 , poorly controlled type 2 diabetes ????
• History of prior weight management attempts
• Motivation and engagement in lifestyle modifications

8. Bariatric Surgery Exclusion Criteria *
• Active substance use, including nicotine and alcohol,
<6 months prior to surgery.
• Medical or surgical conditions that may make surgery
a high risk to perform.
• Severe or poorly controlled current psychiatric illness
or undertreated symptoms.

9. Other Lifelong Criteria and Guidelines
• NSAIDS are contraindicated for gastric bypass
– Significantly increased risk of GI bleeding
• Avoidance (pre / post op) : nicotine, caffeine
– Potential ulceration

10. Multidisciplinary team

11. Complete H & P
Routine labs (FBS , kidney function, liver
profile, lipid profile, prothrombin time/INR,
blood type, CBC)
Nutrient screening with iron studies, B12 and
folic acid and vitamin D
Cardiopulmonary evaluation with sleep apnea
screening (ECG, CXR, echocardiography)
Preoperative Checklist for Bariatric Surgery

12. GI evaluation (H pylori screening ; gallbladder
evaluation and upper endoscopy if clinically
indicated)
Endocrine evaluation (Hb A1c; TSH with,
screening for Cushing’s syndrome if clinically
suspected
Clinical nutrition evaluation
Psychosocial-behavioral evaluation

13. Informed consent
Provide relevant financial information
Optimize glycemic control
Pregnancy counseling
Smoking cessation

14. Bariatric surgery history and
evolutions

15. Restrictive procedures are:
 Sleeve gastrectomy surgery
 Gastric band surgery
 VBG
Malabsorptive procedures:
 Jejunoileal bypass
Restrictive and malabsorptive weight loss surgeries are:
 Roux-en-Y gastric bypass surgery
 Duodenal switch surgery
 Sleeve bipartition

16. jejunoileal bypass: 1963, Payne et al.
35cm
15 cm

17. Advantages
Simple and easy
Rapid weight loss
Disadvantage:
Sever malnutrition
Diarrhea
Electrolyte imbalances
Renal failure

18. Vertical Banded Gastroplasty: 1982 –
Mason and Laws

19. Advantage:
• No dumping syndrome.
• No nutritional deficiencies/malabsorption.
Disadvantage:
• Reversal of a VBG requires a much more
complex
• Vomiting and severe discomfort.
• Not adjustable

20. Adjustable Silastic Gastric Band
1986 - Kuzmak

21. Advantages
Weight loss of approximately 40 – 50 percent
 No cutting of the stomach or rerouting of the
intestines
 Shorter hospital stay,
Reversible and adjustable
 Lowe complications and mortality
 Has the lowest risk for vitamin/mineral deficiencies

22. Disadvantages
Slower and less weight loss
Foreign device to remain in the body
Slippage or erosion
Dilation of the esophagus
Requires strict adherence to the postoperative
diet and to postoperative follow-up visits
Highest rate of re-operation

23. Sleeve gastrectomy: Marceau et al
1960
75-80%

24. Advantages
Weight loss similar to that of the RNGB >50%
No foreign objects (AGB), and no bypass or
Short hospital stay
Changes in gut hormones improve satiety
Disadvantages
 Is a non-reversible procedure
 Vitamin deficiencies
leaks
Refluxogenic
 potential weight regain

25. Roux en y gastric Bypass: Mason
1960s
60-100 cm
50 cm
30-50 ml

26. Advantages
long-term weight loss (60 to 80 %)
Changes in gut hormones that reduce appetite and
enhance satiety
Typical maintenance of >50% excess weight loss
Disadvantages
Technically complex →greater complication rates
Vitamin/mineral deficiencies
Longer hospital stay than the AGB
Internal hernia

27. Scopinaro procedure 1979
50-125 cm 60%
40 %

28. Advantages
 Greater weight loss than. 60 – 70%
 Allows patients to eat near “normal” meals
 Changes in gut hormones to reduce appetite and improve
satiety
 The most effective against diabetes compared to RYGB, LSG,
and AGB
Disadvantages
 Has higher complication rates and risk for mortality
 Requires a longer hospital stay
 Malnutrition

29. Modification of duodenal switch
•Min gastric bypass
•SADI

30. Min gastric bypass
150-200 cm

31. Advantages
 Reversible.
 Simple, lower cost .
 early recovery
 The weight loss ranges from 50% to 80% .
 Short operative time
 Metabolic effect
Disadvantages
 There are no long-term studies available
 biliary reflux → ulceration, inflammation or erosion around
the stomach walls.
 Malnutrition

32. SADI
300 cm50-125cm

33. Advantages
There is no at-risk gastric remnant.
No dumping .
↓ Calcium and iron deficiency, since 1st part of
duodenum is preserved.
Reduces risk of internal hernias.
Malabsorption is much less compared to
duodenal switch
Disadvantages
Dissection around duodenum is technically
difficult, and so the learning curve is prolonged.

34. Novel techniques

35. 1- SG TB (SLEEVE GASTRECTOMY WITH TRANSIT
BIPARTITION) , Santoro - 2012

36. Advantages
duodenum is not transected.
the sleeve has two outlets.
induce hormonal changes and diabetes
resolution.
minimises malabsorption.
Disadvantages :
higher risk of internal herniation as the
anastomosis is a Roux-en-Y type,
higher risk of marginal ulcers
Technically difficult

37. 2- SG LB (SLEEVE GASTRECTOMY WITH
LOOP BIPARTITION) Mui - 2014

38. Advantages
Endoscopic access to biliary tract
↓ sleeve leaks and gastroesophageal reflux.
Hormonal changes are high.
Malabsorption is less.
Diarrhoea and steatorrhoea risks are rare .
Disadvantages:
Biliary reflux
No long-term results

39. How to choose your procedure
RNGB:
The standard procedure up till now, Technically
demanding, the best for GERD
Sleeve:
Easy, contraindicated in sweat eater & GERD,
durability weight regain ? leaks
 MBG:
Simple, effective metabolic control, but reflux and
malnutrition
SASI: reflux , long-term??? may by the future

40. Follow up

41. Thrombophylaxis:
Respiratory care:
Diet:
 1st week: Clear fluid
 2nd week: liquid diet
 3rd week: soft diet
 4th week →: ordinary high protein low calorie diet
Ppi: 1 year
Post-operative lab work
Lab work is done at 4, 12, 18, and 24 month visits after surgery, and
then yearly:
CBC
Ferritin, iron
parathyroid hormone
RBC folate
Vitamins A, B1 (thiamine), B12, and 25 hydroxy Vitamin D