bariatric surgery- procedure for morbid obesity

1. Bariatric surgery
DR B D SONI

2. What is Bariatric Surgery?
 1950- first operation , malabsorptive procedure
 1960- Jejunal bypass
 1988- sleave gastrectomy – Bowling Green

3. classification BMI (principle cut off)
Underweight < 18.5
Severe wasting <16.00
Moderate wasting 16.00- 16.99
Mild wasting 17.00-18.49
Normal 18.50 – 24.99
Pre-obese 25.00 – 29.99
obese ≥ 30.00
Obese class I 30.00 – 34.99
Obese class II 35.00 – 39.99
Obese class III ≥ 40.00

4. Treatment of obesity

5. What is morbid obesity?
 100 lb above ideal weight
 Twice of ideal body weight
 BMI > 40 kg/m2
 Class III obesity
NIH 1991- severe obesity ↔ morbid obesity

6. Why to treat?
Medical condition/ risk associated with sever obesity
CVS – HTN, sudden cardiac death MI, cardiomyopathy, Venous stasis disease, DVT
Pulmonary HTN
RS- OSA, hypoventilation syndrome of obesity
Metabolic- metabolic syndrome, Type II DM, hyperlipidemia, NASH/NAFLD
GIT- GERD, cholelithiasis
Musculoskeletal- degenerative joint disease, PIVD, ventral hernia

7. Why to treat?
GUT- stress incontinence, ESRD
Gynecological- menses irregularity/ DUB
Oncologic condition - uterus, colon, kidney, breast, prostate
CNS- depression, CVA

8. Bariatric surgery in obese?
 Recommends bariatric surgery for obese people:
BMI > 40 without co morbidities
BMI >35 with 1 or more co morbidities.
or
BMI of 30 to 35 with significant or serious co morbidities.
or
When less invasive methods of weight loss have failed and the
patient is at high risk for Obesity-associated morbidity and mortality.

9. criteria for surgery
1. A Body Mass Index (BMI) ≥ 40 or a BMI ≥ 35 with obesity related co-morbid
conditions.
2. Age – 16 to 65 yrs
3. Screening for mental or behavioral disorders
4. no tobacco products & alcohol, 4 weeks prior to surgery.
5. No absolute contraindication to major abdominal surgery
6. Obesity of long standing

10. Criteria for surgery
6. Should have completed a weight loss program is recommended
7. counseling by a credentialed expert.
8. Follow up on regular basis
9. Adherence with wt loss /exercise programme.

11. contraindication
Bariatric surgery carries the potential for serious complications,
morbidity and possibly mortality
1. Cardiac complications with poor myocardial reserve.
2 Chronic obstructive airways disease or respiratory dysfunction.
3.Significant psychological disorders, or significant eating disorders.

12. Classification of bariatric surgery
1. Predominantly restrictive procedures
2. Predominantly malabsorptive procedures
3. Mixed or combination procedures

13. Restrictive procedure
Procedures that are solely restrictive by creating a small gastric
pouch & a degree of outlet obstruction leading to delayed
gastric emptying
• Reduce oral intake by limiting gastric volume
• Produce early satiety
• 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)

14. Malabsorptive procedure
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
Purely malabsorptive operations are no longer recommended due to
their potential hazard to cause serious nutritional deficiencies

 1. BILIOPANCREATIC DIVERSION
2.THE JEJUNAL-ILEAL BYPASS
 3. ENDOLUMINAL SLEEVE

15. Mixed procedure
1. GASTRIC BYPASS ROUX-EN-Y ( RYGBP)
2. SLEEVE GASTRECTOMY WITH DUODENAL SWITCH
3. IMPLANTABLE GASTRIC STIMULATION

16. Vertical Banded Gastroplasty (VBG)
 The stomach is partitioned along its
axis with a non- adjustable poly-
urethane band and with linear&
circular staples to create a small
upper stomach pouch with a
restrictive orifice to the rest of the
stomach
 No malabsorption of micro or
macro nutrients is expected
 No longer done

17. 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
 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.

18. LAGB
This Band in the stomach 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

19. LAGB- complication
• 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

20. Lap sleeve gastrectomy
 Laparoscopic sleeve gastrectomy (LSG) is a standard
procedure for the surgical management of morbid
obesity
 Rapid and less traumatic operation
 Good resolution of co-morbidities and good weight loss
 A further second surgical step/combine the
procedures

21. Lap Sleeve gastrectomy
 Stomach is reduced to about 25% of its original size
 A bougie between 36 - 40 Fr is used with the
procedure
 Ideal approximate capacity of the stomach after
the procedure is about 30- 60 ml pouch

22. Sleeve gastrectomy
 greater curvature gastrectomy,
 vertical or longitudinal gastrectomy or
 Pylorus preserving ‘gastric tube creation’

23. Sleeve gastrectomy
 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.

24. 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

25. Steps
1. 4 port placed usually
2. Liver Retraction –using Nathansons Liver Retractor
3. Gastrolysis of greater curvature- distal to prox. (Upto angle of of His.)
4. Resection of stomach by Stapling – starts from 4 cm distal to pylorus
5. Suturing for staple line reinforcement
6. Leak test- Methylene blue, air or UGIE
7. Extraction of specimen
8. Closure of Ports- by needle passer.

26. No nasogastric tube is placed at the end of the procedure
GASTROGRAFFIN STUDY:
A water-soluble upper gastrointestinal study is performed all cases , and for patients
with clinical symptoms and signs of leakage
If no leak observed, then patient is allowed to drink
Postoperative period
From D2 to D14, the patient remains on a liquid diet. Over the next 3 weeks on
soft diet
Normal diet after 1 month

27. 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.
Complications

28. 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
Psychological Side effects –
Increased manifestations of depression, disruption of social
relationships

29. Intragastric balloon involves placing a deflated balloon into the
stomach, and then filling it to decrease the amount of gastric
space
Soft silicon balloon
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 over
half a year.
Done endoscopically
The intragastric balloon may be used prior to another bariatric
surgery as a stepdowm procedure
Intra gastric balloon

31. Endo barrier liner system
Mimics the effects of gastric bypass surgery
It’s designed to work by inserting a flexible tube-like
barrier into the duodenum & prox. Jejunum
The barrier is placed endoscopically via the mouth and
thus helps patients to loose weight by delaying digestion
Has to be removed after 6 months

32. Mal- absorptive procedures
Rearrange and/or remove part the digestive system which limits the amount of calories and
nutrients that the body can absorb. Treatments with a large malabsorbtive component result
in the good amount of weight loss but tend to have slightly higher complication rates.
1. JEJUNAL ILEAL BYPASS
2. ILEAL TRANSPOSITION- For treatment of DM type 2 and metabolic disorders.

33. Combination procedures
Restrictive + malabsorbtive
1. LAP. GASTRIC BYPASS – ROUX-EN- Y – more malabsorption than the restrictive
2. MINI- GASTRIC BYPASS- mainly restrictive
3. DUODENAL SWITCH – the sleeve stomach is the restrictive portion &the intestinal bypass( duodenal
switch) is the mal absorptive component

34. Lap. Gastric bypass/ LGB
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

35. 1. Most commonly performed.
2. Most reliable operation for long term weight loss.
3. Long term weight loss averages 60 to 75 percent of EBW.
6. Malnutrition is unusual.
7. Substantial improvement & resolution in many co-morbid obesity conditions:
Type 2 DM – 90% Sleep apnea -90%
Hypertension-70% Hyperlipidaemia -70%
Heartburn from GERD- all patients.
Urinary stress incontinence-75%
89%reduction in mortality over 5 yrs. Following surgery, compared to non-surgically treated
group.
Advantages:

36. Gastric bypass/ lrygbp
• 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

37. • The small intestine (the jejunum) is divided
using a surgical stapler
Approx. 50-70 cm from the DJ Junction

38. 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 cm

39. 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%.
Complications

40. BPD
 Open/ lap
 Wt loss- malabsorption>> restrictive
 Distal hemigastrectomy
 Effective ileum length – 250 cm
 Distal common chennal- 50 cm
 Bile + pancreatic + intestinal juice mix for
only short length,
So proper digetion/absorption doesn’t take
Place.

41. Duodenal switch
 Less incidence of marginal ulcer
 Mechanism same BPD
 Open/ lap , lap- preferred.
 Common channel- 100 cm
 Entire length of alimentary length -250 cm
 First step- sleeve gastrectomy (150-200ml)
 Duodenum divided, distal connection same as
BPD (100 cm common channel), perform DIA (EEA)

42. DS

43. 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).
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.

44. RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

45. Thanks …