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Indications & c.i in bariatric surgery

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Bariatric Surgery is rapidly gaining popularity. Knowing the right Indications and Contra Indications is paramount for Surgeons starting their career in Bariatric Surgery.

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Indications & c.i in bariatric surgery

  1. 1. Bariatric Surgery Indications & Contraindications DR. SUMEET SHAH MS, DNB, MNAMS, FIAGES Fellowship (Minimal Access Surgery) SENIOR CONSULTANT & COORDINATORMINIMAL ACCESS, METABOLIC & BARIATRIC SURGERYMAX SUPER SPECIALTY HOSPITAL, SHALIMAR BAGH NEW DELHI (INDIA)
  2. 2. Bariatric SurgeryIndications & Contraindications What is obesity? ?
  3. 3. Bariatric SurgeryIndications & Contraindications Morbid obesity is a chronic, lifelong, multifactorial, genetically related disease of excessive fat storage with highly significant medical, psychological, social, physical and economic co- morbidities IFSO Sept, 1996
  4. 4. Bariatric SurgeryIndications & Contraindications  Quantification of obesity BMI = Body Mass Index = Body weight (Kg) Height (in m2)
  5. 5. Bariatric Surgery Indications & ContraindicationsBARIATRIC RECOMMENDATIONS WHO CRITERIA RECOMMENDATION FOR ASIANS BMI (kg per m2) Normal < 25.0 < 23.0 Overweight > 25.0 > 23.0 Obese > 30.0 > 27.5 Severe Obesity > 35.0 > 32.5 Morbid Obesity > 40.0 > 37.5
  6. 6. Bariatric Surgery Indications & ContraindicationsBariatric Surgery: Multiple Health Benefits  ~77 % Excess weight loss  ~ 85 % resolution of OSA  ~ 52 to 92 % resolution of HTN  ~ 73 – 83% resolution of type 2 diabetes  > 80 % resolution of Metabolic Syndrome Sjostrom et al New Engl J Med 2004 Sjostrom et al, N Engl J Med 2007
  7. 7. Bariatric Surgery Indications & Contraindications Optimal Patient Selection Assess indications / contraindications Multi-disciplinary evaluation Optimize & manage comorbidities Educate,set realistic expectations
  8. 8. Bariatric SurgeryIndications & Contraindications NIH Consensus Conference Criteria(1991) BMI > 40 or > 35 kg/m2 with co-morbidity Failure of non-operative Rx Absence of contraindications Well informed, compliant, motivated patient
  9. 9. Bariatric SurgeryIndications & Contraindications Controversies Surgery for Adolescents & Elderly ( Age < 18 / > 65 yrs ) Surgery for BMI < 35 Surgery for Metabolic indications only
  10. 10. Bariatric Surgery Indications & Contraindications ? Surgery for Adolescents  Adolescent bariatric surgery (<18 yrs) has proven effective but should be performed only in a specialty centre  Selection criteria similar to adultsSAGES Guidelines for Clinical Application of LaparoscopicBariatric Surgery, 2008; Level II, Grade B,C evidence.
  11. 11. Bariatric SurgeryIndications & Contraindications Panel of experts on Adolescent Obesity BMI > 40 with comorbidities Skeletal / physiologic maturity Failure of > 6 mths of structured wt loss attempts Commitment, ability to follow post-op instructions Decision making capacity Commitment to avoid pregnancy x 1 year Curr Opin Paediatr 2005.
  12. 12. Bariatric SurgeryIndications & Contraindications ? Surgery for Age > 65 Patients > 65 yrs at risk of death (early & late) after WLS Should have life expectancy > 5 yrs Should be evaluated & treated in an established Center of Excellence JAMA 2005 Annals of Surgery 2004 SAGES Guidelines for Clinical Application of Laparoscopic Bariatric Surgery, 2008; Level II, Grade B evidence.
  13. 13. Bariatric SurgeryIndications & Contraindications ? Surgery for BMI < 35 “Individuals with BMI 30-35 kg/m2 may benefit from Lap. bariatric surgery given the poor results of non-surgical Rx” SAGES Guidelines for Clinical Application of Laparoscopic Bariatric Surgery, 2008; Level I, Grade B evidence.
  14. 14. Bariatric Surgery Indications & ContraindicationsSurgery for Diabetes / Metabolic Syndrome ? Risks vs Benefits? Choice of procedure? Economic Considerations? When to intervene? ? BMI < 35
  15. 15. Bariatric SurgeryIndications & Contraindications Contraindications
  16. 16. Bariatric Surgery Indications & Contraindications Medical Severe co-morbidities / unacceptable risk Uncontrolled coagulopathy Incurable disease (cancer,AIDS, cirrhosis) ? Certain GI diseases (Crohns, dysmotilities) V.Poor QOL not expected to improve with WLS
  17. 17. Bariatric Surgery Indications & Contraindications Unacceptable risk of Anaesthesia Uncontrolled severe OSA + Pulmonary HTN (Pulm. Syst. Pressure > 50mm Hg) Severe COPD (Gold Spirometric Criteria) - FEV1 / FVC < 0.7 - FEV1 < 30% predicted, or - FEV1 < 50% predicted + chr. resp. failure CHF, unstable angina ? Complete prolonged immobility
  18. 18. Bariatric Surgery Indications & Contraindications Surgical (Relative) Multiple previous surgeries Abdominal irradiation / Liver transplant Very large incisional hernia Previous int. resection for GBP / BPD-DS Severe GERD / Barrets for LAGB Need for surveillance endoscopy for GBP
  19. 19. Bariatric SurgeryIndications & Contraindications Behavioral / Psychosocial Significant psychatric dis./ major depression Severe mental retardation Self destructive tendency Active bullimia, drug or alcohol abuse Inability to comprehend behavioral changes Inability to integrate basic lifestyle adjustments
  20. 20. Bariatric Surgery Indications & ContraindicationsIndications for Retreat / Change of surgical plan Extreme hepatomegaly / cirrhosis with large varices Profuse visceral fat Poor exposure Extensive adhesions Cardiopulmonary instability
  21. 21. Bariatric Surgery Indications & ContraindicationsIndications for Retreat / Change of surgical plan
  22. 22. Bariatric SurgeryIndications & ContraindicationsRevision Surgery: After Lap. Gastric Banding Early Late  Gastric perforation  Stomach slippage  Stomach slippage  Malpositioned band  Erosion  Psychological intolerance  AIDS  Gastric necrosis
  23. 23. Bariatric SurgeryIndications & ContraindicationsRevision Surgery: After Lap. Gastric Bypass Mechanical problems Marginal ulcer Refractory GJ stricture Entero-enterostomy stenosis
  24. 24. Bariatric SurgeryIndications & ContraindicationsRevision Surgery: After Lap. Gastric Bypass Insufficient Weight loss Normal anatomy Abnormal anatomy - Disrupted staple line - Gastro-gastric fistula in divided GBP - Enlarged pouch Metabolic / Functional Nut. deficiency / food intolerance Severe dumping / unexplained chronic pain
  25. 25. Bariatric SurgeryIndications & Contraindications
  26. 26. Bariatric SurgeryIndications & Contraindications
  27. 27. Bariatric SurgeryIndications & Contraindications

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