bariatic surgery.pptx DR SYED OBAID PROFESOR OF SURGERY

1. BARIATRIC SURGERY
DR. SYED UBAID
Professor of surgery

4. DEFINITIONS OF OVERWEIGHT AND OBESITY*
Body mass index (BMI) = weight (kg)/height (m)2.
Adult weight status BMI (kg/m2)
• Normal 18.5–24.9
• Overweight 25–29.9
• Class 1 obesity 30–34.9
• Class 2 obesity 35–39.9
• Class 3 obesity ≥40
* Obesity for children is defined as BMI at or above the 95th
centile.

5. CLASSIFICATION OF OVERWEIGHT
AND OBESE BY BODY MASS INDEX
Who guidelines Asian pacific
region
guidelines
• Underweight < 18.5 <18.5
• Normal 18.5-24.9 18.5-22.9
• Overweight 25-29.9 ≥23
• At risk 23-24.9
• Obesity 30-34.9 (class l)
35-39.9 (class ll)
25-29.9 (class l)
≥30 (class ll)
• Extremely
obese
≥ 40(class lll)

6. MORBID,COMPLEX OR SEVERE OBESITY
• BMI ≥40 by itself
• or patients with body mass index (BMI) ≥35
and obesity-related disease,

7. BMI Chart

8. CONDITIONS THAT ARE ASSOCIATED WITH
SEVERE AND COMPLEX OBESITY.
• Type 2 diabetes
• Hypertension
• Dyslipidaemia
• 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
• Functional impairment

9. Bariatric surgery is the branch of surgery
involving manipulation of the stomach and/or
small bowel to aid weight loss.

10. RATIONALE FOR SURGERY
• LongTermOutcomeData
SustainedWeightLoss
• ImprovementorResolutionofCo-
morbidities
• Improvedlongtermsurvival
• MinimallyInvasiveSurgery
• PublicAwareness
• Obesityasadisease
• Celebrities

11. RATIONALE FOR SURGERY
• Bariatric surgery leads to weight loss of 25–
35% of body
• Additional benefits are that most or all of the
obesity-related diseases improve as weight
is lost.
• Quality of life improves.
• survival benefit

12. RATIONALE FOR SURGERY
• Due to the tendency for basal metabolic rate
to decrease with dieting, most people will
regain all their weight, returning to the
previous homeostatic set point
• Bariatric surgery appears to alter this
mechanism and ‘reset’ this point, with 15–
25% weight loss maintenance up to 20 years

13. SURGICAL TREATMENT OF OBESITY
According to the NATIONAL INSTITUTE OF
HEALTH (NIH)
• BARIATRIC SURGERY IS THE PERMANENT
TREATMENT OF CHOICE AND THE ONLY
TREATMENT THAT HAS BEEN PROVEN TO BE
SUCCESSFUL IN THE LONG TERM ( MORE
THAN 10 YEARS).

14. METABOLIC SYNDROME
Clustering of at least three of the five conditions:
• central obesity,
• high blood pressure,
• high blood suger,
• high serum triglycerides ,
• low serum high density lipoprotein
• polycystic ovary syndrome.
Metabolic syndrome is associated with the risk of
developing cardiovascular diseases and type 2DM.

15. METABOLIC SYNDROME
American Society for Metabolic and Bariatric
Surgery (ASMBS), and British Obesity and
Metabolic Surgery Society (BOMSS), to
emphasise the goal of surgery as an accepted
treatment option for metabolic syndrome,
rather than just for weight loss.

16. METABOLIC SURGERY
• The term refers to the marked effects of some
operations on diabetes and the metabolic
syndrome, which may have an impact more
important than weight loss itself
• The improvement in type 2 diabetes may be
additional to the weight loss
• Surgery is very cost effective since medications
reduce or stop as glycaemic control improves

17. RECOMMENDS BARIATRIC SURGERY
• BMI > 40without co morbidities
• BMI >35 with 1 or more co morbidities
• BMI of 30 to 35 with significant or serious co
morbidities.
• Obesity not related to a metabolic or endocrine
disorder
• Multiple failed weight loss attempts by other
methods
• Age 18-60

18. PATIENT SELECTION CRITERIA IN INDIA
•BMI ≥ 35 without any co-morbidities
•BMI ≥ 32 with co-morbidities

19. CONTRAINDICATIONS TO BARIATRIC SURGERY
• Cardiac complications with poor myocardial
reserve.
• Chronic obstructive airways disease or
respiratory dysfunction.
• Significant psychological disorders, or
significant eating disorders.

20. CLASSIFICATION
1.PREDOMINANTLY RESTRICTIVE PROCEDURES
2.PREDOMINANTLY MALABSORBTIVE
PROCEDURES
3.MIXED OR COMBINATION PROCEDURES

21. RESTRICTIVE PROCEDURES
Procedures that are solely restrictive by creating a small gastric pouch & a degree of
outlet obstruction leading to delayed gastric emptying.
•The goal is to reduce oral intake by limiting gastric volume, produce early satiety,
and leave the alimentary canal in continuity, minimizing the risks of metabolic
complications
1. VERTICAL BANDED GASTROPLASTY
2. ADJUSTABLE GASTRIC BANDING (LAGB )
3. SLEEVE GASTRECTOMY
4. GASTRIC PLICATION
5. INTRA GASTRIC BALLOON (GASTRIC BALLOON)

22. MALABSORPTIVE PROCEDURES
Malabsorption is achieved by creating a short
gut syndrome and/or by accomplishing distal
mixing of bile and pancreatic juice with ingested
nutrients thereby reducing absorption..
1.BILIOPANCREATIC DIVERSION
2.THE JEJUNAL-ILEAL BYPASS
3.ENDOLUMINAL SLEEVE

23. MOST COMMON PROCEDURES
Most procedures are now performed
laparoscopicaly
1. Gastric bypass 45%
2. Sleeve gastrectomy 37%
3.Gastric banding 10%
4.Biliopancreatic diversion 1.5%.
/duodenal switch (BPD/DS)
Endoscopic Procedures like – Intra- Gastric Balloon

24. Intra Gastric Balloon

25. Intra Gastric Balloon
• Patients who don’t want
surgery but want to loose
weight.
• Done endoscopically
• Placing a deflated balloon into
the stomach, and then filling it
to decrease the amount of
gastric space.
•The balloon can be left in the
stomach for a maximum of 6
months and results in an
average weight loss of 5–9
BMI

26. ADJUSTABLE GASTRIC BANDING

27. ADJUSTABLE GASTRIC BANDING
• Restrictive Procedure
• An inflatable silicone BAND is
placed around the top portion of
the stomach, to form a small
stomach pouch & sewed .
• This band is connected to a tube that
leads to a port above the abdominal
muscles placed below the skin (FILL –
PORT).
• During follow up visits, inject or
remove saline solution to make the
band tighter or looser.

28. ADJUSTABLE GASTRIC BANDING
Induces weight-loss in 3 ways:
1.The small stomach pouch causes a sensation
of fullness
2.“Squeezing of the stomach pouch like an hour
glass prolongs the sensation of fullness.
3. Suppresses appetite by central action.

29. Complications Adjustable Gastric Banding
•Port displacement/tube break 7%
•Wound infection 4%
•Stoma obstruction 2%
•Slippage 2%
•Elective removal 2%
•Erosion <1%
•Conversion to open <1%
•Hemorrhage <1%
•Death <0.05%

30. SLEEVE GASTRECTOMY
• Laparoscopic sleeve
gastrectomy (LSG) is a
standalone procedure for
the surgical management
of morbid obesity.
• It is a rapid and less
traumatic operation and
thus far is demonstrating
good resolution of co-
morbidities and good
weight loss.

31. SLEEVE GASTRECTOMY
• Stomach is reduced to about 20% of its original
size, by surgical removal of a large portion of
the stomach, along the greater curvature.
• The open edges are then attached together to
form a sleeve or tube with a banana shape.
• Mean excess weight loss at 1 year of 60%
• The procedure is performed
laparoscopically and is not reversible.

32. THE SLEEVE GASTRECTOMY (SG) INDUCES
WEIGHT LOSS BY 2 MECHANISMS:
1.MECHANICAL RESTRICTION by reducing the volume of the stomach
and impairing stomach mobility. Also called ‘Food limiting’
operation.
2.HORMONAL MODIFICATION by removing a great part of the Ghrelin
(Hunger Hormone) production tissue.
•(Ghrelin is a 28 amino-acid-peptide, secreted by the oxyntic glands of the
gastric fundus. It is a potent orexigenic (appetite-stimulating) peptide
mediated by the activation of its receptors in the hypothalamus or pituitary
area.)
•The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue
than the duodenum. In the SG, resection of the fundus removes the major
portion of ghrelin release, therefore, appetite decreases.

35. COMPLICATIONS OF SLEEVE GASTRECTOMY
•Peri-operative Complications of anesthesia, bleeding, positioning or pressure, and those of a
technical nature. Injury to Liver or Spleen.
•Early Post-operative Complications (30 days) Bleeding: anastomosis leak, infection secondary to
leak, wound or other infection, strictures, and deep venous thrombosis/pulmonary embolism.
•Pulmonary complication -Atelectatsis, pneumonia, pulmonary embolism, respiratory
arrest secondary to sleep apnea, and acute respiratory distress syndrome (ARDS).
•Gastrointestinal (GI) complication - Ulcer, stricture, anastomonic obstruction, and small
bowel obstruction.
•Late Complications (greater then 30 days) GI ulcer (stricture, obstruction), nutrition deficiency
(one or more nutrients, protein, vitamin or mineral), internal/ incisional hernia, redundant skin,
failure of weight loss or regain of lost weight, and psychological.

36. MAL- ABSORPTIVE PROCEDURES
• Malabsorptive surgeries rearrange and/or remove part of
digestive system which then limits the amount of calories
and nutrients that body can absorb. Treatments with a
large malabsorbtive component result in the most weight
loss but tend to have slightly higher complication rates.
1. JEJUNAL ILEAL BYPASS – no longer performed for high
complication rates.
2. ILEAL TRANSPOSITION- New malabsoptive procedure on trial
for treatment of DM type 2 and metabolic disorders.

37. COMBINATION PROCEDURES RESTRICTIVE
+ MALABSORBTIVE
When surgery combines both restrictive and malabsorptive
techniques, it is know as a “combination” procedure. Most types of
bariatric surgery carry at least a small element of both
components, but the following surgeries achieve a notable portion
of weight loss from each…
1. LAP. GASTRICBYPASS – ROUX-EN- Y – more malabsorption than
the restrictive
2. DUODENAL SWITCH – the sleeve stomach is the restrictive
portion &the intestinal bypass( duodenal switch) is the mal
absorptive component

38. Gastric Bypass + Roux-en-Y

39. Gastric Bypass + Roux-en-Y
• Most frequently performed
bariatric procedure
• Long-term sustained
weight loss
• 65 to 70 % of EWL
• No protein-calorie
malabsorption
• Little vitamin or mineral
deficiencies
• Technically difficult
procedure

40. Gastric Bypass + Roux-en-Y
The stomach is stapled into
2 pieces, one small and one
large.
• The small piece becomes
the “new” stomach pouch.
• The larger portion of the
stomach stays in place,
however will lie dormant
for the remainder of the
patient’s life.

41. Gastric Bypass + Roux-en-Y
•The small intestine
(the jejunum) is
divided using a
surgical stapler
•Approx.50-70 cm from
the DJ Junction.

42. Gastric Bypass + Roux-en-Y
The end of the Roux limb is then
attached to the newly formed stomach
pouch .
• The Roux limb carries food to the
distal intestine.
•The Y limb or BPD limb
carries digestive juices from
the pancreas, gall bladder, liver
and duodenum to the intestines
• The food and the digestive
juices mix where the Roux limb
and Y limb meet much below
say 100-170 cm from DJ

43. Complications:
Roux-en-Y Gastric Bypass
1. Not reversible.
2. Mortality 0.5- 1%
3. Peri operative complications 5-10%
4. Stricture of gastrojejunostomy.-10% (long term)
5. Long term risk of protein &vitamin deficiency, and marginal ulceration of GJA.
6.Long term risk of intestinal obstruction – 2%.
7.Dumping syndrome.

44. JEJUNOILEAL BYPASS
Payne and Dewind, Archives of Surgery, 1973

45. Biliopancratic Diversion
w/o duodenal switch w/ duodenal switch

46. COMPLICATIONS:
BPD WITH DUODENAL SWITCH
• Leak
• Bleeding
• Infection
• Dehydration
• Malnutrition
• Death

47. Medical Co-Morbidities Resolved after Bariatric Surgery
Type 2 Diabetes
95%
Hypertension
92%
Cardiac Function
95%
improvement
Osteoarthritis
82%
Sleep Apnea
75%
GERD
98%
Stress Incontinence
87%
Hypercholesterolemia
97%
Wittgrove AC, Clark GW. Laparoscopic Gastric Bypass roux-n-y-500 patients. Obes Surg 2000. And others.

48. Resolution of T2DM is
“Dose-Related”
Band Bypass Duodenal
Switch
Excess
weight loss
47% 62% 70%
Operative
mortality
0.1% 0.5% 1.1%
Resolution
of T2DM
48% 84% 98%
Buchwald et al. JAMA 2004;292:1724-1737

49. EFFECTS OF BARIATRIC SURGERY ON
DIABETES
•The Hindgut hypothesis theory- Diabetes control results from the
more rapid delivery of nutrients to the distal small intestine,
thereby enhancing the release of hormones such as glucagon-like
peptide-1 (GLP-1).
•The foregut hypothesis theory – Exclusion of the proximal
small intestine reduces or suppresses the secretion of anti-
incretin hormones, leading to improvement of blood glucose
control as a consequence increases GLP-1 plasma levels which
stimulate beta cells to produce insulin secretion and suppress
glucagon secretion, thereby improving glucose metabolism.

50. DIETARY MODIFICATION AFTER SURGERY
• Reduce food volume consumed, chew food very
well, slow pace of eating
• Avoid fluids with food
30 minutes before or after meal
• Protein rich-food should be major component
of each meal
• Cheese, fish, poultry, eggs & meat
• Avoid empty calories

51. DIETARY SUPPLEMENTS
All patients should receive
• Multivitamin with iron
• Vitamin B12, B complex with thiamine
• Vitamin C
• Calcium
• Depending on procedure, patient may need fat
soluble vitamin supplements (BPD)

52. SUMMARY OF ALL TYPES OF SURGERIES
GASTIC BANDING- low complications, varying range
of wt. loss, frequent post-op visits
SG- needs long term research, 1st step procedure, low
risks, higher wt. loss, pouch could Stretch over time,
long staple line could cause problems in future.
GASTRIC BYPASS – worlds best procedure, 60-
70% WL, dumping syndrome, malnutrition.
DS/BPD- more wt. loss , high complications,
good for high BMI > 50, malabsorption +

53. Success Rate of Weight Loss
treatment for morbid obesity
Eliosoff 1997; Sjostrom NEJM 2004,
Obrien J Laparoendosc Adv Surg Teh A. 2003 Aug;13(4):265-70.
Treatment
Average Weight Loss (%
Total)
% Excess Weight Loss at
Five Years
Placebo 4–6%
Diet / Behavior Modification 8–12%
Drug Therapy < 10%
0%
1.6%
(10 Years)
10%
Gastric Bypass Surgery 65–85% Up to 100%
Laparoscopic Adjustable Gastric
Banding
45–50% 56%
Sleeve Gastrectomy 50-60% 65%

54. Risk of surgery

55. Is Bariatric Surgery a cosmetic surgery ?
No
• It is approved by Central Government
• No service tax

56. MYTH – SURGERY FOR WEIGHT LOSS IS NEW & EXPERIMENTAL
 Open surgery ~ 50 years
 Laparoscopic surgery
• ~ 15 years
• Proven results of > 10 years
of Lap.Weight Loss
Surgery

57. Myth - surgery for weight loss means
liposuction

58. Surgery Will Not Work Alone…
Commitment to Diet & Exercise

60. THANK YOU

61. 6
Dumping Syndrome
Dumping Syndrome
 Early: immediately associated with food intake
(GI symptoms)
 Late: delayed onset, usually 1½ to 2 hours after
food intake (neurological symptoms)
 Some patients never experience Dumping
Syndrome
Some surgeons consider dumping syndrome to be
a beneficial effect of Gastric Bypass surgery.
It provides a quick and reliable negative feedback

62. How does surgical treatment
affect Type 2 Diabetes Mellitus?

63. • increase insulin sensitivity
• decrease insulin resistance
• protect pancreatic beta-cell function
Impact of Weight Loss
Kahn et al. Nature.2006;444:840

64. Components of Intestinal Bypass
Goldfine et al
Nature Med
2009;15:616

65. Murphy & Bloom
Nature
2006;444:854
Gut Hormones

66. Incretins
• Glucagon-Like Peptide 1 (GLP-1)
• Released by intestinal L cells
(ileum>jejunum)
• Stimulate release of insulin
• Anorectic

67. Gut Hormone Profiles Following
Bariatric Surgery
• Compared with lean and obese controls, gastric
bypass patients had increased postprandial
plasma PYY and GLP-1
• Gastric bypass patients had early and
exaggerated insulin responses
• Neither effect observed in patients losing
equivalent weight through gastric banding
le Roux et al. Ann Surg 2006;243:108-114

68. Hindgut or Distal Small Intestinal
Hypothesis
Expedited delivery of nutrients to
distal small bowel results in:
•Increased release of GLP-1 and PYY
– Anorectic
– Incretin effect
•Triggers the ileal brake mechanism

69. Ghrelin
• Only known hormone that increases
appetite – “Hunger Hormone”
• Diabetogenic
– increases growth hormone, cortisol, and
adrenaline levels
– suppresses insulin

70. Anti-Incretins
Rubino & Gagner
Ann Surg 2002

71. Anti-Incretins:
The Effect of Duodenal Exclusion
Rubino & Gagner
Ann Surg 2002

72. Foregut or Proximal Small
Intestinal Hypothesis
Exclusion of stomach, duodenum and
proximal jejunum from the alimentary circuit
–Decreased release of “anti-incretin”
from duodenum/proximal jejunum
–Suppression of Ghrelin (?)