Dr Sreejoy PatnaikMember OSSI,IFSO,SAGES

Minimal Access , Bariatric & Metabolic Surgery

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 ???

Kancherla Ravindranath

August 8th 1992 did the first lapchole in Orissa

With help of Dr Vinay Taunk at SCBMCH & at SHANTI

MANMOTH TASK

Obesity associated conditionsDiabetes

Hypertension

Sleep apnea

Congestive heart failure

Hyperlipidemia

Stroke

Coronary Artery Disease

Osteoarthritis

Gastroesophageal Reflux Disease

Non-alcoholic fatty liver

Psychological disturbances

Cardiovascular: CAD, HTN, CHF, LVF, Venous stasi ulcers, DVT, Hyperlipidaemia

Pulmonary: OSA,OHS,PAH, AsthmaEndocrine: Insulin Resistance, Type 2 DM, PCOSHaemopoietic: DVT, Pulmonary EmbolismG.I /Hepatobiliary: GERD, NAFLD, Hernias, GallstonesGenitourinary: Stress incontinence, UTIObstetrics/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

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)

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

Open Surgery (big cuts)

Laparoscopic Surgery (key-hole sized cuts)

Natural Orifice Surgery (no cuts)

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

Bariatric Surgery

Diet

Exercise

Behavior Modification

“Postoperative care, nutritional counseling, and surveillance should continue for an indefinitely long

period.”

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

1. PREDOMINANTLY RESTRICTIVE 1. PREDOMINANTLY RESTRICTIVE PROCEDURESPROCEDURES

2. PREDOMINANTLY MALABSORBTIVE 2. PREDOMINANTLY MALABSORBTIVE PROCEDURESPROCEDURES

3. MIXED OR COMBINATION 3. MIXED OR COMBINATION PROCEDURESPROCEDURES

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:

-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

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.

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

Armamentarium in OT

INSTRUMENTS TELESCOPES,TROCARS

LIVER RETRACTORS ENDO-GIA STAPLERS

LED MARTIN LIGHTS

MINDRAY BARIATRIC TABLE

VALLEYLAB STERRAD

LIGASURE HARMONIC

EXTRA LONG TROCARS

OPTI-VIEW TROCARS GASTRIC CALIBRATION TUBE

OPTICAL TROCARS & GCT

WARM BLANKET- BAIR HUGGER

SERIAL COMPRESSION DEVICE

TYCO – KENDALL COMPRESSION DEVICE

Dr. Cadiere 1992 Technically simple Purely restrictive

Decrease hunger Early satiety Food aversion

Adjustment to stoma diameter

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.

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.

• 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

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

TEN STEPS OF LSGTEN STEPS OF LSG

1.1.Assembly of instruments, in order of Assembly of instruments, in order of useuse

2.2. OT set up and Trocar PositionOT set up and Trocar Position3.3.Liver Retraction –using Nathansons Liver Retraction –using Nathansons

Liver RetractorLiver Retractor4.4.Gastrolysis of greater curvature- distal Gastrolysis of greater curvature- distal

to prox. Upto> of His.to prox. Upto> of His.5.5.Resection of stomach by Stapling – Resection of stomach by Stapling –

starts from 4 cm distal to pylorusstarts from 4 cm distal to pylorus6.6.Suturing for staple line reinforcementSuturing for staple line reinforcement7.7.Leak test- Methylene blue, air or UGIELeak test- Methylene blue, air or UGIE8.8.Extraction of specimen- fish tail Extraction of specimen- fish tail

techniquetechnique9.9.Closure of Ports- by needle passer.Closure of Ports- by needle passer.

DONE UNDER G.A

5 TO 6 PORTSThe 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

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

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

1.1.Resection of Resection of

Stomach by Stomach by Stapling – starts Stapling – starts from 4 cm distal to from 4 cm distal to pyloruspylorus

Stomach stapling ends up at angle of His

Suturing for staple line Suturing for staple line reinforcementreinforcement

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

SLEEVE GASTRECTOMY

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

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.

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.

• The small intestine (the jejunum) is divided using a surgical stapler

Approx. 70 cm from the DJ Junction.

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

“Gold Standard” 80% of bariatric

proc. Restrictive and

Malabsorptive: Reduced calorie

intake Macronutrient

malabsorption

LAP GASTRICT BYPASS

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

ICCSSG NEW YORK 2007

Staple line leakage Bleeding from the staple line Gastric stenosis

Late complications Marginal ulcer GERD ++ Gastric dilatation and weight regain

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

N=1041 year post op Number

Pre-op % Worse% No

change

% Improve

d%

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 Resolved Schauer, et al. Ann Surg 2000 Oct;232(4):515-29

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.

70% complete resolution 50% reduced medications Swedish Obese Subject Trial: 2

years post opDecreased relative risk of new

onset HTN = 10 Time interval for resolution not

cleared1. 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.

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.

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.

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.

Revisional Surgery

Endoscopic Procedures

Gastric Neuromodulation

Durable

Excess Weight Loss > 50%

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

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

Research Ranking scores using a combination of factorsTypes 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

OUR SERIES OF PATIENTS

THE FUTURE –WHO KNOWS THIS DAY MIGHT COME SOON

THANK YOU