Bariatric surgery

1. An Overview of Bariatric
Surgery
BY : DR. SHAHEED ALAAMRY

3. Obesity is a BIG problem…
 According to the Global Burden of Disease study, 4.7 million people
died prematurely in 2017 as a result of obesity.
 This is close to 4 times the number that died in road accidents, and
close to 5 times the number that died from HIV/AIDS in 2017.
 Obesity is particularly widespread on the global scale, resulting in an
epidemic.
 In 2019, 5 million deaths as a result of obesity.

4. US Incidence of Obesity
 Approximately 2/3 of the United States population is overweight.
 Of those, almost 50% are obese.
 In total, approximately 5% of the US population is morbidly obese
 Alarmingly, the BMI subgroups with a BMI of 35 or higher are growing
the most rapidly.

5. BMI Categories
 A adult BMI of: Classifies one as:
 <18.5 Underweight
 18.5-24.9 Normal weight
 25-29.9 Overweight
 30-34.9 Obesity Class I
 35-39.9 Obesity Class II
 40-49.9 Obesity Class III
 50 and above Super Obesity
For children :
 overweight is weight-for-height greater than 2 standard deviations above WHO
Child Growth Standards median;
 obesity is weight-for-height greater than 3 standard deviations above the WHO
Child Growth Standards median.

8. What causes obesity and
overweight?
 Obesity is caused by an energy imbalance between calories
consumed and calories expended.
 It's due to an increase in energy-dense foods high in sugar and fat,
and a decrease in physical activity.
 These changes are often due to societal and environmental changes
and a lack of supportive policies in various sectors.
 Secondary causes should be excludes.

9. TREATING
OBESITY

11. Weight Loss Strategies
 Diet therapy
 Increased Physical Activity
 Pharmacotherapy (e.g., Orlistat, Meridia)
 Behavioral Therapy
 Hypnosis
 Any combination of the above
 Surgery

14. Pharmacological therapy

15. Bariatric Surgery
AN EFFECTIVE TREATMENT FOR COMBATING OBESITY

16. Bariatric Surgery
 Bariatric surgery is a popular procedure globally with over 579,000 surgeries
performed in 2014.
 In the US, nearly 2 million patients had bariatric surgery between 1993 and
2016.
 The surgery has become safer over time, with a decrease in complication and
mortality rates.
 However, only 0.5% of eligible patients received the surgery in 2016 for
various reasons, such as:
 increased patient numbers,
 weight management without surgery,
 unsuitable candidates,
 and limited insurance coverage..

17. contraindications of bariatric
surgery
 Reasons for not qualifying for weight loss surgery may
include:
 correctable medical causes of obesity,
 substance abuse,
 conditions that impede postoperative care, psychiatric,
psychosocial, or cognitive condition
 Severe heart or lung disease that makes surgery unsafe
 gastrointestinal inflammation,
 blood-clotting disorders,
 and pregnancy.

18. A Brief History of Bariatric
Surgery
 The first bariatric surgery was performed on King Sancho in 10th century
Spain. It helped him lose half his weight and regain his throne.
 Weight loss interventions became popular in the 1990s when surgical
approaches were recognized for their effectiveness against the obesity
epidemic.

19. Preoperative Evaluation and Preparation

20. Types of Bariatric Surgery
 Purely Restrictive
 Gastric Balloons
 Vertical-banded gastroplasty
 Gastric adjustable banding (BWH)
 Sleeve gastrectomy
 Restrictive > Malabsorptive
 Short-limb/Roux-en-Y gastric bypass (BWH)
 Long-limb/distal Roux-en-Y gastric bypass
 Malabsorptive > Restrictive
 Biliopancreatic diversion (BPD)
 BPD with duodenal switch
 Very long limb Roux-en-Y gastric bypass
 Purely Malabsorptive
 Jejunoilieal bypass
 Jejunocolonic bypass

21. Gastric balloon
 It's a quick, outpatient procedure performed in an endoscopy
center.
 nausea, vomiting, or GERD symptoms may worsen but can be
controlled with medication.-
 A 2016 study showed GB can lead to short-term weight loss
without mortality risks.
 Overall, weight loss was 4.6 kg and 3-month .

22. Evolution of Gastric Banding
 1970s
 Alternative to Roux-en-Y in Europe & Scandinavia
 1980s
 Adjustable silicone band developed
 1990s
 Laproscopic techniques for placement developed Laparoscopic
Adjustable Gastric Banding

23. Vertical Banded Gastroplasty

24. Vertical Banded Gastroplasty (VBG)
 Complications of the VBG include
 stomal stricture (20%), vomiting, (30%)
 gastroesophageal reflux (20%),
 staple line dehiscence (40%), and
 weight regain.
 Weight loss following VBG is less than after gastric bypass.
 Mortality 0.3%
 The adjustable gastric band is now preferred over VBG due to better
weight loss results and fewer complications..

25. Laparoscopic Adjustable Gastric Banding
(LAGB or Lap Band)
 Adjustable Lap Band
 1 hr procedure
 1 day in-house
 1 wk – Return to work
 40-45% EBW loss @ 2 yrs
 <0.1% Risk of Death
 Self-sabotage easier

26. Postoperative Care and Follow-Up
 Gastrograffin study is done on
1st postoperative day to assess
band position and lumen
patency.
 Band adjustment is done under
fluoroscopic guidance in 2
months.
 Adjustment is done to achieve
weight loss at a rate of 2
kg/week.

27. Laparoscopic sleeve gastrectomy
(LSG)
 ASMBS recommends SG for weight loss in
select patients who have not seen
superior results from other operations or
as part of a staged DS procedure
 During the surgery, a 80% of the stomach
is removed,
 limiting the amount of food that can be
consumed.
 Additionally, hormonal changes
prompted by the procedure can lead to
weight loss.

28. Advantages , Disadvantages of the
LSG
Advantages
 no need for serial adjustments
(as for the LAGB),
 reduction in internal hernias
 reduction in malabsorption
 ability later modify the gastric
sleeve to either a laparoscopic
RYGB or a DS as second stage of
the operation.
 Around 65 %excess weight loss
can be expected at two years
without any malabsorption
issues.
Disadvantages
 leak along the long gastric staple line.
 early leaks (≤2 days postoperatively)
related to stapler misfires or tissue
trauma,
 late leaks are related to ischemia and
high intragastric pressure, particularly
when there is distal stenosis, often at
the incisura angularis.
 The rate of severe complications <5%.

29. Evolution of the Roux-en-Y
 Gastric partitioning (Roux-en-Y
GBP)
 Based on observations of
weight loss in pts receiving
subtotal gastric resections for
other conditions
 1967 – First performed
 Restrictive > Malabsorptive

30. Roux-en-Y
 Open*
 2 hour procedure
 3 days in-house
 4 weeks – Return to work
 60-70% EBW loss @ 2 yrs
 0.5-1.0% Risk of Death
 Dumping Syndrome
 Laparoscopic*
 2-4 hour procedure
 3 days in-house
 2-3 weeks – Return to work
 60-70% EBW loss @ 2yrs
 0.5-1.0% Risk of Death
 Dumping Syndrome

31. Bilio-Pancreatic Diversion – with or
without a Duodenal Switch (BPD/DS)
 the most malabsorptive operations,
 is the most effective with 75–85 per cent
excess weight loss
 the highest perioperative mortality of 1–2
per cent.
 Prophylactic cholecystectomy is performed
due to the high incidence of gallstone
formation
 The operation had limited popularity due to
:
 technical difficulty and postoperative
nutritional complications.

34. Jejunoileal bypass (JIB)
 It was the first malabsorptive procedure
done for obesity.
 This operation was first performed in the
early 1960s and was very popular in the
1970s.
 because of its dramatic complications, no
longer used for the management of
morbid obesity.

35. Complications of JIB

36. Medical Nutrition Therapy
and
The Post-op Bariatric Patient

37. Post-Surgical Nutrition
 Balanced/healthy diet
 Liquids to pureed to soft to solid*
 High nutrient density, quality
 Modified in lactose, fat, sugar
 Adequate fluid
 Meal Periods/Eating time
 MVI/MIN
 Ca (>1200mg/d) + D (10-20mg)
 Folate (800-1000mcg) +B12
 Iron (45-100mg elemental – pre-menstrual)
 Vitamin C (75-100mg)
 Thiamin
 Self-monitoring
 Eating triggers/behaviors
 Exercise

38. Post-op Lap Band Diet
 Stage One (1 day)
 Water & Clear Liquids
 Non-carbonated, non-caffeinated, non-caloric liquids
 Fluid goal: 900ml/d
 Stage Two (14 days)
 150-240ml servings of High Protein, low sugar Beverage
 Fluid goal: 1800ml
 Protein goal: 50-60g
 Chewable MVI + Ca

39. Post-op Lap Band Diet
 Stage Three (14 days)
 Pureed Foods, Semi solids
 2 small meals, 3 snacks
 Fluid goal: 1800ml
 Protein goal: 50-60g
 Chewable MVI + Ca
 Stage Four (ongoing)
 Regular meals: 3 meals,2 snacks (1000-1200)
 Fluid goal: 1800ml
 Protein goal: 50-60g
 Chewable MVI + Ca

40. Post-Op Roux-En-Y Diet
 Stage One (1 day)
 Water and clear liquids
 Non-caloric, non-carbonated, non-caffeinated liquids
 Fluid goal: 900ml/d
 Stage Two (14 days)
 High protein, low sugar beverages
 Fluid goal: 1800ml
 Protein goal: 60-70g/d
 Chewable MVI + Ca

41. Post-Op Roux-En-Y Diet
 Stage Three (4 weeks)
 5 – 2oz servings diced protein
 Fluid goal: 56oz
 Protein goal: 60-70g
 Chewable MVI + Ca
 Stage Four (4 months)
 3 meals, 2 snacks
 850kcal/d
 Fluid goal: 56oz
 Protein goal: 60-70g
 Chewable MVI + Ca
Stage Five (ongoing)
Regular Meals
1200-1500kcal
Fluid & Protein goals: same
as above

42. Post-Surgical Nutrition
& Exercise
 Exercise
 No heavy lifting or exercise 6-8wks post-op
 Walking daily OK, encouraged
 After cleared, strength training important to help skin
stretch back
 Helps with weight loss in the long run

43. When Surgery and
Follow-Up Go Well…

44. Efficacy of Bariatric Surgery for
Weight Loss
 Mean percentage excess weight loss:
 61.2% - All Patients
 47.5% - Gastric Banding
 61.6% - Gastric Bypass
 68.2% - Gastroplasty
 70.1% - BPD or duodenal switch

45. Effect on Comorbid Conditions
 Diabetes
 76.8% - Completely resolved
 86.0% - Resolved or improved
 Hyperlipidemia
 70% - Improved
 HTN
 61.7% - Resolved
 85.7% - Resolved or improved
 Obstructive Sleep Apnea
 83.6% - Resolved
 85.7% - Resolved or improved

46. Effect on Quality of Life
 Studies show overall QOL greatly improved
 Relief from comorbidities
 Improved appearance
 Perception of improved:
 Well-being
 Social function
 Body self-image
 Self confidence
 Ability to interact with others
 Enhanced productivity
 Increased economic opportunities
 Often new employment
 More lucrative employment

47. PROBLEMS AND
COMPLICATIONS
of Bariatric Surgery

48. Possible Complications of Bariatric
Surgery
 General Complications
 Pulmonary embolism
 Incisional hernia
 Gallstone formation
 Major wound infection and seroma
 Abdominal fluid collection
 Subphrenic abscess
 Peritonitis

49. Procedure-Specific
Complications (RYGB)
 Anastomotic or staple-line leak
 Acute gastric distention
 Staple-line disruption
 Stomal stenosis
 Stomal ulceration
 Small-bowel obstruction
 Occlusion of Roux limb

50. Intermediate Complications
 Wound Infection
 Intra-abdominal bleed
 Gastric remnant necrosis
 Ischemic Roux-limb
 Internal hernia

51. Long-Term GI Complications
 Nausea
 Constipation
 Abdominal pain
 Marginal ulcers
 Incisional hernias
 Vomiting
 Diarrhea
 Gallstones
 Gastritis
 Intestinal Obstructions

52. Incidence of Complications
 Operative mortality (< 30 days):
 0.1% for Purely Restrictive Procedures
 0.5% for Gastric Bypass
 1.1% for BPD or Duodenal Switch

53. Long-Term Nutrition
Complications
 Malnutrition
 Vitamin and mineral deficiencies
 Weight loss failure
 Dehydration
 Anemia
 Dumping Syndrome
 Hair loss
 Dry skin

54. Risk of Vitamin and Mineral Deficiencies
 Calcium and Vitamin D
 Reduced absorption d/t bypassed duodenum, proximal jejunum (R-en-
Y)
 Life-long supplements mandatory
 Iron
 Absorption decreased d/t decreased contact of food with gastric acid;
reduced conversion of iron from ferrous to ferric form (MVI)
 Vitamin B12
 Absorption decreased d/t decreased contact with intrinsic factor (SG)
 60% of patients require long term supplementation of B12
 Thiamine
 Connection to Wernicke’s syndrome (R-en-Y), (SG)

55. Long Term Impact
&
Future Directions

56. Long-Term Changes: Weight
Regain
 One study of 342 gastric bypass pts showed
excellent long-term weight maintenance:
 % weight loss at:
 1 year (89%)
 2 years (87%)
 5 years (70%)
 10 years (75%)
 However, potential for pouch stretch, self-sabotage,
etc. leading to weight regain over time.
 Surgery relatively new, will have to wait and
reanalyze data in a few years.

57. Summary
 Bariatric surgery is an effective therapy for morbid
obesity, becoming increasingly popular.
 Bariatric surgery provides significant
 Loss of excess body weight
 Relief from comorbidities:
 DM, HTN, hyperlipidemia
 Improvement in QOL for patients
 However, these surgeries put pts at risk for
 Post-op complications & mortality
 Nutritional deficiencies & GI complications
 Psychosocial complications

58. References