1) Bariatric surgery is recommended for patients with a BMI over 40, or over 35 with significant comorbidities. It includes both restrictive procedures that reduce stomach size and malabsorptive procedures that alter digestion. 2) The Roux-en-Y gastric bypass is the most commonly performed procedure, resulting in 60-80% excess weight loss. However, it is technically complex with greater risks. Sleeve gastrectomies have increased in popularity as they are less complex but still effective. 3) Careful patient selection and lifelong nutritional supplementation and monitoring are important for success and safety. Outcomes have greatly improved with experience and new procedures continue to be developed and refined.

1. Overview on bariatric surgery
By
Dr Alas ElSewefy
Assistant prof. of general surgery & laparoendoscopy

2. Obesity: BMI of 30 or more
BMI= W in kg/(H in meter)2

3. Epidemiology
• 600 million obese
• 13% adults are obese
• 39% adults are overweight
• Worldwide obesity has doubled between 1980
and 2014

4. Pathophysiology
4
Bray GA, et al. Lancet. 2016;387:1947-1956.
Obesity
Epigenetic
Genetic
Physiologic
Behavioral
Sociocultural
Environmental

6. Treatment
• Dietary changes
• Exercise and activity
• Behavior change
• Prescription weight-loss medications
• Weight-loss surgery

7. Bariatric Surgery Criteria *
• Age ≥ 18 years < 60
• Body Mass Index (BMI) ≥ 40
• BMI ≥ 35 with significant co-morbidities
– Heart disease, Type 2 diabetes, Hypertension, Sleep
Apnea, GERD
• 30–35 , poorly controlled type 2 diabetes ????
• History of prior weight management attempts
• Motivation and engagement in lifestyle modifications

8. Bariatric Surgery Exclusion Criteria *
• Active substance use, including nicotine and alcohol,
<6 months prior to surgery.
• Medical or surgical conditions that may make surgery
a high risk to perform.
• Severe or poorly controlled current psychiatric illness
or undertreated symptoms.

9. Other Lifelong Criteria and Guidelines
• NSAIDS are contraindicated for gastric bypass
– Significantly increased risk of GI bleeding
• Avoidance (pre / post op) : nicotine, caffeine
– Potential ulceration

10. Multidisciplinary team

11. Complete H & P
Routine labs (FBS , kidney function, liver
profile, lipid profile, prothrombin time/INR,
blood type, CBC)
Nutrient screening with iron studies, B12 and
folic acid and vitamin D
Cardiopulmonary evaluation with sleep apnea
screening (ECG, CXR, echocardiography)
Preoperative Checklist for Bariatric Surgery

12. GI evaluation (H pylori screening ; gallbladder
evaluation and upper endoscopy if clinically
indicated)
Endocrine evaluation (Hb A1c; TSH with,
screening for Cushing’s syndrome if clinically
suspected
Clinical nutrition evaluation
Psychosocial-behavioral evaluation

13. Informed consent
Provide relevant financial information
Optimize glycemic control
Pregnancy counseling
Smoking cessation

14. Bariatric surgery history and
evolutions

15. Restrictive procedures are:
 Sleeve gastrectomy surgery
 Gastric band surgery
 VBG
Malabsorptive procedures:
 Jejunoileal bypass
Restrictive and malabsorptive weight loss surgeries are:
 Roux-en-Y gastric bypass surgery
 Duodenal switch surgery
 Sleeve bipartition

16. jejunoileal bypass: 1963, Payne et al.
35cm
15 cm

17. Advantages
Simple and easy
Rapid weight loss
Disadvantage:
Sever malnutrition
Diarrhea
Electrolyte imbalances
Renal failure

18. Vertical Banded Gastroplasty: 1982 –
Mason and Laws

19. Advantage:
• No dumping syndrome.
• No nutritional deficiencies/malabsorption.
Disadvantage:
• Reversal of a VBG requires a much more
complex
• Vomiting and severe discomfort.
• Not adjustable

20. Adjustable Silastic Gastric Band
1986 - Kuzmak

21. Advantages
Weight loss of approximately 40 – 50 percent
 No cutting of the stomach or rerouting of the
intestines
 Shorter hospital stay,
Reversible and adjustable
 Lowe complications and mortality
 Has the lowest risk for vitamin/mineral deficiencies

22. Disadvantages
Slower and less weight loss
Foreign device to remain in the body
Slippage or erosion
Dilation of the esophagus
Requires strict adherence to the postoperative
diet and to postoperative follow-up visits
Highest rate of re-operation

23. Sleeve gastrectomy: Marceau et al
1960
75-80%

24. Advantages
Weight loss similar to that of the RNGB >50%
No foreign objects (AGB), and no bypass or
Short hospital stay
Changes in gut hormones improve satiety
Disadvantages
 Is a non-reversible procedure
 Vitamin deficiencies
leaks
Refluxogenic
 potential weight regain

25. Roux en y gastric Bypass: Mason
1960s
60-100 cm
50 cm
30-50 ml

26. Advantages
long-term weight loss (60 to 80 %)
Changes in gut hormones that reduce appetite and
enhance satiety
Typical maintenance of >50% excess weight loss
Disadvantages
Technically complex →greater complication rates
Vitamin/mineral deficiencies
Longer hospital stay than the AGB
Internal hernia

27. Scopinaro procedure 1979
50-125 cm 60%
40 %

28. Advantages
 Greater weight loss than. 60 – 70%
 Allows patients to eat near “normal” meals
 Changes in gut hormones to reduce appetite and improve
satiety
 The most effective against diabetes compared to RYGB, LSG,
and AGB
Disadvantages
 Has higher complication rates and risk for mortality
 Requires a longer hospital stay
 Malnutrition

29. Modification of duodenal switch
•Min gastric bypass
•SADI

30. Min gastric bypass
150-200 cm

31. Advantages
 Reversible.
 Simple, lower cost .
 early recovery
 The weight loss ranges from 50% to 80% .
 Short operative time
 Metabolic effect
Disadvantages
 There are no long-term studies available
 biliary reflux → ulceration, inflammation or erosion around
the stomach walls.
 Malnutrition

32. SADI
300 cm50-125cm

33. Advantages
There is no at-risk gastric remnant.
No dumping .
↓ Calcium and iron deficiency, since 1st part of
duodenum is preserved.
Reduces risk of internal hernias.
Malabsorption is much less compared to
duodenal switch
Disadvantages
Dissection around duodenum is technically
difficult, and so the learning curve is prolonged.

34. Novel techniques

35. 1- SG TB (SLEEVE GASTRECTOMY WITH TRANSIT
BIPARTITION) , Santoro - 2012

36. Advantages
duodenum is not transected.
the sleeve has two outlets.
induce hormonal changes and diabetes
resolution.
minimises malabsorption.
Disadvantages :
higher risk of internal herniation as the
anastomosis is a Roux-en-Y type,
higher risk of marginal ulcers
Technically difficult

37. 2- SG LB (SLEEVE GASTRECTOMY WITH
LOOP BIPARTITION) Mui - 2014

38. Advantages
Endoscopic access to biliary tract
↓ sleeve leaks and gastroesophageal reflux.
Hormonal changes are high.
Malabsorption is less.
Diarrhoea and steatorrhoea risks are rare .
Disadvantages:
Biliary reflux
No long-term results

39. How to choose your procedure
RNGB:
The standard procedure up till now, Technically
demanding, the best for GERD
Sleeve:
Easy, contraindicated in sweat eater & GERD,
durability weight regain ? leaks
 MBG:
Simple, effective metabolic control, but reflux and
malnutrition
SASI: reflux , long-term??? may by the future

40. Follow up

41. Thrombophylaxis:
Respiratory care:
Diet:
 1st week: Clear fluid
 2nd week: liquid diet
 3rd week: soft diet
 4th week →: ordinary high protein low calorie diet
Ppi: 1 year
Post-operative lab work
Lab work is done at 4, 12, 18, and 24 month visits after surgery, and
then yearly:
CBC
Ferritin, iron
parathyroid hormone
RBC folate
Vitamins A, B1 (thiamine), B12, and 25 hydroxy Vitamin D