Restrictive Bariatric Surgeries in Obese

1. Bariatric Surgeries and
complication
Moderator : Dr Airind

2. • Morbid obesity is defined as being
– 100 pounds above ideal body weight
– twice ideal body weight
– or body mass index of 40 kg/m2 or more

3. Who needs Bariatric Surgery?
• To advise adults with
– BMI ≥40 or
– BMI ≥35 with obesity-related comorbid conditions
who are motivated to lose weight
who have not responded to behavioral
treatment (with or without pharmacotherapy)

4. Bariatric surgery can be categorized
into
• Restrictive
– Laparoscopic adjustable gastric banding (LAGB)
– Laparoscopic sleeve gastrectomy (LSG)
• Largely Restrictive, Moderately
Malabsorptive
– Roux-en-Y gastric bypass (RYGB)
• Largely Malabsorptive, Mildly Restrictive
– Biliopancreatic diversion (BPD)
– Duodenal switch (DS)

5. Definition of Obesity

6. For Asians
• The suggested categories are as follows:
– Underweight : less than 18.5 kg/m2
– Normal : 18.5–23 kg/m2
– Overweight : 23–27.5 kg/ m2
– Obesity : 27.5 kg/m2

7. Medical conditions associated with
obesity
• Cardiovascular
– Hypertension
– Myocardial infarction
– Venous stasis disease
– Deep venous thrombosis
– Pulmonary hypertension
– Right-sided heart failure

8. • Pulmonary
– Obstructive sleep apnea
– Hypoventilation syndrome of obesity
• Metabolic
– Metabolic syndrome :
abdominal obesity, hypertension, dyslipidemia, insulin
resistance
– Type 2 diabetes
– Hyperlipidemia
– Hypercholesterolemia

9. • Gastrointestinal
– Gastroesophageal reflux disease
– Cholelithiasis
• Neurologic and Psychiatric
– Pseudotumor cerebri
– Depression
– Low self-esteem Stroke

10. Incidence Rate of obesity is US
Age 20–39 40–59 60+
Male 3.3% 3.9% 1.7%
Female 6.4% 7.8% 5.6%

11. MECHANISM OF ACTION OF
BARIATRIC SURGERY
• Restrictive operations LSG and LAGB
– mediated through the
• decrease in appetite
• early induction of satiety

12. Mechanism in RYGB
• RYGB is Largely Restrictive, Moderately
Malabsorptive
• Mechanism
– It causes changes in glucose metabolism
– The small gastric pouch and early satiety
induced by the gastric stretch fibers and the vagal
feedback of the satiety center

13. Mechanisms playing larger role in the
effectiveness of Gastric Bypass
• Enteroencephalic Endocrine Axis
– It is the complex interplay between the
satiety/metabolism centers of the brain and the
alimentary tract through nerves and hormones
• Ghrelin is a gut hormone creates increased
appetite state
• Ghrelin levels fall after meals, the person
achieves a sense of satiety

14. • Patients undergoing RYGB and LSG have
– Suppressed postoperative levels of ghrelin
• This explains
– loss of appetite and continued success of dieting

15. • The decrease in calorie intake and resulting
profound weight loss results in
– Twofold improvement in insulin muscle sensitivity and
– Fourfold increase in hepatic insulin sensitivity
• Improved beta cell function and Glucose
homeostasis is measured by C-peptide level
which is usually seen after few months of thes
surgeries

16. • Alterations in the gut microbiome
– induced by the bypass of the duodenum
– play a significant role in metabolic changes after
bariatric surgery
• Differences in the gut microbiome alter
– Absorption of nutrients and leads to weight loss.

17. PREOPERATIVE EVALUATION AND
SELECTION

20. Evaluation of Specific Comorbid
Conditions
• Cardiovascular Evaluation
– history of recent chest pain or a change in exercise
tolerance need to undergo a formal cardiology
assessment
• Obstructive sleep apnea
– Sleep study
– To reduce postop hypoxic stress
– Using positive airway pressure apparatus

21. • Musculoskeletal conditions
– especially arthritis and degenerative joint disease,
are the most common group of comorbid diseases
found in severely obese patients

22. Indications for Bariatric Surgery
Patients must meet the following criteria for consideration for bariatric
surgery:
• BMI >40 kg/m2
• BMI >35 kg/m2 with an associated medical comorbidity
• Medical comorbidity worsened by obesity
• Failed dietary therapy
• Psychiatrically stable without alcohol dependence or illegal drug use
• Knowledgeable about the operation and its sequelae
• Motivated individual
• Medical problems not precluding probable survival from surgery

23. IFSO-APC consensus statements 2011
• Bariatric surgery should be considered for BMI greater than
35 regardless of the existence of comorbidities.
• Bariatric/GI metabolic surgery should be considered for the
treatment of T2DM or metabolic syndrome, for patients
who are inadequately controlled by lifestyle alternations or
medical treatment for acceptable Asian candidates with
BMI greater than 30 kg/m2
• The surgical approach may be considered as a nonprimary
alternative to treat inadequately controlled T2DM or
metabolic syndrome for suitable Asian candidates with BMI
greater than 27.5 kg/m2

24. • Any surgery for T2DM or metabolic syndrome for Asian patients
with a BMI less than 27.5 kg/m2 should be strictly performed
only under clinical study protocols with the informed consent
of the patient and prior approval from an ethics committee
• IFSO-APC generally recommends the following procedures for
Bariatric and GI metabolic surgery for Asians: Gastric bypass,
sleeve gastrectomy, gastric banding, biliopancreatic diversion
with duodenal switch (BPD-DS).
• Clinical study should be organized by highly experienced
bariatric surgeons, with experience in over 100 cases of bariatric
surgery

25. • LAPAROSCOPIC ADJUSTABLE GASTRIC
BANDING

26. Preoperative Preparation
• Patient is able and willing to undergo the recommended
schedule of band adjustments
• Patient is able and willing to undergo a regular exercise
regimen
• Patients expected and optimal weight loss is in the 100 lb
or less range.
• Patients whose weight is over approximately 350 lb, and
who have a BMI over 50–55, have a less optimal outcome
after LAGB

27. • Patient can maintain a “dieter’s mentality”.
– This is documented by the fact that the patient has at least
one previous episode in their life of successful dieting,
sustained over greater than 6 months
• Lap-Band is an excellent operation for the patient
– BMI is 50 or less, and has no severe comorbid condition..
• The patient should receive appropriate perioperative
antibiotics as well as deep venous thrombosis
prophylaxis

28. Operative procedure
• The patient will be positioned in steep reverse
Trendelenburg’s position
• Port number and position vary among
surgeons.
• The pneumoperitoneum is established in the
left upper quadrant, at the midclavicular line,
one hand breadth below the xiphoid

29. • Its preferred to use a Veress needle through
an incision just large enough to admit a 15-
mm trocar

30. • Placement of other trocars
– A 12-mm port for the camera in the midline
approximately 15 cm from the xyphoid.
– A 5-mm port is placed in the right upper quadrant
for the surgeon’s left hand.
– A 5-mm port in the left upper quadrant is placed
for the assistant and
– a port in the epigastrium is placed to assist in
retracting the left lobe of the liver

32. Procedure
• Dissection is begun at the angle of His.
• The peritoneum over the left crus and the
gastrophrenic ligament is opened dissection is
carried down into the retrogastric fat
• The gastrohepatic omentum is then opened in
its avascular area, the pars flaccida.

33. Procedure
• This allows exposure of the base of the right crus
• The peritoneum over the right crus is incised just
wide enough to allow a grasper or the gold finger
to pass
• The grasper is passed just cephalad to the
attachments of the proximal stomach to the
retroperitoneum thus remaining outside the
lesser sac.

34. Procedure
• Positioning the band in this space has decreased
posterior slippage or prolapse of the gastric band.
• Once the instrument is visualized in the left upper
quadrant, the band is placed into the abdomen
through the 15-mm port
• The tubing or suture is grasped and pulled through
behind the stomach, pulling the band into place
posteriorly

35. Procedure
• The band is then buckled into its ring configuration
• Gastrogastric plication sutures secure the anterior
fundus to the small portion of the stomach (optimally
about 1–2 cm) above the band Usually two to three
sutures are sufficient.
• The tubing is removed from the abdomen through the
epigastric or 15-mm port, depending on the surgeon’s
preference, and attached to the reservoir port.

36. Procedure
• The reservoir port is secured to the abdominal
wall fascia
• It is important to place the port in as thin a
portion of the abdominal wall as possible to
facilitate future access.
• The band system is accessed percutaneously with
a Huber needle to add and withdraw to confirm
reservoir capacity and rule out leakage

37. • All fluid is then removed from the reservoir at
the end of the procedure, to be added later in
adjustments postoperatively.
• It is recommended to begin with the band
system empty so as not to have too much
restriction initially for the patient.

38. POSTOPERATIVE CARE
• The patient and family members should receive
instructions on diet, activity, and pain
medications
• The patient is discharged on a liquid diet for 2–3
wks.
• After 3 wks during follow up
– the diet is advanced to a soft diet
– medications and comorbidities are checked as well

39. • A multivitamin is recommended as sufficient
supplementation
– Because Banding does not cause nutritional
deficiencies seen in other bariatric procedures
• Patients are often ready to return to work

40. • The success of LAGB depends on
– Adjustments
– adherence to dietary changes and
– exercise
• The timing of adjustments varies among surgeons;
– But usually it is adjusted to achieve weight loss of 1–2
lb/wk.
• Less weight loss, later satiety, or larger meal size are
indications that an adjustment is needed.
• This is done after careful evaluation of the patients’
weight, dietary history, and exercise. .

42. • Adjustment algorithm
– It is with the amount of fluid added based on
• Hunger
• weight loss

43. OUTCOMES
• Outcomes after LAGB are generally good
– In terms of weight loss and resolution of
comorbidities versus significant adverse problems.
• Patients undergoing LAGB will
– take longer time to achieve maximum weight loss
than patients with RYGB/LSG/DS.
• The %Excess weight loss at 2yrs after surgery has
been reported in the 45–55% range

44. • Resolution of medical comorbidities is seen
– the prospective randomized trial by Dixon et al in which
patients with type 2 diabetes showed 73% remission rate
of their disease 2 years after undergoing Banding
• Other comorbidities are improved as well
• Optimal outcomes for patients with LAGB seem
to be correlated with
– frequent band adjustments
– participation in support groups and
– regular physical exercise

45. COMPLICATIONS
• Complications following gastric banding
include
– prolapse or slippage,
– Erosion

46. • Prolapse or slippage
– is the most common complication requiring
reoperation.
• The mechanics of the process :
– prolapse : gastric tissue from below the band
lumen pushes up through the band circumference
– slippage : the band slips down on the stomach
further than desired, resulting in too much
stomach above the circumference of the band

48. • The effect of both is similar:
– food intolerance or
– Heartburn
• New onset of GERD symptoms in banding
strongly suggests prolapse and it needs to be
ruled out

49. • A plain radiograph will usually show the band in
an abnormally horizontal position
• Barium swallow will show a significantly greater
amount of stomach above the band
• Initial treatment of the prolapse is
– withdrawal of all fluid from the band. This will often
allow the prolapse to spontaneously resolve.

50. – If symptoms persist and radiographic evidence shows
persistence of the prolapse, operative intervention to
reduce the prolapse is indicated.
– This can usually be done laparoscopically.
– The band must be unbuckled to allow full reduction of
the prolapse
– Repositioning the band and resuturing the fundic
plication to maintain its position complete the
operation.

51. • Band erosion
– is an uncommon
problem, occurring
in 1% or less
– Band removal and
repair of the
erosion with
appropriate
antibiotic and
supportive care, are
indicated.

52. • Esophageal dilation
– Most severe complication that results from
LAGB.
– Cause : band position is too high, restricting the
distal esophagus instead of the proximal
stomach.
– The incidence is in the 1–2% range
– presenting symptoms : Reflux, dysphagia, pain,
and food intolerance
– Treatment for the problem : immediately
remove all fluid from the band, minimizing the
restriction and obstruction.

53. • Port and tubing problems
– These are issues that can be repaired with
procedures under local anesthesia or limited
intervention under general anesthesia.
– Kinking of the tube
– Band overfilling
– They Presents with Dysphagia within the next day
– Treatment : Removal of all or most of the fluid

54. • Nutritional complications after LAGB are rare
and are solely based on poor intake.
• LAGB does not alter the digestive process
whatsoever, and hence there is no
malabsorption
• A standard multivitamin supplement is all that
is necessary for patients following LAGB.

56. • Laparoscopic Sleeve Gastrectomy

57. • LSG is a restrictive operation
• It is easier to perform than LRYGB and avoids
the risk of two anastomoses.
• LSG has a risk profile between that of LAGB
(safest) and LRYGB

58. • Candidates for LSG : weight above or including
class 2 obesity.
• LSG is also effective as a primary operation for
patients with BMI less than 50.

59. OPERATIVE PROCEDURE
• The patient is positioned supine reverse
Trendelenburg’s position
• The surgeon stands on the patient’s right side,
the assistant on the patient’s left side, and the
camera operator adjacent to the surgeon, on
his or her right.
• A suggested port configuration is

63. Procedure
• The LSG begins by dividing the blood supply along
the greater curvature of the stomach, beginning
at a point approximately 5 cm proximal to the
pylorus on the greater curvature of the stomach
• The gastroepiploic vessels are divided as they
come off the greater curvature of the stomach,
proceeding from distal to proximal along the
greater curvature.

64. Procedure
• The division of vessels continues with the
short gastric vessels, until the top of the
greater curvature of the stomach is reached
• Complete devascularization of the greater
curvature above the distal antrum has been
achieved

65. Procedure
• A bougie, dilator, or comparable space-occupying
device is positioned along the lesser curvature of
the stomach
• This bougie may be in the 32–40F range, based
on surgeon preference and experience.
• The smaller the bougie, the better the
postoperative weight loss, but also the greater
the potential for a stricture of the gastric channel.

66. Procedure
• A linear stapler is now used to begin dividing the
stomach
• Division of the stomach is begun from the area
where devascularization was initiated
• The stomach is divided adjacent to the bougie or
endoscope, leaving only a relatively narrow tube
of lesser curvature

67. • Care should be taken not to divide the
proximal fundus portion of the stomach too
close to the gastroesophageal junction and
the angle of His
• Devascularization of this narrow segment of
tissue may produce an ischemic leak
postoperatively, which is a difficult and
persistent problem to heal

68. Procedure
• Staple line refinforcement is used by some
surgeon
• it is appropriate to take particular care to
avoid the complications of staple line bleeding
or leakage after surgery during the stapled
division of the stomach
• Similarly, stenosis must be avoided as well.

69. Procedure
• The devascularized piece of greater curvature
stomach is removed through the largest of the
ports in a laparoscopic bag.
• Intraoperative performance of a leak test is
done by surgeons at the completion of the
operation

70. POSTOPERATIVE CARE
• Postoperative length of stay is often
determined by the patient’s medical
comorbidities.
• Pain control is initially achieved with
appropriate parenteral medications.
• Oral medications can be started within 24
hours

71. • Discharge from Hospital
– Once patient takes adequate liquids
– After adequate pain control and
– Shows no signs of leakage, hemorrhage or stenosis
• Patients must adhere to a liquid diet until they get used
to the restriction of the long and narrow gastric lumen.
• The length of such a liquid diet is usually in the
– 2- to 3-week range.

72. • Thereafter, initiation of soft followed by well-
chewed solid food over the next few weeks
• Patients have a limited appetite due to the
anatomic arrangement of the operation.
• Follow-up for the first year should be frequently
enough to detect problems of long-term like
– stenosis, and occasional nutritional issues

73. • Protein intake must be encouraged
– liquid protein supplements as well as dairy-related
protein foods often serve as the initial largest
component of protein intake.
• Vitamin B12 needs supplementation for most
patients
– Vit B12 level needs to be checked after few
months of surgery

74. • Iron intake, due to low intake of iron-rich foods,
may need supplementation.
• A multivitamin is a standard recommendation for
daily intake by patients.
• LSG is still in its early phases of follow-up, and
thus far no other major nutritional deficiencies
have been identified after the procedure.

75. OUTCOMES
• LSG has produced
– Excellent Excess weight loss in 1-year follow-up of 50–70%
• Resolution of comorbidities associated with obesity
• The short-term results have been excellent but long
term reports are not yet available
• The incidence of weight regain or recidivism is not yet
reported after this procedure.

76. COMPLICATIONS
• Mortality for the operation : under 1%
• Complications include
– Bleeding
– Stenosis
– staple line leakage

77. • Treatment of postoperative hemorrhage
– Endoscopic correction is difficult due to narrow
gastric tube
– Needs surgery if conservative therapy with
transfusions fails or hemodynamic instability
occurs.

78. • Treatment of Leaks from the staple line
– surgical intervention to repair them is always the
best approach
– But depending on the circumstances Eg: degree of
peritonitis and soiling a jejunal feeding tube may
be placed for enteral nutrition.
– Drainage of the repaired area is always indicated.

79. • For Recurrent leakage :
– Endoscopic stent placement can be done depending on
the lumen of the gastric pouch and the location of the
leakage.
• For Stenosis of the gastric lumen :
– Balloon endoscopic dilation is the initial treatment of
– Temporary endoscopic stents can also be tried
• Megaloblastic anemia
– Because most of the stomach is removed, decreased
intrinsic factorand hence low vitamin B12

81. Reference
• Maingot’s Abdominal Operations 12th ED
• Sabiston Textbook of Surgery 20th ED