This document discusses advances in bariatric surgery. It covers indications for surgery such as BMI over 40 or 35 with comorbidities. The most common procedures are Roux-en-Y gastric bypass, sleeve gastrectomy, and gastric banding. Newer techniques like mini gastric bypass and endoscopic procedures are also discussed. Complications include leaks, bleeding, and nutritional deficiencies. The conclusion discusses the mechanisms of weight loss involving gut hormones, microbiota, and bile acids.

1. ADVANCES IN BARIATRIC
SURGERY

2. LAYOUT
• INTRODUCTION
• INDICATIONS OF SURGERY
• BARIATRIC SURGERY TRENDS
• SURGICAL PROCEDURES
• COMPLICATIONS
• CONCLUSIONS

3. INTROUDUCTION
• Obesity is a chronic disease that is increasing in
prevalence in adults, adolescents, and children,
and is now considered to be a global epidemic.
• Obesity and lack of physical activity have the
second largest public health impact after
smoking.

4. INTROUDUCTION(CONTD)
• The World Health Organization identified that
a reduction of physical activity in combination
with an increased consumption of more
energy- dense, nutrient-poor foods with high
levels of sugar and saturated fats, have led to
obesity .

5. INTROUDUCTION(CONTD)
• Obesity rates in the United Kingdom are the
highest in Europe. The prevalence of obesity
among adults raised from 14.9% to 24.9%
between 1993 and 2013.
• The rate of increase has slowed down since 2001,
although the trend is still upward.
• The prevalence of overweight has remained
broadly stable during this period at 37-39%.

6. INTROUDUCTION(CONTD)
• Morbidly obese subjects are at risk of numerous
physical and metabolic comorbidities that
severely impair their health and increase
mortality.
• This burdens societies with premature mortality,
morbidity associated with many chronic
disorders, and negative effects on health-related
quality of life.

7. INTROUDUCTION(CONTD)
• Obese individuals have a higher relative risk of
hypertension, hyper- cholesterolemia, and
diabetes mellitus compared with normal weight
individuals.
• Obesity reduces life expectancy by an average
of 3 years, or 8-10years in the case of severe
obesity [body mass index (BMI) over 40].

8. INTROUDUCTION(CONTD)
• These alarming figures represent the unmet
need for more effective treatments for obesity
complicated by T2DM, both for the individual
and the healthcare system as a whole.

9. Adult Weight Status Body mass index (BMI) = weight
(kg)/height (m)².
Normal
Overweight
Class 1 Obesity
Class 2 Obesity
Class 3 Obesity
18.5-24.9
25-29.9
30-34.9
35-39.9
≥40

10. Conditions associated with severe obesity
Type 2 diabetes
Hypertension
Dyslipidemia
Obstructive sleep apnoea (OSA)
Arthritis and functional impairment
Gastro-oesophageal reflux disease
Non-alcoholic fatty liver disease/non-alcoholic steatohepatosis
Polycystic ovary syndrome
Clinical depression
Various cancers in particular endometrial cancer

11. Indications for bariatric surgery
 Patients must meet the following criteria for
consideration for bariatric surgery :
• BMI >40 kg/m2 or
• BMI >35 kg/m2 with an associated medical
comorbidity worsened by obesity.
• Failed dietary therapy.

12. NICE eligibility criteria
Summary of 2014 updated NICE guidance on bariatric surgery
Bariatric surgery is a treatment option for anyone with a BMI ≥40.
Offer an expedited assessment for people with a BMI ≥35 with onset of type 2
diabetes in the past 10 years.
Consider an assessment for people with a BMI of 30-34.9 with onset of type 2
diabetes within 10 years.
Consider an assessment for people of Asian origin with onset of type 2 diabetes at a
lower BMI than other populations.
Bariatric surgery is the option of choice for adults with BMI >50when other
interventions have not been effective.
People fitting the above criteria are also required to be receiving, or to receive,
assessment in a specialist weight-management service before referral to a surgical
team.

13. BARIATRIC SURGERY TRENDS
• United States of America and Canada were the
region with the highest number of bariatric
procedures with 154,276 procedures in 2013.
• In Europe, France is the leading country with
37,300 procedures in 2013.
• Southeast Asia and China are emerging with
increasing numbers of procedures done
currently.

14.  The most commonly performed procedure in the
world in 2013 was
• Laparoscopic Roux-en-Y gastric bypass (RYGB)
(45%), followed by
• Laparoscopic sleeve gastrectomy (SG) (37%),
• Laparoscopic adjustable gastric banding (LAGB)
(10%).

15. • Roux-en-Y gastric bypass decreased from 2003
to 2013, but it still represents the most
performed bariatric/metabolic procedure in the
world.
• Sleeve gastrectomy showed a steep increase
from 2003 to 2013 ,thus becoming the second
most performed bariatric/metabolic procedure in
the world.

16. • Laparoscopic adjustable gastric banding was the
most common procedure becoming very popular
in the beginning of the century and between 2008
and 2010, it became the most commonly
performed bariatric procedure worldwide.
 Advantages
• The reduced number of complications , and the
technical ease of the procedure, being even
performed on an outpatient basis.

17.  Disadvantages
• Difficulty in achieving and maintaining weight
loss.
• Secondary to long term complications(slippage,
pouch dilation, dysphagia, erosions) higher
reoperation required.

18. Total number of bariatric surgeries worldwide and in
the Asia-Pacific region according to statistics from International
Federation for the Surgery of Obesity and Metabolic Disorders
(IFSO)

19. Preoperative Preparations and
Evaluation
• Complete cardiac, respiratory/renal/hepatic
evaluation.
• Lipid profile and blood glucose assessment.
• Obstructive sleep apnoea in obese patient
should be assessed using polysomnography
and be treated.
• Risk assessment for DVT should be done.

20. • If GERD symptoms are present gastroscopy
should be done.
• USG abdomen to identify gallstones should be
done, if gallstones present it is of usual practice
to do cholecystectomy along with bariatric
procedure.
• Nutritional evaluation and dietician advice for
preoperative and postoperative diet
management.

21. • Psychological screening is needed to all patients
to counsel their postoperative care and diet.
• Separate theatre table is needed for morbid
obese patient.
• Equipment's should be long and flexible. In
laparoscopic surgery, special ports and
instruments are needed.

22. Bariatric Operations:
Restrictive
• Vertical banded gastroplasty .
• Laparoscopic adjustable gastric banding (AGB).
• Laparoscopic sleeve gastrectomy (LSG).
Largely Restrictive, Mildly Malabsorptive
• Roux-en-Y gastric bypass (RYGB).
Largely Malabsorptive, Mildly Restrictive
• Biliopancreatic diversion (BPD).
• Duodenal switch (DS).

23. Newer techniques
• Mini gastric by pass
• Endoscopic bariatric interventions
 Restrictive
Endocinch system
Transoral gastroplasty system(TOGA)
Primary obesity surgery endoluminal
(POSE)
Bioenterics intra gastric balloon
 Malabsorptive
Duodeno-jejunal bypass

24. SURGICAL PROCEDURES
MINI GASTRIC BYPASS
• A newer type of surgery, the mini gastric bypass
(MGB)has been devised as a more cost-
effective procedure to address issues with the
RYGB.
• This is now considered the most promising
modification to RYGB since its original
conception.

25. • This operation consists of first creating a long
vertical gastric pouch along the lesser curvature
usually starting at the antrum distal to the crow's
feet .
• Second, a Billroth type II loop gastrojejunostomy
is performed with a 200 cm or longer afferent
limb from the ligament of Treitz.

26.  ADVANTAGES
 Simpler procedure as it includes
 Only one anastomosis, with shorter operative time.
 Fewer sites of anastomotic leaks and internal
hernias.
 Easy to teach with a shorter learning curve than the
RYGB.
 The ease of its reversibility, which is technically
much easier than the RYGB .

27.  DISADVANTAGES
• Side effect of the long biliopancreatic limb and
higher malabsorptive effect is a higher incidence
of anemia and diarrhea, which are more
frequent after MGB than after RYGB.

28. MINI GASTRIC BYPASS

29. Roux-en-Y Gastric Bypass(RYGB)

30. ENDOSCOPIC BARIATRIC INTERVENTIONS
• These endoscopic procedures shown a potential to
bridge the gap between medical therapy and
surgery.
• These procedures are potentially less invasive,
reversible, and may have a lower cost when
compared to surgical procedures.
• Thus, they can be used as a revisional procedure
after bariatric surgery.

31.  Current primary endoscopic bariatric therapies
include
• Restrictive procedures (space occupying or
suturing devices)
• Malabsorptive procedures (endoluminal
bypass)and
• Other procedures like neuroelectrostimulators,
injection of substances such as botulinum toxin,
etc.

32. Endoscopic restrictive procedures
• Endoscopic restrictive procedures remodel the
stomach via suturing, stapling, or tissue anchor
placement to reduce gastric volume.
 These include the
• EndoCinch Suturing System,
• Transoral Gastroplasty System (TOGA),
• POSE (Primary Obesity Surgery Endoluminal)
devices.

33. EndoCinch System
• EndoCinch, which originally developed as an
endoscopic treatment for gastroesophageal
reflux disease, is a suturing device that
endoscopically uses a suction chamber to
capture the gastric wall and creates pleats using
tagged sutures to reduce gastric volume.

34. • The initial results showed a mean excess
weight loss (EWL) of 21% at 1 month and 58%
at 12 months achieved after performing the
gastroplasty with this device (decreasing BMI
from 39.9 to 30.6 kg/m²).
• The simple procedure was completed in 45
minutes, discharging the patient at the same
day. No serious adverse events were reported.

35. EndoCinch Procedure

36. Transoral Gastroplasty System (TOGA)
• The TOGA system is the first endoscopic device
created to perform the gastric restrictive surgery,
designed to be less invasive, with less
complications and with a faster recovery.

37. • An 18-mm metal device is inserted
endoscopically in the stomach. With a set of
guided staplers, a stapled pouch is created
along the lesser gastric curvature.
• The gastroplasty is fashioned as an 8-cm long
tube from the gastroesophageal junction. The
procedure lasts about 2 hours.

39. Primary Obesity Surgery Endoluminal (POSE)
• Primary obesity surgery endoluminal is a simple
restrictive endoscopic method based on
performing and suturing (plicating) gastric folds
main fundus (also in antrum), aimed to reduce
the size and limit the stomach and producing
early satiety sensation.
• The system is designed to stay in place for life,
but it can be reversed.

40. • It can be done as an outpatient procedure, and
lasts around 60 minute It seems as an effective
and safe procedure.

41. Primary Obesity Surgery Endoluminal (POSE)

42. SPACE OCCUPYING DEVICES
• The intragastric balloon (IGB) is thought to
induce early satiety by partially filling the
stomach, increasing the feeling of fullness, early
satiety, and slow gastric emptying, mainly during
the first 3 months.

43. Bioenterics Intragastric Balloon
• The most popular and commonly used IGB.
• It consists of a silicone spherical balloon, very
resistant to gastric acids, with a smooth surface
to reduce the gastric mucosa erosion risk, and is
filled with isotonic saline and possesses a
radiopaque self sealing value that allows
localizing it with simple radiation.

44. • It is a large capacity balloon and is usually filled with
600-800 mL of saline.
• The maximum duration accepted for the balloon in
situ is 6 months.
• A meta-analysis including 30 studies (18 prospective
and 12 retrospective) and a total of 4,877 patients
found that the overall short-term (6 months) weight
loss was 17.8 kg after bioenterics intragastric
balloon placement.

45. Bioenterics Intragastric Balloon

46. Malabsorptive Techniques
• The role of bypassing the small intestine has
been studied and is known to play a role in the
mechanism of weight loss and metabolic effects
after some types of bariatric surgical procedures.

47. Duodenal-Jejunal Bypass (EndoBarrier
Gastrointestinal Liner)
• The EndoBarrier gastrointestinal liner is a single
use endoscopic implant mimicking a duodenal-
jejunal bypass.
• It comprises a nickel-titanium implant attached to
a 60-cm polymer impermeable sleeve.

48. • The 60-cm long, impermeable plastic sleeve is
anchored in the duodenal bulb and extends into
the proximal jejunum . The device is open at
both ends to allow food to pass.

49. • Because the impermeable sleeve covers the
duodenum and a portion of the jejunum, it
creates a barrier to absorption and delays the
mixing of food with biliopancreatic secretions.

50. • These biliary and pancreatic secretions pass in
between the intestinal wall and outer surface of
the liner and mix with the food bolus distally,
after the impermeable sleeve, in the and thus
inducing malabsorption and creating a bypass of
the proximal intestinal tract.
• It also allows a faster food transit into the mid-
jejunum.

51. • The device is placed endoscopically, with
fluoroscopic guidance, under general anesthesia
and is usually anchored in the duodenal bulb -5
mm distal to the pylorus.
• It may be removed endoscopically also under
general anesthesia with the use of a procedure-
specific grasping device. The liner is indicated
for maximum implant duration of 12 months. 18

52. Duodenal-Jejunal Bypass (EndoBarrier
Gastrointestinal Liner)

53. COMPLICATIONS
EARLY LATE
Gastric band Access port infection (1%)
DVT/PE (<0.1%)
Band infection
Tubing leak
Slippage
Erosion into stomach
Band intolerance
Failure to lose
weight/weight regain
Gastric bypass Anastomotic leak (<1%)
Intra-abdominal bleed (2-
3%) Unspecified
obstruction (1-29%)DVT/PE
(<1%)
Internal hernia Chronic
abdominal pain
Malnutrition if long limb
bypass
Anastomotic ulcer/stricture
Weight gain
Sleeve gastrectomy Leak at angle of His (2-
39%) Intra-abdominal
bleed (2-3%)DVT/PE (<1%)
Gastro –oesophageal reflux
Weight gain

54. CONCLUSION
• The focus is now on understanding the
mechanisms by which these procedures work.
Traditionally restriction and or malabsorption
were favored as the main cause of weight loss,
by reducing the calorie intake.
• More recently, scientists have studied the
metabolic effects of bariatric surgery and
postulated that other mechanisms

55.  There are two known ways by which gut hormones
respond
• Foregut theory ,implies that after excluding the
duodenum from the alimentary pathway, this may
eliminate the physiologic response of duodenal gut
hormone and related enzyme secretion.
• Hindgut theory that help in weight loss as well as
T2DM remission, implies that a rapid food transit to
the distal gut induces the secretion of distal gut
hormones.

56. • In the last few years, the role of the gut
microbiota has been studied.
• Obesity and diabetes are associated with an
unfavorable colonization of the gut with bacteria
that are more efficient in extracting energy from
food that is then absorbed by the gut and stored
in the adipose tissue.

57. • A profound change in the compos tion of gut
bacteria (gut microbiome) has been observed
after RYGB and is thought to contribute to
weight loss and glycemic improvements after
surgery.

58. • More recently, bile acids have emerged as
versatile signaling molecules endowed with
systemic endocrine functions.
• They act on TGR5 receptors to stimulate
secretion of GLP-1 in the gut and increase
energy expenditure in brown adipose tissue.

59. • In recent years there has been an increase in
the development of endoscopic techniques for
managing obesity.
• These different techniques have been used as
primary therapy, as a bridge to bariatric surgery,
or as a revisional procedure after bariatric
surgery.

60. • Understanding the mechanisms by which the
different bariatric surgical procedures work will
help us in the development of safer, more
effective, and less invasive therapies.

61. REFERENCES
• Bailey & Love 28th edition.
• Sabiston text book of surgery 21st edition
• Taylor's Recent Advances in Surgery 38th edition.
• Lee WJ, Almalki O. Recent advancements in
bariatric/metabolic surgery. Ann Gastroenterol Surg.
2017 Sep 10;1(3):171-179.

62. THANK YOU