This document discusses the credentials and experience of Dr. Sreejoy Patnaik in various types of bariatric and metabolic surgery procedures over the years. It then provides details on the procedures, including sleeve gastrectomy, gastric bypass, and gastric banding. The risks, benefits, and resolution of comorbidities for various bariatric surgeries are outlined.

1. Dr Sreejoy Patnaik
Member OSSI,IFSO,SAGES
Minimal Access , Bariatric & Metabolic
Surgery

3.  General Surgeon -1991
 Laparoscopic Surgeon -1993
 Endoscopic Surgeon- 1998
 Single Incision Lap. Surgeon - 2010
 Bariatric Surgeon -2010
 NOTE Surgeon -2012
 VAAFT Surgeon-2012
 Metabolic Surgeon -2013
 What Next ???

5. Kancherla Ravindranath
August 8th
1992 did the first lapchole in Orissa
With help of Dr Vinay Taunk at SCBMCH & at SHANTI

17. MANMOTH TASK

19. Obesity associated conditions
Diabetes
Hypertension
Sleep apnea
Congestive heart failure
Hyperlipidemia
Stroke
Coronary Artery Disease
Osteoarthritis
Gastroesophageal Reflux Disease
Non-alcoholic fatty liver
Psychological disturbances

20. Cardiovascular: CAD, HTN, CHF, LVF, Venous stasi ulcers, DVT,
Hyperlipidaemia
Pulmonary: OSA,OHS,PAH, Asthma
Endocrine: Insulin Resistance, Type 2 DM, PCOS
Haemopoietic: DVT, Pulmonary Embolism
G.I /Hepatobiliary: GERD, NAFLD, Hernias, Gallstones
Genitourinary: Stress incontinence, UTI
Obstetrics/Gynecology: Infertility, Miscarriage, Fetal abnormalities,
Infant mortality, Gestational DM
Musculoskeletal: Degenerative Joint diseases, Gout, Plantar
fascitis, Carpel T.S
Neurologic/Psychiatric: Stroke, Pseudomotor cerebri, Depression,
Anxiety
Cancer: Esophagus, Pancreas, Colon & Rectum, Breast,
Endometrium, Kidney, Thyroid, GB

21.  BMI ≥ 35 kg/m²:
 Risk of death ≈ 2.5 times greater than if BMI of 20-25
kg/m²
 BMI ≥ 40 kg/m²:
 Risk of death 10 times greater
Obesity
2nd
leading cause of preventable premature
death in US (smoking)

23.  Global epidemic of obesity
 Bariatric surgery is the only effective and
sustained treatment for morbid obesity
 Bariatric surgery resolves diabetes and other
co-morbidity and saves lives
 Laparoscopic surgery has significant
advantages over open procedures
 Surgical morbidity and mortality are very low
in experienced units

24. Open Surgery (big cuts)
Laparoscopic Surgery (key-hole sized cuts)
Natural Orifice Surgery (no cuts)

25.  Consensus Guidelines 2003
 Surgical therapy should be considered for
individuals who:
 Have a BMI of greater than 40 kg/m²
OR
 Have a BMI greater than 35 kg/m² with significant
comorbidities
AND
 Can show that dietary attempts at weight control
have been ineffective
Derived from American Society of Bariatric Surgery website: www.asbs.org

26. Bariatric Surgery
Diet
Exercise
Behavior Modification
“Postoperative care, nutritional counseling, and surveillance should
continue for an indefinitely long period.”

27.  Obesity related to a metabolic or
endocrine disorder
 H/O substance abuse or major
psychiatric problem
 High risk patients
 Women who want to become
pregnant = 18 months

28.  1. PREDOMINANTLY RESTRICTIVE1. PREDOMINANTLY RESTRICTIVE
PROCEDURESPROCEDURES
 2. PREDOMINANTLY MALABSORBTIVE2. PREDOMINANTLY MALABSORBTIVE
PROCEDURESPROCEDURES
 3. MIXED OR COMBINATION PROCEDURES3. MIXED OR COMBINATION PROCEDURES

29. By creating a small gastric pouch & a degree of outlet obstruction
leading to delayed gastric emptying.
The goal - 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)
RESTRICTIVE PROCEDURES:

30. -Malabsorption is achieved by creating a short gut syndrome
-Distal mixing of bile and pancreatic juice with ingested nutrients
thereby reducing absorption..
-No longer recommended due to their potential hazard to cause
serious nutritional deficiencies.
1.BILIOPANCREATIC DIVERSION
2. THE JEJUNAL-ILEAL BYPASS
3. ENDOLUMINAL SLEEVE
4. MINI GASTRIC BYPASS
MALABSORPTIVE PROCEDURES

31. MIXED OR COMBIATION PROCEDURES:
1. GASTRIC BYPASS ROUX-EN-Y ( RYGBP)
2. SLEEVE GASTRECTOMY WITH DUODENAL SWITCH
3. IMPLANTABLE GASTRIC STIMULATION
The following procedures combine restrictive and malabsorptive approaches.
By adding malabsorption, food is delayed in mixing with bile and pancreatic juices
that aid in the absorption of nutrients.
The result is an early sense of fullness, combined with a sense of satisfaction that
reduces the desire to eat.

32. LABORATORY EVALUATION:
Basic chemistry panel, full blood count, thyroid function tests. Serum cortisol, urine cortisol,
lipid profile, vitamin (A, B1, B6, B12, C).Serum Insulin, C-Peptide.
UPPER ENDOSCOPY:
Rule out inflammatory ulcerous gastric pathology, search and treat H pylori infection when
present.
ULTRASOUND OF THE ABDOMEN:
To rule out cholelithiasis, which would indicate cholecystectomy along with the gastric
sleeve.
PREOPERATIVE EVALUATION
CARDIOVASCULAR/RESPIRATORY EVALUATION:
Exclude any contraindications to anesthesia by TMT, Echo, PFT, ABG , CXR etc.
PSYCHIATRIC EVALUATION:
To rule out any behavioral abnormalities that would contraindicate limited food intake.
ENDOCRINE EVALUATION: Rule out an endocrine abnormality as the etiology of
morbid obesity.
DENTAL EVALUATION

33. Armamentarium in OT
INSTRUMENTS TELESCOPES,TROCARS
LIVER RETRACTORS ENDO-GIA STAPLERS

34. LED MARTIN LIGHTS
MINDRAY BARIATRIC TABLE

35. VALLEYLAB STERRAD

36. LIGASURE HARMONIC

38. EXTRA LONG TROCARS
OPTI-VIEW TROCARS GASTRIC CALIBRATION TUBE
OPTICAL TROCARS & GCT

39. WARM BLANKET- BAIR HUGGER

40. SERIAL COMPRESSION DEVICE
TYCO – KENDALL COMPRESSION DEVICE

42.  Dr. Cadiere 1992
 Technically simple
 Purely restrictive
 Decrease hunger
 Early satiety
 Food aversion
 Adjustment to stoma
diameter

43. LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING
(LAP BAND SURGERY/ LAGB)
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, we inject or remove saline
solution to make the band tighter or looser.

44.  This Band in the stomach and 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.

45. • Perforation of Stomach
• Mal positioning
• Abdominal Pain
• Heartburn
• Vomiting
• Inability to Adjust the Band
• Failure to Lose Weight
• Slippage
• Gastric Erosion
• Dilated Esophagus
• Infection of System
• Fatigue or malfunction
Complications of Gastric Lap-Band

46. Sleeve gastrectomy is a procedure in
which the stomach is reduced to about
25% of its original size, by surgical
removal of a large portion of the stomach
along the greater curvature. This is done
by using surgical staplers to form a sleeve
or a tube with a banana shape.
A bougie or GCT between 36 - 40 Fr is
used with the procedure .
Ideal approximate capacity of the stomach
after the procedure is about 30- 60 ml
pouch
Sleeve Gastrectomy

47. TEN STEPS OF LSGTEN STEPS OF LSG
1.1. Assembly of instruments, in order of useAssembly of instruments, in order of use
2.2. OT set up and Trocar PositionOT set up and Trocar Position
3.3. Liver Retraction –using Nathansons LiverLiver Retraction –using Nathansons Liver
RetractorRetractor
4.4. Gastrolysis of greater curvature- distal to prox.Gastrolysis of greater curvature- distal to prox.
Upto> of His.Upto> of His.
5.5. Resection of stomach by Stapling – starts from 4Resection of stomach by Stapling – starts from 4
cm distal to pyloruscm distal to pylorus
6.6. Suturing for staple line reinforcementSuturing for staple line reinforcement
7.7. Leak test- Methylene blue, air or UGIELeak test- Methylene blue, air or UGIE
8.8. Extraction of specimen- fish tail techniqueExtraction of specimen- fish tail technique
9.9. Closure of Ports- by needle passer.Closure of Ports- by needle passer.

48. DONE UNDER G.A
5 TO 6 PORTS
The benefits are:
•Less Pain
•Quicker recovery and return to
normal activity
•Fewer complications
•Less noticeable scar
•Shorter hospital stay
1.1.Assembly of instruments, in order of useAssembly of instruments, in order of use
2.2. OT set up and Trocar PositionOT set up and Trocar Position

49. 1.1.Liver Retraction –using NathansonsLiver Retraction –using Nathansons
Liver RetractorLiver Retractor

50. 1.1.Gastrolysis of greater curvature- distalGastrolysis of greater curvature- distal
to prox. Upto> of His.to prox. Upto> of His.

51. 1.1.Resection ofResection of
Stomach byStomach by
Stapling – startsStapling – starts
from 4 cm distal tofrom 4 cm distal to
pyloruspylorus

52. Stomach stapling ends up at angle of His

53. Suturing for staple lineSuturing for staple line
reinforcementreinforcement

54. Leak test- Methylene blue,Leak test- Methylene blue,
air or UGIEair or UGIE

55. SLEEVE GASTRECTOMY

56. The Roux-en-Y gastric bypass (known simply as the LRYGBP) is the most
commonly performed procedure. It primarily causes weight loss by restricting the
food intake, however there is more amount of mal absorption that occurs with this
operation.

57. Bariatric surgery represents the main option for substantial and long-term weight loss
in morbidly obese subjects..
Two hypotheses have been proposed to explain the early 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) or Incretins.
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.

58. 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.

59. • The small intestine (the jejunum) is
divided using a surgical stapler
Approx. 70 cm from the DJ Junction.

60. Y- LIMB/ BP
LIMB
• 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
Roux limb or alimentary limb
100-150 cmBPD LIMB OR Y

61.  “Gold Standard”
 80% of bariatric proc.
 Restrictive and
Malabsorptive:
 Reduced calorie
intake
 Macronutrient
malabsorption

62. LAP GASTRICT BYPASS

63.  Staple line disruption (revision procedure..)
 Bougie stapling
 Bleeding from the staple line
 Bleeding from gastric or short gastric vessels
 Bleeding from the spleen
 Exposure difficulty in supersuper obese patients

64. ICCSSG NEW YORK 2007
 Staple line leakage
 Bleeding from the staple line
 Gastric stenosis
Late complications
 Marginal ulcer
 GERD ++
 Gastric dilatation and weight regain

65.  1. Pulmonary Embolism
 2. Myocardial Infarction
 3. Anastomotic Leak
 4. Management of Leaks
 5. Bleeding
 6. Wound Infection
 7. Small Bowel
Obstruction
 8. Band Obstruction
 9. Dumping Syndrome
 10. Stomal Stenosis
 11. Esophageal Dilation
 12. Band Slippage
 13. Band Erosion
 14. Marginal Ulcers
 15. Cholelithiasis
 16. Gastro-gastric Fistula
 17. Malabsorption
 18. Procedure Failure

66. N=104
1 year post op
Number
Pre-op % Worse
% No
change
%
Improved
%
Resolved
Osteoarthritis 64 2 10 47 41
Hypercholesterolemia 62 0 4 33 63
GERD 58 0 4 24 72
Hypertension 57 0 12 18 70
Sleep Apnea 44 2 5 19 74
Hypertriglyceridemia 43 0 14 29 57
Peripheral Edema 31 0 4 55 41
Stress Incontinence 18 6 11 39 44
Asthma 18 6 12 69 13
Diabetes 18 0 0 18 82
Average 1.6% 7.8% 35.1% 55.7%
90.8%
Improved or ResolvedSchauer, et al. Ann Surg 2000 Oct;232(4):515-29

67.  Rapid decrease in serum blood sugar
 Decrease in medication requirements
 66% to 75% complete resolution
 Increased insulin sensitivity
 Inhibits progression of disease
 Swedish Obese Subject Trial:
 Reduced relative risk by factor of 30 compared to
medically treated population
1. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-
analysis. JAMA 2004;292: 1724-37.
2. Pories WJ, Swanson MS, MacDonald KG, Long SB, Morris PG, Brown BM, et al. Who would have thought it ? An operation
proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;22:339-50, discussion 350-2.
3. SjostromL, Lindros AK, Peltonem M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk
factors 10 years after bariatric surgery. N Engl J Med 2004;351: 2683-93.

68.  70% complete resolution
 50% reduced medications
 Swedish Obese Subject Trial: 2 years post
op
Decreased relative risk of new onset
HTN = 10
 Time interval for resolution not cleared
1. SjostromL, Lindros AK, Peltonem M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular
risk factors 10 years after bariatric surgery. N Engl J Med 2004;351: 2683-93.

69.  70% prevalence in gastric bypass pts
 80% improvement
 No more CPAP
 Decreased pCO2
 Increased pO2
1. Dixon JB, et al. Predicting sleep apnea and excessive day sleepiness in the severity obese: indicators for
polysomnography. Chest 2003;123:1134-41.
2. Sugerman HJ, et al. Gastric surgery for respiratory insufficiency of obestiy. Chest 1986;90:81-6.

70.  Non-alcoholic fatty liver:
 Resolution of steatosis
 Improved liver contour
 Osteoarthritis:
 50% reduced medication intake
 Decreased joint stress from weight loss
 Delayed operative joint intervention
 Depression:
 High prevalence in obese
 Decreased medication use
1. Clark JM, et al. Roux-en-Y gastric bypass improves liver histology in patients with non-alcoholic fatty liver disease. Obes Res
2005;13:1180-6
2. Abu-Abeid S, et al. The influence of sugically-induced weight loss on the knee joint. Obes Surg 2005;15:1437-42.
3. Sarwer DB, et al. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg 2004;14:1148-56.

73.  Endoscopic plication of the pylorus with
laparoscopic gastrojejeunostomy
 N.O.T.E.S
 SILS
 ROBOTIC SURGERY
1. Kantsevoy SV, et al. Technical feasibility of endoscopic gatric reduction: a pilot study in a porcine model. Gastrointes
Endosc 2007;65:510-3.
2. Deviere J, et al. Safety, feasibility and weight loss after trans-oral gastroplasty (TOGA): first human multicenter study.
Surg Endosc 2007;21(suppl 1): S303.

74. Revisional Surgery
Endoscopic Procedures
Gastric Neuromodulation

75. Durable
Excess Weight Loss > 50%

76. Technique Product
Sclerotherapy
Suturing EndoCinch (Bard)
Spiderman (J&J)
Anchors ROSE, POSE (USGI)
T-Fasteners StomaphyX (Endogastric Solutions)
Staplers TOGa (Satiety Inc.)
Sleeves EndoBarrier (GI Dynamics)
ValenTx
Endoscopic Bariatric Procedures

77.  Class 3 & Super-Obesity:
 Conventional Bariatric Surgery e.g.
laparoscopic gastric bypass
 Less Severe Obesity - Classes 1 and 2
 Gastric Electrical Stimulation
 Endoscopic Bariatric Procedures

78. Research Ranking scores using a combination of factors
Types of Bariatric
Surgery
Category Average Long Term
Excess Weight Loss
(approx. %)
Complication Rate Research Ranking*
(and reason if below ‘A’
LGB Combination (primary
restrictive
50 to 70% Up to 15% A
Lap Gastric Banding Restrictive 25% to 80% Up to 33% A
BPD/DS Mal absorptive 65% to 75% Up to 24% A
Vertical Banded
Gastroplasty
Restrictive 50% TO 60% Up to 21% B
Vertical Sleeve
Gastrectomy
Restrictive 65% to 75% Up to 10% B
Mini Gastric Bypass
Surgery
Combination (primary
restrictive
60% to 70% Up to 8% C
TGVR Restrictive Needs more research n/a C
TOGA System Restrictive n/a n/a
Endobarrier
Endoluminal Lining
Mal absorptive n/a n/a D
Implantable Maestro
System
Neither restrictive nor
mal absorptive;
electrical impulses said
to affect hunger
n/a n/a

79. S.L
NO
PATIENT
NAME
INTIAL
BODY
WEIGHT
B.M.I I.B.W P.B.W WEIGHT
LOSS (K.G)
D.OO PROCEDURE % OF
WEIGH
T LOSS
1 RAGHAV
GOENKA
135 KG 44.5 76 KG 72 KG 63 KG 27.02.2010 SLEEVE
GASTRECTOMY
96 %
2. SANJAY
SWAIN
158 KG 56 72 KG 80 KG 68 KG 23.04.2010 SLEEVE
GASTRECTOMY
79 %
3. DIGBIJAY
SAHOO
127 KG 45 70 100 KG 27 KG 23.04.2010 SLEEVE
GASTRECTOMY
47%
4. MANOJ DAS 139 KG 56 60 KG 90 KG 49 KG 09.12.2010 SLEEVE
GASTRECTOMY
58%
5. SANTOSH
PRASAD
108 KG 46 57 KG 67 KG 41 KG 16.01.2011 SLEEVE
GASTRECTOMY
80%
6. M.ARUNA 112 KG 44 63 KG 75 KG 32 KG 07.04.2011 SLEEVE
GASTRECTOMY
65%
7. MANASMITA
PRIYADARSINI
110 KG 43 60 KG 78 KG 29 KG 25.07.2011 SLEEVE
GASTRECTOMY
58%
8. UMESH
GOENKA
100KG 35.5 72 KG 80 KG 20 KG 04.11.11 SLEEVE
GASTRECTOMY
53%
9. HEENA
AGARWAL
132 KG 53 63 KG 92 KG 40 KG 17.04.2011 SLEEVE
GASTRECTOMY
58%
10. KISHANLAL
PANCH
109 KG 38 72 KG 83 KG 26 KG 12.05.2012 SLEEVE
GASTRECTOMY
70 %
TABLE SHOWING % OF WEIGHT LOSS AT SHANTI MEMORIAL HOPSPITAL

80. S.L
NO
PATIENT
NAME
INTIAL
BODY
WEIGHT
B.M.I I.B.W P.B.W WEIGHT
LOSS (K.G)
D.OO PROCEDURE % OF
WEIGH
T LOSS
11. CHANDAN
MOHANTY
149 KG 47 79 KG 95 KG 54 KG 12.05.2012 SLEEVE
GASTRECTOMY
77%
2. PUSPITA DAS 100 KG 41 60 KG 75 KG 25 KG 10.06.2012 SLEEVE
GASTRECTOMY
62.5%
3. GOPAL
SIKARIA
107 KG 37.5 73 KG 86 KG 21 KG 10.06.2012 SLEEVE
GASTRECTOMY
61%
4. SUDATTA DAS 90 KG 43 52 KG 56 KG 34 KG 07.07.2012 SLE EVE
GASTRECTOMY
84.5%
5. RABINDRANAT
H SENAPATI
107 KG 42 66 KG 81 KG 26 KG 15.07.2012 SLEEVE
GASTRECTOMY
63%
6. SMITARANI
SWAIN
100 KG 40.5 57 KG 71 KG 29 KG 19.08.2012 SLEEVE
GASTRECTOMY
60%
7. VIJAY
SHARMA
174 KG 56 76 KG 153 KG 21 KG 03.09.2012 SLEEVE
GASTRECTOMY
21.5%
8. VINOD
SHARMA
154 KG 55 71 KG 126 KG 28 KG 03.09.2012 SLEEVE
GASTRECTOMY
35%
9. DINESH
AGARWAL
122 KG 43 65 KG 98 KG 24 KG 01.10.2012 SLEEVE
GASTRECTOMY
42%
10. APARAJITA
PATNAIK
100 KG 38 65 KG 83 KG 17 KG 04.11.2012 SLEEVE
GASTRECTOMY
33%
TABLE SHOWING % OF WEIGHT LOSS AT SHANTI MEMORIAL HOPSPITAL

81. OUR SERIES OF PATIENTS

102. THE FUTURE –WHO KNOWS THIS DAY MIGHT COME SOON

108. THANK YOU