Bariatric Surgery

1
Bariatric Surgery

• Nicole Mancinelli

2
Objectives

• Be familiar with the most common types of
  bariatric surgery procedures performed today.
• Learn the criteria that need to be met to be
  considered a candidate for surgery.
• Be familiar with the advantages/disadvantages of
  the most common procedures.

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Burden of Obesity

• Approx.72.5 million adults considered obese in
  2007-2008
• Biggest contributor of healthcare spending over
  last 20 yrs
• Oklahoma was ranked 7th most obese state in 2011

4
History of Bariatric Surgery

• 1954 first introduced by Kremen
• 1976 safer approach developed by Scopinaro
• 1988 crossbreed of Biliopancreatic diversion
  developed by Hess
• 1994 laproscopy was introduced by Wittgrove

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Qualification for Surgery

• BMI 40 kg/m2
• BMI 35 kg/m2 co-morbidities of obesity
• Failed conventional weight control

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Current Surgical Procedures

• Adjustable gastric banding
• Vertical banded gastroplasty
• Roux-en-Y procedure
• Laproscopic sleeve gastrectomy
• Biliopancreatic Diversion with duodenal switch

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Vertical Banded Gastroplasty

• Created in 1982
• Band/staples used to create a small stomach pouch
• Limited weight loss results and high re-operation
  rates
• Up to 56 as compared to other procedures
• Complications
• Stromal erosion, weight regain, severe GER
  symptoms

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Lap Sleeve Gastrectomy

• Fairly new restrictive procedure
• Originally created as a bridging procedure
• Ranked between LAGB and Roux en Y
• More data needed to determine relative benefits

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Biliopancreatic Diversion with Duodenal Switch

• Originally created in 1988 for treatment of bile
  gastritis
• Decrease usage due to increased risk of
  micro/macro nutritional deficiencies
• Increased risk for metabolic consequences
• Protein malnutrition
• Fe deficiency anemia
• Hypocalcemia
• Develop bone demineralization that could double
  fracture risk

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Adjustable Gastric Banding

• Approved in 2001
• Ability to fine tune desired effects of silicone
  band and decrease adverse effects
• Lowest morbidity and mortality among bariatric
  procedures
• Disadvantages
• Foreign object
• Stomach prolapse
• Inferior weight loss when compared to Roux en Y

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Long term efficacy/Safety

• Followed 82 pts Jan. 1994- Dec 1997
• 22 experienced minor complications
• Incisional hernia, port tube disconnections,
  infection
• 39 (23)experienced major complications
• Dilation of pouch, erosion
• Re-operations
• 49 (59.8) due to lack weight loss
• Mean BMI ? from 41.57 to 33.79
• Nearly 50 required removal band, 1out of 3 had
  band erosion

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Roux-en Y Procedure

• First appeared in 1967
• Most widely performed
• Combo of restrictive/ malabsorption
• Roux limb varies and each has its own advantages
• Best results for long term weight loss, decrease
  GERD symptoms 95 of pts

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RYGB vs LAG

• Prospective randomized study
• 196 pts
• 111 LRYGB
• Mean BMI 47.5 kg/m2
• 86 LAG
• Mean BMI 45.5kg/m2

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Weight loss Results
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Early/ Late Complications
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Long term consequences

• Improves associated co-morbities related to
  obesity
• Diabetes
• Sleep Apnea
• HTN
• gt75 had HTN prior to surgery
• 69 reported HTN resolved in 1 year and sustained
  over 7 years
• GERD
• gt50 obese have GERD, gt95 had resolution after
  bariatric procedure

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DM
Prevalence of DM in 1990
Prevalence of DM 1997-1998

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Efficacy of surgery in the management of obesity
related type 2 Diabetes Mellitus
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Nutritional Deficiencies

• Fe Deficiency
• gt 50 were below pre op levels despite adequate
  oral supplements
• Only 3.5 required transfusion
• B12
• Most commonly after RYGB
• Below normal in 26 of 66 pts after RYGB

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Calcium Deficiency243 pts followed after RYGB
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Dumping Syndrome

• Caused when ingested food bypasses the stomach
  too rapidly and enters the small intestine
  largely undigested
• Expansion of the duodenum occurs too quickly due
  to the presence of hyperosmolar food from the
  stomach
• gt70 of individuals experienced at least one
  symptom of this syndrome after RYGB

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Future of Bariatric Surgery

• Single incision
• Uses silicone band around upper portion of the
  stomach

• Incision Free
• Transoral gastroplasty
• Endolumenal
• Both create stapled, restrictive pouch

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Conclusion

• Most common bariatric procedures are Roux en Y,
  and Adjustable Gastric Band
• Certain procedures should be selected based on
  multiple factors

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References

• Scozzari, MD, Toppino M, Famiglietti F, et al. 10
  year follow up of laparoscopic Vertical banded
  gastroplasty. Annals of Surgery. November 2010
  225 (5) 831-839.
• CDC. State-specific prevalence of obesity among
  adults- United States, 2009. MMWR
  201059951-955.
• Padwal R, Klarenbach S, Tonelli M, et al.
  Bariatric Surgery A systematic Review of the
  Clinical and Economic Evidence. JGIM Journal of
  General Internal Medicine. October 201126
  (10)1183-1194.
• Suter M, Donadini A, Romy S, Demartines N,
  Giusti V. Laproscopic Roux-en-Y Gastric Bypass
  Significant Long term weight loss, Improvement of
  Obesity-related Comorbidities and Quality of
  Life. Annals of Surgery. 2011254 (2) 267-273.
• Gan S. Talbot M, Jorgensen J. Efficacy of Surgery
  in the management of obesity related type 2
  diabetes mellitus. Surgery. October 2007
  77958-962.

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References

• Johnson J, Maher J, DeMaria E, Downs R, Wolfe L,
  Kellum J. The Long term effects of Gastric Bypass
  on Vitamin D Metabolism. Annals of Surgery.
  Scientific Papers of the 117th Annual Meeting of
  the Southern Surgical Association. 2006 243 (5)
  701-705.
• Mokad A, Ford E, Bowman B, Nelson D, Engelgau M,
  Vinicor F, Marks J. Diabetes trends in the US
  1990-1998. Diabetes Care. September 2000
  231278-1283.
• Maggard MA, Shugarman LR, Suttorp M, et al.
  Meta-analysis Surgical treatment of obesity.
  Annals of Internal Medicine. 2005 142547-559.
• Scopinaro N, Adami GF, Marinarir GM, et al.
  Biliopancreatic Diversion. World Journal of
  Surgery. 1998 22936-946.
• Special Thanks to G. Michael Steelman M.D.