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Bariatric & Metabolic Surgery : Then & Now
- 2. INTRODUCTION • Worldwide Public health problem & AN EPIDEMIC
- 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
- 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
- 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
- 20. BPD + DS [ DUODENAL SWITCH ] • 1998 – Hess & Hess • Initially for duodeno-gastric reflux • Gastrectomy along greater curvature • Pylorus preserved • Duodeno-Ileostomy • Jejuno-Ileostomy
- 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
- 30. MECHANISMS FOR WEIGHT LOSS RESTRICTION & SATIETY METABOLIC & NEURO- HORMONAL MOST IMPORTANT & SIGNIFICANT
- 33. CURRENT SCENARIO
- 37. Reversal of DM 90% Dyslipidemi a 66% Resolution of kidney function 86% HTN 74% Anxiety Depression OSA Self concept
- 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
- 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
- 44. RECENT ADVANCES
- 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.
- 47. • Rapid weight loss [ EWL ] • 21.4% - 1 month • 54% - 6 months • 61% -12 months • 60% - 24 months • 57% - 36 months
- 48. LAGB WITH LGGCP [ LAGB-P ]
- 49. SINGLE ANASTOMOSIS/MINI GASTRIC BYPASS (SAGB/MGB) Omega loop
- 50. SADI [ SINGLE ANASTOMOSIS DUODENO-ILEAL BYPASS ]
- 51. EXPERIMENTAL STAGE ILEAL INTERPOSITION BILE DIVERSION
- 52. EBT
- 53. EBT [ ENDOSCOPIC BARIATRIC THERAPY ] • Need of STILL LESSER invasive interventions • Principle - Anatomic alterations • Advantages • LESSER invasive • Reversibility • Repeatability • Cost-effectiveness
- 54. Gastric Interventions Small bowel interventions Restrictive/ Reducing capacity Space occupying devices - Balloons Alteration of anatomy Endoscopic suturing / Plication devices Endobarrier DJ bylass sleeve GDJ bypass sleeve Duodenal mucosal resurfacing Self assembling magnets for endoscopy
- 59. ESG [ ENDOSCOPIC SLEEVE GASTROPLASTY ]
- 64. • Recently – Even BMI < 35 – Surgery is better for Glycemic Control c/w medical Rx
- 65. ABCD SCORE
- 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
- 69. THANK YOU ...